The term mild traumatic brain injury (TBI) is used interchangeably with the term concussion. A mild TBI or concussion is a disruption in the function of the brain as a result of a forceful blow to the head, either direct or indirect. This disturbance of brain function is typically not detected with a normal CT scan or MRI. A concussion results in a set of physical, cognitive emotional and/or sleep-related symptoms and often does not involve a loss of consciousness. Duration of symptoms is highly variable and may last from several minutes to days, weeks, months, or even longer in some cases.
A complete evaluation is important to determine the effects of the concussion and to develop an appropriate treatment plan. This will also be an important tool in deciding when the child is ready to return to normal activities including school, social activities and sports.
How common are concussions?
Concussions are probably more common than we know because they often go unrecognized. It is estimated that each year more than three million children sustain a traumatic brain injury, 80 to 90 percent of which are mild. Some of the more common causes of a mild TBI/concussion include:
Pedestrian-motor vehicle accidents
Sports and recreation activities
Although we used to think that about 300,000 people in the United States sustained sports and recreation-related mild TBI/concussions every year, new estimates now indicate that up to 3.8 million people sustain a concussion each year. Most of these mild TBIs are not treated in a hospital or emergency department. Concussions can occur in any sport but have higher frequencies in the collision/contact sports such as:
What are the signs and symptoms, and how do I recognize a possible concussion?
The biggest problem in treating concussions is the lack of recognition and identification. This problem has been labeled the “silent epidemic.” People are often not familiar with the signs and symptoms of a concussion. Contrary to popular belief, the child does not have to lose consciousness to sustain a concussion. In fact, nine out of ten children do not lose consciousness.
To help recognize a concussion you should watch for the following two things in the child or adolescent:
A forceful blow to the head or body that results in rapid movement of the head
Any change in their behavior, thinking, or physical functioning (See the signs and symptoms of concussion listed in the table below)
Recognizing a Possible Concussion
BY THE CHILD/ADOLESCENT
Appears dazed or stunned
Appears dazed or stunned Headache
Is confused about what they are doing
Forgets plays or current activities
Balance problems or dizziness
Is unsure of recent events (game, score, or opponent)
Double or fuzzy vision
Sensitivity to light or noise
Answers questions slowly
Feeling sluggish or slowed down
Feeling foggy or groggy
Shows behavior or personality changes- irritability, more emotional
Concentration or memory problems
Can’t recall events before or after the hit or blow
The child or adolescent did not lose consciousness after a blow to the head. Does he or she have a concussion?
Yes, it is possible that the athlete did have a concussion. Loss of consciousness is not necessary for the diagnosis. It is only one sign of this injury and occurs in 10% of injuries or less. Most importantly watch for any of the signs and symptoms – if any of them are present, you should suspect a concussion.
If a parent or coach suspects a concussion, should the child/adolescent go to the Emergency Room or to go to their pediatrician?
In most cases, check with the pediatrician first if at all possible. Emergency Department (ED) personnel can evaluate your child’s neurological (brain) functions to determine the severity of injury and whether additional tests are needed. Not all concussions require emergency care, but the ED can provide a diagnosis and rule out more severe injury.
The pediatrician may want to schedule an appointment to examine the child or adolescent, send them to the Emergency Room, or choose to refer them to a concussion specialist. However, he or she should be taken emergency care if any of the following danger signs are demonstrated:
Appropriate evaluation and treatment is the key to a safe outcome. The symptoms of a concussion can cause problems when the child returns to school, home or community activities. The concussion evaluation assesses possible cognitive, behavioral or physical symptoms to assist in planning during recovery.
During an evaluation, a child or adolescent will be given tests of attention, memory and speed. Test results are used to determine any needed interventions, as well as plan for return to school, sports, and other physical activities. Often children or adolescents with concussions experience prolonged symptoms, which interfere with their daily activities and sports. Clinicians will evaluate the child and help put a plan together that provides the necessary support for school, work, and return to play decisions.
The child or athlete’s CT scan was normal. Does that mean he or she did not have a concussion?
No. CT scans are not used to diagnose a concussion. They can detect bleeding and swelling in the brain, usually signs of a more significant brain injury. A concussion, or mild traumatic brain injury, results in changes in the chemical and physiological properties of the brain that cannot be seen on a CT scan, so most scans are normal after concussion.
After a concussion, when can I expect the child/adolescent to be better?
The time to recovery from a concussion can range widely, from days to weeks or months. It can be difficult to predict the length of recovery for any one person, especially right after the injury occurs. Parents and other professionals can help athletes minimize their recovery time by maximizing rest and reducing the student-athlete’s physical and cognitive (thinking) activity. These activities can put too much strain on the brain.
There are certain factors that may prolong recovery such as a prolonged loss of consciousness or amnesia (memory loss) for the event, repeat concussion before the first injury has healed, and multiple concussions that occur within a short period of time (within several months). Children or adolescents who have been diagnosed with ADHD, learning disabilities, headaches, sleep problems, or emotional problems can also take longer to recover.
What is the treatment for a concussion?
What can I do to help my child/adolescent recover?
There are two important things to do after a concussion to help child or adolescent. First, make sure that the he or she does not participate in any higher risk activities where they could take additional blows to the head. You may need to increase supervision (particular for younger children) to make sure that they are not too active or put themselves in situations where they could be re-injured. Second, to help the brain heal as quickly as possible, cognitive (thinking) and physical rest are also very important. Parents should monitor the child or adolescent for symptoms regularly – at least several times per day.
As symptoms lessen, it is OK to increase activity as long as symptoms do not worsen. It is important to remember; too much activity done too early may delay recovery. Only allow a higher risk activity (practices, scrimmages, and competition) after a qualified health care professional evaluates and clears your child to do so.
Just like all injuries or illnesses, every concussion must be managed and treated individually. The evaluation of the child or adolescent is important in determining the treatment for that person.
REST and minimizing over-exertion (physical, mental) is the key to recovery
Guidelines for managing concussions have been developed within the sports context due to the need for safe return to play in order to minimize the risk for re-injury. These guidelines are also relevant to the return of the child or teenager to any activity involving increased physical or mental exertion.
The 2001 International Concussion in Sport (CIS) Group recommended the following new guidelines for returning athletes to play:
Emphasis on careful on-field evaluation
Restriction of play for symptomatic athletes: No athlete with any symptoms is to return to play.
Once the athlete no longer has symptoms and their cognitive function has returned to normal, a graduated approach should be used in returning them to play, guided by careful individualized assessment and monitoring of post-concussive symptoms and neurocognitive functioning at each successive stage of activity, with the following progression:
How do I know when the child/adolescent has fully recovered?
The individual has fully recovered from a concussion when the his or her functioning has returned to normal – as determined by an appropriate healthcare professional trained in concussion evaluation and management. This means they have no concussion symptoms at rest or with normal cognitive and physical activity, and their cognitive and balance performance is normal. Children who have not fully recovered should not return to contact sports or put themselves in situations where they could be re-injured. When in doubt, sit them out!
Are there different levels (grades) of concussions?
There are different levels of severity of a concussion. Some professionals may use concussions grading systems to describe the early aspects of the injury. Grading systems, though, are not directly related to the length of time it will take to recover. The best way to judge the severity of the injury is based on how long it takes for the individual to recover, although other factors may be involved. Do not automatically assume that a more “severe” grade of a concussion given at the time of the injury will translate necessarily to a longer recovery time.
There is a lot of attention being paid to concussions in television and other media. There are several reasons for this increased attention, including better methods to identify the injury and a better scientific understanding of this brain injury and its risks. Increased awareness is always positive, although we continue to need to understand more about the injury.
Can the child or adolescent still attend sports practices after a concussion, either to observer or participate?
Under no circumstances should a child participate in practice unless evaluated and cleared by a health care professional with training and experience in concussion management. Although it is important for the athlete to support their team and demonstrate their dedication, getting enough rest is much more important than sitting through practices, at least early in recovery. By staying home and resting, rather than going to watch practice, the athlete may in fact recover faster and be able to join the team sooner than if they had stayed to watch practice! It is also safer for a child who is tired and has slow reaction time to steer clear of sports settings. While rare, we have heard stories of children being hit in the head by a stray ball while sitting on the sidelines!
When can the athlete come back to practice and games?
The decision to allow return to sports practices or games is to be made by an appropriate healthcare professional trained in concussion evaluation and management. That professional will help to direct the athlete’s return to sports participation. An athlete who still has symptoms (at rest or with activity) or who is not performing at their baseline cognitively should NEVER return to a practice or game where there is a possibility they could be re-injured. The athlete can return to practice only after having successfully completed a graduated return to play program under the supervision of a trained healthcare provider, and received written clearance. This program can take between 3-7 days (after resolution of symptoms and cognitive effects) to complete and sometimes longer, depending on the injury.
Other important facts to know
The developing brain appears to be more vulnerable to trauma
High school athletes may take longer to recover from concussion than college athletes
Amnesia (loss of memory at the time of injury), not loss of consciousness, appears to be the main indicator of concussion severity and predictor of post-injury deficits.
Even seemingly mild concussions can have significant effects. Many athletes often continue to demonstrate significant problems one week post-injury despite the absence of overt signs or symptoms.
Effects of multiple concussions can be cumulative. Prior concussions, especially if full recovery has not been achieved, may lower the threshold for the next concussion injury and increase symptom severity in subsequent
Continued headaches indicate incomplete recovery. Athletes experiencing headaches one week post-injury are more likely to experience more overall symptoms and perform more poorly on neurocognitive measures than those who do not report headaches.
Premature physical and/or mental exertion, before the brain has fully recovered, can both prolong recovery and worsen outcome of a concussion.