Concussions: Parents Are Critical Participants in Recognition, Treatment, Recovery

The subject of sports concussions has been in the news a lot lately. But while the recent media  focus has been on hits to the head in the National Football and Hockey Leagues, which have led to player fines, suspensions, and to legislative action at the state level, the important role parents play after their kids suffer concussions doesn't usually receive the same kind of attention.

The fact is that an athlete's parents, along with teachers, coaches, school nurses and administrators, play a crucial role in a child's treatment and recovery from a suspected concussion, especially the all-important decisions about when to return to school ("return to learn") and everyday social and home activity, and, in most cases, to sports. (1)  

Parent involvement in their child's recovery from a concussive event is, of course, not surprising, considering that:

• Active involvement of the parent is standard practice in pediatrics (especially, of course, for younger children);
• The student-athlete's everyday environments at home and at school are important places to observe post-concussion symptoms; and
• Parents and teachers possess a wealth of information about the child's behavior and ability to function in these settings that is directly relevant to an assessment of their post-concussion symptoms ( and when it is safe for them to return to the classroom (often with accommodations) and sports.

Parent concussion checklist

But what, exactly, is the parent's role?  Here's a 10-point checklist.

1.  Regularly and closely monitor athlete for first 24 to 48 hours. (2,7)

• While all concussions should be taken seriously, the potential always exists for a life-threatening head injury, such as an epidural hematoma (bleeding between the skull and the brain), subdural hematoma, subarachnoid hematoma, or from second-impact syndrome (a rare, but often fatal brain injury suffered before the brain has fully healed from previous brain trauma).
• Because delayed onset of symptoms during the first 24 to 48 hours is possible (and more likely in children), parents - or another responsible adult - should closely monitor the athlete during this time. 
  
  • Even if an athlete has been removed from a game or practice because of a suspected concussion (as is required under laws in an increasing number of states), he or she should not be sent to the locker room alone, and should never be allowed to drive home.
  • The traditional rule has been to wake up a concussed athlete every 3 to 4 hours during the night to evaluate changes in symptoms and rule out the possibility of an intracranial bleed, such as a subdural hematoma.
  • The new thinking (3) is that there may be more benefit from uninterrupted sleep than frequent wakening, which may make symptoms worse.  As a result, waking up your child during the night to check for signs of deteriorating mental status (see #2) is now recommended only if your child  experienced a loss of consciousness or prolonged amnesia after the injury, or was still experiencing other significant post-concussion signs or symptoms at bedtime. There is no need to check your child's eyes with a flashlight or test their reflexes. 

2. Immediate hospitalization if condition deteriorates (2,7).  If your child experiences any of the following signs of deteriorating mental status, take her to the hospital immediately:

• Has a headache that gets worse
• Is very drowsy or can't be awakened (woken up)
• Can't recognize people or places
• Is vomiting repeatedly
• Behaves unusually, seems confused or very irritable
• Experiences seizures (arms and legs jerk uncontrollably)
• Has weak or numb arms or legs
• Is unsteady on his feet or has slurred speech.

3.  Use acetaminophen (e.g. Tylenol®) or codeine for headache.  Do not give aspirin or non-steroidal anti-inflammatory medicine(NSAIDs)(e.g. Ibuprofen/Advil®) (2,7) An ice pack on the head and neck is okay as needed for comfort.  A 2010 clinical report from the American Academy of Pediatrics' Council on Sports Medicine and Fitness³ notes that, because no studies have actually documented any harm from use of NSAIDS after a sport-related concussion, the common recommendation against their use is based more on a theoretical risk.

4.  No drugs or alcohol: Warn your child about the dangers of drinking alcohol, engaging in recreational drug use, or using any other substance that could interfere with cognitive function and neurologic recovery.  Do not give sleeping tablets.

5. No driving until symptoms have cleared (2).  While an athlete is experiencing concussion symptoms - such as sensitivity to noise or light or dizziness, inability to detect quick movements of the head, sleep problems, problems with memory or concentration, or anxiety, even a narrowing of their field of vision - he should not be driving.  If symptoms persist, it may even be advisable for the athlete to be undertake a more formal evaluation to determine whether it is safe for him to resume driving a car. 

6.  Normal diet: Limited information is available regarding the recommended diet for the management of concussion. A normal well-balanced diet that is nutritious in both quality and quantity should be maintained to provide the needed nutrients to aid in the recovery process. Avoid spicy foods.

7.  Physical and "cognitive" rest:

• Treating young athletes after a concussive event is uniquely challenging, because their brains are still developing. The cornerstone of concussion management of young athletes is physical and cognitive rest until symptoms clear, and then completion of a 5-step graduated exercise program leading to medical clearance and return to play (1).   
  
  • limit their day-to-day and school-related activities until symptom free. 
    
    • This generally means no homework, video games, text messaging and staying home from school (2,7) while still experiencing concussion symptoms (although some experts, including the authors of the most recent international consensus statement on concussions (1), mindful of the fact that it is difficult for parents to constantly be monitoring their child and to enforce strict limits, along with the lack of research in this area, suggest that the most important thing for a parent to take a common sense approach about their child's level of cognitive activity, having the child avoid activities that seem to make their symptoms worse; the Child - SCAT3 (7) recommends at least 24 hours of rest after concussion and no return to school until medically cleared).
    • Academic accommodations, including temporary leave of absence from school (
    the Child - SCAT3 (7) says it "is reasonable for a child to miss a day or two of school after concussion"), shortening of the athlete's school day, reduction of workloads in school, and/or allowing an athlete more time to complete assignments or take tests, may be necessary.(2,3,7)
    • Taking standardized tests while recovering from a concussion should be discouraged, because lower-than-expected test scores may occur and are likely not representative of true ability.
  • Avoid strenuous activity until the athlete has no post-concussion symptoms at rest because physical activity may make symptoms worse and has the potential to delay recovery.  While bed rest is not recommended, some evidence suggests that a limited amount of physical activity may aid in recovery, and the effect of physical activity on concussion recovery has not been extensively researched, there is general consensus among concussion experts recommending broad restrictions of physical activity, including: 
    
    • the sport or activity that resulted in the concussion
    • weight training
    • cardiovascular training
    • PE classes
    • sexual activity
    • leisure activities such as bike riding, street hockey, and skateboarding that risk additional head injury or make symptoms worse (3).
  • No further treatment is required during the recovery period apart from limiting physical and cognitive activities (and other risk-taking opportunities for re-injury) while concussion symptoms are still present, and most athletes typically resume sport without further problem.

8.  Graduated, individualized, conservative return-to-play. The Zurich Consensus Statement on Concussion in Sport (1), SCAT3(2)(for athletes 13-years of age and older), Child SCAT3 (7)(for student-athletes ages 5 to 12)(7), and American Academy of Pediatrics (3) recommend against - and most of the new state laws prohibit - same day return to play under any circumstances.  When returning athletes to play, they should be off all academic accommodations, symptom-free, have returned to baseline on neurocognitive, balance, and visual tests, and successfully complete a 5 step, symptom limited exercise program which will usually about a week to complete, with each stage taking 24 hours or longer to complete, and the athlete returning to the previous stage if symptoms recur with exertion or at rest. 

Parents need to remember that concussion management is not one-size, fits all and that it needs to follow an individualized course tailored to their child's unique situation, as each athlete will recover at a different rate (especially for athletes who have a history of multiple concussions).

However, as a general rule, because a number of studies have shown that younger athletes take longer to fully recover cognitive function than college-aged or professional athletes, a more conservative approach is recommended in deciding when a pediatric and adolescent athlete can return to play, even if they show no symptoms of concussion (1,3), with the Zurich consensus statement stating that it "is appropriate to extend the amount of asymptomatic rest and/or length of the graded exertion in children and adolescents."  Indeed, MomsTEAM expert sports concussion neuropsychologist, Rosemarie Scolaro Moser, Ph.D., recommends in her book, Ahead of the Game: The Parents' Guide to Youth Sport Concusson (8) that children and teens be held at least three weeks before returning to sports. 

9.  Further testing/management. It used to be that concussions were "graded" based on severity, with the concussion grade, the number of concussion suffered, and whether the athlete suffered a loss of consciousness or amnesia determining return to play. Over the last decade, however, concussion grading scales and one-size fits all return to play guidelines have been abandoned in favor of a much more individualized approach. 

The most recent consensus of experts (1) calls for consideration of so-called "modifying factors," the presence of any of which may suggest the need for more sophisticated concussion management strategies,  such as examination by a specialist, more sophisticated testing, and a longer recovery time.  These factors include:

• Lingering symptoms. In most cases, obvious symptoms of concussions clear within a week (4). The presence of post-concussion signs or symptoms lasting more than 7-10 days, or symptoms that recur with exercise, suggest a more serious concussion;
• Prolonged LOC or amnesia.  An athlete who experiences concussive convulsions or prolonged loss of consciousness (LOC) (one minute or more) or amnesia at the time of injury should be treated more conservatively (although a 2013 study (9) suggests that amnesia is not a risk factor for prolonged recovery from concussion);
• Multiple concussion history.  If the athlete has suffered one or more concussive events in the past, especially where the injuries appear to be recurring with progressively less impact force (e.g. a minor blow) or takes longer to recover after each successive concussion, a longer recovery time, or even a recommendation against returning that season or to that sport in the future may be warranted; and
• Other neurological disorders present.  A concussed athlete with learning disorders and/or attention deficit hyperactivity (ADHD) may require different concussion management that takes these conditions into account.

10.  Trust your instincts. Be as involved in the management of your child's concussion as your instincts tell you to be. Don't be afraid to ask your child how he is feeling, or take him to his pediatrician or a specialist if you suspect something is wrong or you notice a change in his/her personality (he is solemn or unusually subdued), appetite (eating more or less than usual), sleep patterns, or that he is, for lack of a better word, "off."  Remember: you know your child better than anyone.  Because there is a lot medical science does not know about concussions, a common sense approach makes - in a word - sense.  

As Dr. Robert Cantu observes in his 2012 book, Concussion and Our Kids  (6), while parents shouldn't attempt to diagnose concussions - that's the job for physicians trained to manage head trauma - that "doesn't excuse moms and dads from the important job of studying  children for signs."  He recommends using "every tool in the parental toolbox," including a series of simple tests that can be given at home:

• short-term memory: A common concussion symptom is a deficit in short-term memory, which can be easily tested by a parent posing a series of questions about recent events, or giving a child a list of unrelated words such as objects or colors and then asking the child to repeat the list back immediately and again in three or four minutes. 
• balance: Poor balance is common among concussed athletes.  Can your child stand firm with their feet together, in heel-to-toe tandem position, and on one foot, eyes open and then closed; with hands on hips, eyes open and then closed? 
• open-ended questions about how he is feeling: As Dr. Cantu correctly observes, "it's a question that occurs so naturally to a parent that it hardly needs to be recommended."  But, in the case of concussion, answers to questions like "'Are you having trouble with memory? Have you noticed issues with concentration? Is your homework taking longer? Is doing homework causing a headache that it wouldn't normally? When you study for longer periods, does the headache get worse?'" may suggest that there is either no need for further evaluation (because the child "sails through the evaluation without a sign of a deficit") or raise serious concern (a question about yesterday's game, for instance, stumps your child, and they struggle to keep their balance with eyes closed).  Dr. Cantu's view is that "a child should be seen [by a concussion specialist] if he is trying as hard as he can yet struggles to complete cognitive or balance tests." 

"[P]arents should be acutely aware of [concussion] symptoms, potential differences between girls and boys, and alert coaches and healthcare workers to behavioral changes," advises Susan A. Saliba, PhD, PT, ATC, an Assistant Professor at the Curry School of Education; Physical Medicine and Rehabilitation at the University of Virginia, and the co-author of a 2010 study on concussions among high school athletes (5).   

"Parents have the ability to observe the athlete longer and can perceive changes that may affect the outcome.  Any lethargy, continued headache, or change in behavior or affect can be concussion symptoms, especially if agitation or difficulty in concentrating are present.  Many times the parent cannot identify a specific symptom, but should nevertheless alert someone that the athlete is 'not him or herself.' Early return to play during this time presents the most danger," she says.   

An athlete's school and coaches should maintain regular contact with his or her parents to update them on their progress.

For the most comprehensive, up-to-date concussion information on the Internet, click here. 

Brooke de Lench is Founder and Publisher of MomsTeam.com, author of Home Team Advantage: The Critical Role of Mothers in Youth Sports and the Producer and Director of the high school football concussion documentary, The Smartest Team.^TM 

Join MomsTeam on Facebook for tips and youth sports news and follow MomsTeam on Twitter @momsteam. 

Sources:

1. McCrory P, et. al. Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013: 47:250-258.

2. Sport Concussion Assessment Tool 3, Br J Sports Med 2013;47:259.

3. Halstead, M, Walter, K. "Clinical Report - Sport-Related Concussion in Children and Adolescents" Pediatrics. 2010;126(3):597-615.

4. Meehan W, d'Hemecourt P, Comstock D, "High School Concussions in the 2008-2009 Academic Year: Mechanism, Symptoms, and Management" Am. J. Sports. Med. 2010; 38(12): 2405-2409 (accessed December 2, 2010 at http://ajs.sagepub.com/content/38/12/2405.abstract?etoc).

5. Frommer L, Gurka K, Cross K, Ingersoll C, Comstock R.D., Saliba S. "Sex Differences in Concussion Symptoms of High School Athletes" Journal Ath. Training 2011; 46(1):000-000.

6. Cantu, R., Hyman, M. Concussions and Our Kids (Houghton Mifflen Harcourt 2012). 

7. Child-SCAT 3.  Br J Sports Med 2013;47:263. 

8. Moser R. Ahead of the Game: The Parents' Guide to Youth Sports Concussion (Dartmouth College Press 2012), p. 102.

9. Meehan W, Straccioloni A, Elbin R, Collins M. Symptom Severity Predicts Prolonged Recovery after Sport-Related Concussion, but Age and Amnesia Do Not. J Pediatrics 2013;DOI 10.1016/j.jpeds.2013.03.012.