This is a post authored by J. Forrest Bennett, ARNP who works in the rehabilitation department and on the concussion team led by Dr Samuel Browd (@DrBrowd), medical director of Seattle Children’s Sports Concussion Program. Forrest has had the unique experience to care for children after concussions in the immediate time after injury and in weeks to months thereafter when symptoms are prolonged. His wisdom can help us all understand the opportunity we have to improve children’s recovery after a head injury. In this post he explains what happens to the brain cells during a concussion, what constitutes risk for concussions, and the 5 things all of us need to know about concussions. I certainly know more after reading this and suspect you will too. Please leave comments or questions if you have them. Click here to read the first post in this series.
What Happens During A Concussion?
A concussion is a complex process affecting the brain, brought on by biomechanical forces (like a blow to the head, car crash, etc.) The force is transmitted to the head and can result in usually short-lived symptoms such as headaches, brief loss of consciousness, nausea, and/or dizziness. These symptoms are believed to be due to a temporary shift in the neurotransmitters (chemicals that allow cells to communicate) in the brain, resulting in a mismatch where the brain needs more energy but receives decreased blood flow to the brain temporarily. This mismatch in blood flow is believed to last up to 10 days following an injury and helps explain the symptoms associated with a time-limited injury such as a concussion.
Unfortunately this also explains why diagnosing and managing concussions can be vexing. Unlike a broken bone, we do not have validated imagining or blood tests that enable definitive diagnosis. The best practice of diagnosing concussion currently relies on obtaining a detailed history and physical following an injury. Depending on the severity of the injury and initial presentation, a sideline assessment should performed to look for common post-concussive symptoms. If the initial injury is more severe one may need to be evaluated in the emergency department and imaging may be obtained to help rule out a more severe injury. Each traumatic brain injury is unique, and should be treated with respect. There is nothing more heart breaking than a traumatic injury being improperly respected and identified, leading to a delay in care and permanent deficits.
It can be challenging to determine which concussions are mild, severe and which may progress. Ultimately the goal is to prevent injuries, screen for potential head injuries when appropriate and diagnose and treat injuries in a timely fashion to limit their severity.
How To Prevent Head Injuries
Prevention comes down to taking control of what you can influence (and identifying what you can’t) to help reduce your chances of getting injured. Be aware of what sports are high risk. Playing with appropriate protective equipment, preparing for matches and adhering to the rules of the game can be great ways to reduce your individual risk. Also acknowledge that some sports have been termed “contact” sports by the American Academy of Pediatrics (AAP) thus they could be riskier. While the AAP classification is imperfect it helps quantify the risk of sport to help parents focus on prevention of head injuries, while still promoting a healthy and active lifestyle.
- The highest risk sports for school-age girls are soccer, lacrosse, and basketball.
- The highest risk sports for school-age boys are football, ice hockey, and lacrosse.
The growing awareness of the seriousness of these injuries (especially in football) has attracted efforts to improve the research and understanding of concussions and mild traumatic brain injuries. While we continue to improve our understanding of concussions, our work in clinic and at the hospital centers around applying the current state of science to manage prolonged post-concussive symptoms and prevent more severe injury. The Concussion program at Seattle Children’s Hospital is just one of many speciality concussion clinics nationwide that have been developed in response to the growing recognition of concussions related to sports as well as trauma such as motor vehicle crashes.
5 Things Everyone Should Know About Concussions And Mild Traumatic Brain Injuries
Ask professionals for help
- If you think your child is concussed go to their coach or athletic trainer and allow them to do perform a proper sideline assessment. Getting an immediate sense of how your child is doing after impact is the single most important step to protect from worsening sports related head injuries.
When in doubt – sit it out
- If there is a loss of consciousness seek immediate sideline assessment. The 2014 World Cup raised a lot of questions about when to allow a player back in a match after clearly sustaining a concussion. If you are concussed your decision making, balance and motor coordination are all potentially compromised. If you are truly interested in helping your child’s team, don’t place your child at undue risk; help children and teens allow another player take their place until they are evaluated.
- You can sustain a concussion without a loss of consciousness. If your child is playing in a match or a game and they take a hit to the head (head-to-head contact, head-to-ground contact, etc.) and you are concerned they don’t feel right get the attention of the coach or athletic trainer.
Rest ALONE is not always the answer
- While 80% of concussions get better in the first 2-3 weeks, prolonged symptoms are not uncommon. As a provider in specialty care I frequently see the 20% whom have not recovered within the first 2-3 weeks. If you have concerns have your child reevaluated.
- Frequently providers will use either the Standardized Concussion Assessment tool- 3rd edition (SCAT 3) or a modified version of the symptom checklist to track symptoms and help determine when you become symptom free.
- Interventions including therapies, medications, and activity modulation that can help kids shorten the duration of their symptoms that do not respond to rest alone.
- UPDATE 2/11/2015: Both my colleagues and I, in the Seattle Concussion Group, have field allot of questions regarding the benefits of rest since the release of this recent study which was widely circulated in the news including the New York Times. Studies like this are phenomenal as they assess the effectiveness of the current interventions for concussion and help establish evidenced based practice. The study reinforces my belief that concussion vary widely from individual to individual and that a cookbook approach of set windows for rest is ineffective without taking into account the individuals symptoms, as well as their medical and social history.
Rest and activity modulation following concussion still have a place in managing post-concussive symptoms. What this research does for me is reinforce the need for children\adolescents to seek appropriate evaluation by a trained medical professional when they are hurt, and to escalate care to a concussion clinic for further evaluation if your symptoms linger. Hopefully we will see more excellent studies such as this to further our understanding of what interventions can shorten both the length and duration of these injuries.
Remember to REAP benefits of what we know about concussions
- Rest: Current studies suggest up to 7-10 days of complete rest can be therapeutic. This initial rest is believed to help conserve energy and avoid triggering increased symptoms related to the energy mismatch.
- Evaluate: Evaluation and monitoring of post-concussive symptoms by a medical professional is important to ensure that that your child’s injury is appropriately managed and they don’t return to play too soon.
- Activate: A graduated reentry to academics as well as physical activity is usually beneficial someone with a concussion.
- Prevent: Once your child recovers from their injury you need to be aware of your relative risk factors and actively reduce your risks so that you can enjoy your sports or recreational activities long term. It is easier to sustain a 2nd concussion than it is the first.
- Be aware of what concussions are, and why they should be taken seriously.
- There are a number of excellent resources online with additional information such as HEADSTRONG, the Brain Injury Alliance (BIA), and the CDC.
Clearly what we do to advocate for our children before and after head injuries can really change their experience and symptoms. Acting fast, taking symptoms seriously after injury and getting children the mental and physical rest they need may really change their lives.
Learn more about the Seattle Sports Concussion Program at Seattle Children’s Hospital.