So what's up with concussions?

The weather has begun to warm again and the kids are really itching to get outside. With increased outdoor time comes increased participation in athletic events. Frequently, our young athletes will suffer some kind of head injury and the question always arises as to what to do with these kids.

There are two significant consequences of head injury, concussion and intracranial bleeding. Intracranial bleeding is relatively infrequent. These patients usually (but not always) have a significant head injury. They develop headache, nausea, vomiting and/or irritability that gradually worsens, usually prompting medical attention. We saw this recently with a famous model/actress who'd been skiing, hit her head and over the next 24-48 hours had headaches that came and went, gradually worsening. Unfortunately, she perished due to lack of nearby facilities, lack of recognition of a problem, and patient resistance to admitting her symptoms were getting worse. Anytime that there is a head injury, be very aware of symptoms that are getting worse and have worsening symptoms evaluated quickly.

The second significant consequence is far more common and usually considerably more subtle. A concussion is defined as ANY head injury, no matter how minor, that leads to neurologic symptoms. These symptoms can be as mild as several moments of dysorientation or as severe as "blacking out" for many minutes. Clearly, the more severe the injury or the symptoms, the more seriously physicians take the injury, but studies have shown that even minor injuries can lead to long term changes. These chronic changes include persistant headaches (especially with exercise), persistant trouble concentrating (including one patient I had who developed ADD like symptoms for years after the injury), irritability and other personality changes. These symptoms generally resolve spontaneously, but can persist for weeks, months and potentially even years. The symptoms are treated accordingly, but there is no treatment for the underlying cause, that is, the concussion.

While these symptoms are a serious problem for those who suffer from them, the bigger issue is the risk of secondary concussions and, more importantly, second impact syndrome. The research is very clear that individuals who have had a first concussion are at several fold higher risk of having more concussions in the future. All activities with risk for a head injury most be approached with this risk in mind. Any protection that can be afforded to these individuals to prevent a head injury is appropriate. Second impact syndrome is a rare, but potentially fatal complication of having a second head injury while the symptoms of the first concussion are still present.

With these risks in mind, there are certain guidelines for returning to a risky activity after a concussion. Most experts believe that a very mild concussion (head injury with a little dizziness lasting a minute or so) can return to play once COMPLETELY symptom free for more than five minutes. Any persistent symptoms are a reason to remain out of play. Any loss of consciousness should probably result in an athlete being pulled for the duration of the game. Return to play is determined by persistence of symptoms. There is a very gradual return to full activity. Athletes start with usual activities of daily living (walking, going to school). If there are headaches, difficulty concentrating, trouble with short term memory, or irritability, the athlete doesn't move to the next step. The next step includes basic, gentle exercise. Jogging, biking and swimming would fall in this category. Once these activities can be done completely without symptoms, then the athlete may return to sport specific activities including drills. At this point, weight lifting may be resumed. Only when extensive sport specific skills can be done without any return of symptoms may the athlete be returned to competitive play.

Head injury is a serious injury in any child. Athletes are at much higher risk of complication if they return to play too quickly. The key issue is if there are ANY symptoms that you as a parent can see, don't take any chances. Consult with your pediatrician, trainer or sports medicine specialist on how to proceed.