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Concussion Risk Doesn't End with School Year

With summer all-star games, tournaments, travel ball and sports camps comes risk of brain injury

For an increasing number of kids these days playing sports doesn't end with the school year.  If anything, the competitive intensity of the all-star, tournament, travel ball, showcases, and sports camps that fill up their summer vacations, means increased athletic exposures and increased risk of mild traumatic brain injury or concussion

And, because summer sports are less likely to be staffed by an athletic trainer or other health care professional with specialized expertise in recognizing and treating concussion, parents need to be especially vigilant to the signs and symptoms of concussion.Lacrosse players collide

Concussion, still referred to by some as a "ding" or a "bell ringer," is no joke. Concussions can have a lasting effect on cognition  (e.g. functions of the brain involving thinking, concentrating, learning, and reasoning), as well as physical, and emotional effects, such as depression. They are often undiagnosed and improperly managed because many health care professionals, coaches, and school/athletic personnel have not kept abreast of the most recent identification and treatment guidelines. As a result it is especially important for parents and athletes to stay informed.

With the guidance of athletic trainers, neuropsychologists, and physicians with specific expertise in concussions, high schools across the country are facing this public health menace head on. Concussion education and management programs are sprouting up in response to new national and international concussion guidelines, the enactment of concussion safety laws in virtually every state (federal legislation is pending), and injury lawsuits.

A concussion is any alteration in mental state or consciousness that occurs as a result of a hit or a blow to the head (or blow transmitted to the head).  Signs of concussion may include, but are not limited to, feeling dazed or confused, dizziness, headache (the most common symptom, by far), nausea, fatigue, sensitivity to light or sound, visual disturbance, irritability, and attention, concentration, and memory problems. One does not need to experience loss of consciousness or amnesia in order to sustain a concussion. And one does not have to hit one's head, as a whiplash or strong rotational force can shake the delicate structures of the brain. No helmet or mouth guard can prevent concussion.

Once a concussion is sustained, an athlete is 2.5 to 5.8 times more likely to sustain another. (2) Youth are more vulnerable than adults, experience longer recovery periods (2), and may exhibit delayed symptoms which may not be fully evident until the next day or later. This makes it especially important that a youth athlete who has sustained a blow to the head during a game or practice be carefully monitored during the first 24 to 48 hours after injury.

Youth up to the age of 21 or so are also susceptible to second impact syndrome, a rare but serious condition that results in swift death or catastrophic neurological injury when a youth sustains a second blow before his or her brain has fully healed from the first. It is essential that any youth suspected of sustaining a concussion not be allowed to continue in sports or athletic activity.

The motto should always be: "When in doubt, sit them out." The concussed athlete should be examined by a physician to be sure that there are no serious complications, such as slow brain hemorrhaging, that might not be immediately detected. With concussion, if a CT scan is performed, it is expected to be normal, unless there is a more complicated condition.

Rest is the key to recovery

Concussed youth athletes should be placed on immediate physical and mental rest. That means no physical exercise, no computer games, no texting, no parties, no going to the mall with friends. Youth who do not rest immediately tend to have much longer recovery periods. Because of these factors and the fact that a youth athlete's brain is still developing and growing, some experts suggest that youth remain out of sports for three weeks or more after they are symptom free, especially if they have a history of prior concussions.

The recommendation of cognitive and physical rest has been made despite the fact that, until June 2012, there was no empirical evidence to support such treatment. With the publication of a new study which I co-authored in the Journal of Pediatrics (1) documenting the effectiveness of prescribed rest for the treatment of post-concussion symptoms and cognitive disfunction, whether the rest is applied in the early or prolonged stages of recovery, a follow-up study which I co-authored confirming the results of the initial study (4), and the subsequent publication of a study showing that athletes who engaged in no cognitive rest after concussion took longer to recover (3) my hope is that athletes, parents, and school and athletic officials who do not see the therapeutic value of missing sports and strict cognitive and physical rest, even when weeks or months have passed since the injury, will now be less likely to resist or challenge such clinical judgment.

How long a period of cognitive and physical rest a student-athlete will need varies, which is why I recommend that concussion recovery be managed by a sports concussion specialist.  A neuropsychologist (a scientist and clinician who specializes in the assessment of brain function) can greatly assist in return to play decisions, as well as in the management of post-concussion symptoms and recommendations for academic accommodations while the youth is recovering. Once cleared from a cognitive perspective, physical exertional testing and balance assessment, overseen by an athletic trainer or other health care professional with specialized training in concussion management, should take place prior to return to play.

To assist in return to play decisions, youth athletes in contact/collision sports should undergo baseline neuropsychological testing when they are healthy, such as during the pre-season. Many schools have implemented concussion testing programs. This type of computerized testing documents performance on memory, reaction time, processing speed, and attention tasks. If a youth sustains a concussion, he/she can be retested to help determine when scores are back to pre-concussion levels. This type of assessment increases the accuracy in decisions about recovery, as many athletes who feel physically better may still have brains that are not fully healed. It is important that post-concussion test results be interpreted by a health care professional trained in brain and cognitive functions and in concussion assessment.

Rosemarie Scolaro Moser is the Director of the Sports Concussion Center of New Jersey and the Director of Research Programs for the International Brain Research Foundation.

1, Moser RS, Glatts C, Schatz P. Efficacy of Immediate and Delayed Cognitive and Physical Rest for Treatment of Sport-Related Concussion. J Pediatrics DOI: 10.1016/j.jpeds.2012.04.012 (in press).

2. Harmon K, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med 2013;47:15-26 at notes 28,38,41-46.

3. Brown NJ, Mannix RC, O'Brien MJ, Gostine D, Collins MW, Meehan WP. Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms. Pediatrics 2014;133(2):1-6. 

4. Moser R, Schatz P, Glenn M, Kollias K, Iverson G. Examining prescribed rest as treatment for adolescents who are slow to recover from concussion. Brain Inj. 2014; Early Online: 1-6 DOI: 10.3109/02699052.2014.964771 (e-published ahead of print October 1, 2014)

Most recently revised July 10, 2015