Concussion Management, Over 70% of Doctors Got It Wrong – Part 4Written By: Leah Concannon, MD; Stanley Herring, MD
A Soccer Player With a Headache: Best Practices: When Can a Child Return to Play?
When Can a Child Return to Play?
Jamie’s parents are concerned about her apparent delayed recovery, because they have seen some of her teammates return to games within a few days. They ask you about what they can expect and when Jamie can get back to soccer.
Recovery Time: What Factors Matter?
It is important to recognize that although most concussions resolve within 7-10 days, recovery may take longer in children and adolescents.[2,9] Several factors may increase the risk for prolonged recovery. A history of multiple concussions, repeated concussions occurring in close proximity to one another, or a history of prior prolonged recovery are all risk factors for prolonged symptoms. Recurrent concussions are more likely to result in LOC, take longer for symptoms to resolve and therefore increased time to return to play, and result in medical disqualification or retirement from contact sports.
Personal or family history of migraines, depression or anxiety, ADHD, and learning disabilities can also predispose to prolonged recovery. Some psychological or psychiatric conditions, especially depression, can produce symptoms that may mimic a concussion and make evaluation more challenging.
Jamie has a personal history of ADHD and anxiety, as well as a family history of migraines. In addition, she continued playing with symptoms immediately after the concussion, and she has not yet had a trial of true physical rest. All of these can lead to prolonged symptoms.
Risk for Another Concussion
In the acute period after a concussion, physical and relative cognitive rest is recommended. Physical rest is important to decrease the risk for incurring another head injury while the athlete is still symptomatic. When repeated concussions occur in the same season, almost 92% of them occur within 10 days of the first concussion, perhaps indicating that this is a vulnerable time for the brain during its recovery.
Second-impact syndrome occurs when a patient sustains a second head injury while still symptomatic from a prior head injury. Within minutes, there is a precipitous neurologic decline associated with diffuse cerebral edema and increased intracranial pressure, resulting in death or severe disability. A study of catastrophic head injuries in US football revealed that 71% of these injuries occurred in the same season as a previous head injury, and 39% of the injured athletes were playing with residual symptoms.
A more recent study evaluated sports-related sudden death over the past 30 years and found 17 cases of second-impact syndrome. All of these athletes were playing with continued symptoms from a previous concussion.These catastrophic injuries and deaths are preventable by the simple act of holding youth athletes out from play until they are asymptomatic.
How Much Rest Is Enough?
Excessive physical and cognitive exertion is thought to have the potential to prolong recovery. This therefore necessitates that children rest not only from participation in competitive sport, but also from recreational sports and physical education class.
The management of cognitive rest is more challenging and often requires an individualized approach. Student-athletes are students first, and every effort should be made for them to attend school as they are able. Modified schedules may be necessary for some patients, as well as informal or formal accommodations, including an individualized education program or 504 plan for patients with severely prolonged symptoms. Informal accommodations can include decreased amounts of homework, delayed due dates for projects and papers, and increased time for testing. These accommodations can often be accomplished with a simple letter from the healthcare professional caring for the child, with help in implementation from the school counselor as needed. It is important to inform patients that cognitive rest also mandates reduced screen time, including watching television, using a computer and cell phone, texting, and playing video games, if any of these exacerbate symptoms.
The Return-to-Play Decision
The return-to-play process does not begin until the athlete is asymptomatic or has returned to his or her preinjury symptom status. Patients with a preexisting headache or mood disorder will require more careful evaluation to determine when they are truly at their baseline before return to play is allowed. There should be no same-day return to play in any athlete suspected of having a concussion in either a practice session or a game, even if their initial symptoms have resolved.[2,5] Education of coaches, parents, athletes, and officials on the importance of this statement is essential to help prevent devastating consequences, including second-impact syndrome.
Once the athlete’s status has returned to baseline, he or she can begin a monitored and graduated return-to-play program. This begins with simple aerobic activity, progressing through sport-specific activity, resistance training, noncontact training, and then contact training before full participation. These stages will take at least several days to complete, and in general, young athletes will not return to a competition or game situation in less than 1 week to 10 days, and may often require longer.
Return of symptoms at any stage requires cessation of activity and reevaluation by a healthcare practitioner. The CDC provides an example of a return-to-play protocol.
As many as 1.6 million to 3.8 million sports related TBI’s, occur each year. This number may be low given the significant number of unreported cases. Furthermore, only 8%-19.2% of TBI in sports involve loss of consciousness. (Langlois, Rutland-Brown, & Wald, 2006) Therefore, over 80% of brain injuries are lower grade without loss of consciousness. These lower grade concussions often go undetected as result of their subtle signs and the tendency of athletes to disregard their symptoms as minor or inconsequential.
Concussion awareness is improving. Thankfully, new technology like the CAPS force plate from Vestibular Technologies, may provide a very fast and valid assessment tool for detecting lower grade concussions. Sophisticated force plate technology, like the CAPS unit, can identify postural stability deficits lasting approximately 72 hours following sport-related concussion. “It appears that postural stability testing provides a useful tool for objectively assessing the motor domain of neurologic functioning and should be considered a reliable and valid addition to the assessment of athletes suffering from concussion…” (Paul McCrory, 2009).
From a prevention standpoint the vestibular system is directly responsible for joint stability. Poor integration from vestibular system equals unstable joints which results in greater likelihood of injury. When you consider things from a functional standpoint it is not an either or situation but a continuum. The vestibular system can always be strengthened just like a muscle can always be stronger. David Burns, ND DC DACNB FACFN