Caring for Concussions - Protecting a Child’s Body When It Can’t Protect Itself

As children head back to school – and back to sports – the risk of concussions rises. Concussions can pose even greater risks in children, whose brains are still growing and developing. Arkansas Children’s pediatric sports medicine specialists treat all types of sports injuries, including head injuries that limit the body’s ability to protect itself. Dr. Lauren Poindexter, a non-surgical sports medicine physician at Arkansas Children’s Northwest (ACNW), answered questions about concussions.

What’s a simple description of the physical causes of a concussion?

Simply put, a concussion is brain dysfunction after a head injury, but with normal brain imaging. A CT scan [x-ray images] or MRI [magnetic and radio wave images] of the brain will look normal, but the patient has very real symptoms. This is due to a change in how the brain sends signals. The injury to the head can be from a moving object, or the head can be moving and quickly come to a stop, like hitting the ground while playing soccer or with whiplash in a car accident. The energy absorbed by the brain causes changes in how the nerves function. There is a necessary healing process, much like with broken bones, but there isn't a picture that shows the injury like an x-ray.

What are the differences between concussions in children versus adults?

There is limited data on concussions in children under the age of 12. We know the child's brain is still developing, specifically the pre-frontal cortex. This region of the brain is in the front of the head. It is responsible for calculating risk, making informed decisions, self-regulation and social behavior. It's slow to develop and susceptible to injury. Adolescents already struggle with making important decisions all day long. Injuring this critical region makes life even more difficult. Parents, guardians, teachers, and healthcare professionals may need to step in to help an adolescent make good decisions after a concussion.

Some children - even teenagers - may not know what words to use to describe how they're feeling. It's hard to explain to someone that you have an "invisible injury."
Children might be afraid to speak up due to fear of appearing whiny, or don’t want to be held back from exciting things like the next competition or upcoming dance.

What are the symptoms of a concussion? And how are concussions diagnosed?

There are many different concussion symptoms. Each head injury, and the person experiencing it, is unique. No two concussions are alike, so we look for observable signs of concussion.

Example of concussion signs:

• We see a teenager slow to get off the ground and stumble around after an elbow to the head on the basketball court.
• They might vomit or have difficulty speaking in complete sentences.
• They have trouble remembering who the visiting team is and cannot concentrate on the coach's instructions.
• Reflexes are slowed.

Symptoms (what a person tells us they are experiencing) are wide-ranging.

Here is an example:

• A cheerleader accidentally gets hit in the head when trying to catch the flyer (the one tossed into the air). Her concussion symptoms may include being easily angered, blurred vision after reading on the computer, headache by the end of the school day, dizziness when quickly standing up from a chair and difficulty falling asleep. Some children say they feel "out of it" or there's "pressure in their head." Fatigue, headache and neck pain are common.
  

What advice would you give coaches if they suspect a concussion?

Pull them. You're not wrong for doing so, and according to Arkansas law and the Arkansas Activities Association, any athlete suspected of having a head injury should be removed from play immediately and not return that day. I understand that everyone wants to play. I'm an athlete, and I wanted to play despite my concussion - but the priority is our children's current and future health. Healthy kids make the best athletes, students, friends and citizens. We all do our part to help them have fun and protect their heads. We pull kids from competition at the first suspicion of head injury because their body is less able to protect itself. Even subtle decreases in reflexes and alertness can mean the child cannot quickly get out of the way of an incoming tackle or brace themselves for a collision with an opposing player. Another head injury shortly after the first can cause severe changes in the brain, even death. This is called second impact syndrome. We absolutely want to prevent it.

Studies show that children and adults who continue to play on the same day as a head injury take longer to recover, almost double the time. It's just not worth 15 extra minutes of game time for an additional month of recovery or risking severe injury. We want sports to be fun and safe at the same time. Requiring an injured child to sit out the rest of the game is always the safer option if concerned about a head injury. Severe symptoms, of course, demand that the child go to the emergency room. They should not stay on the sidelines in the case of severe symptoms.

Concussions are sometimes associated with football because players bang their heads against the ground or other players more frequently. What other sports or activities commonly lead to concussions?

Football does carry the greatest risk of head injury. Soccer, hockey, basketball, and lacrosse are other sports where we commonly see concussions. When comparing boys to girls in the same sport, some research indicates girls are more likely to sustain a concussion.

Arkansas Children's uses teams of specialists to care for young athletes, including athletic trainers. Athletic trainers are often on the sidelines during practice and games. They may be the first to see a potential concussion. What is the athletic trainer's role in identifying and treating concussions?

Athletic trainers play a huge role in identifying and managing concussions, but not all schools have them on site. A certified athletic trainer is skilled at looking for signs of possible head injury and removing the athlete from play for an in-depth sideline evaluation. Once a health care professional has evaluated the athlete, they can either go back to play (if it’s not a concussion) or enter the return-to-play protocol. An athletic trainer can take the child through the return-to play-protocol. [The Arkansas Activities Association developed specific guidelines for different sports that schools can use to slowly and safely reintroduce an athlete back into their sport.]

What is the young athlete’s role in self-assessing a concussion?

Being honest with their symptoms! If you don't feel well, tell someone. I teach my patients to respect their injuries and respect their bodies. Focus on giving the body what it needs to heal. The better we treat our bodies, the faster we heal, and the faster we can return to running around and doing the things we love!

How are concussions treated, and what is the importance of getting treated?

We treat each concussion uniquely. Children may need some days off from school to rest and then return with modifications to their day. Some children benefit from physical therapy to help with their vision, neck pain and balance problems. The sooner we can identify a concussion, the sooner we can treat it and feel better!

In addition to concussions, the National Institutes of Health (NIH) says chronic traumatic encephalopathy (CTE) is a possible and dangerous outcome of head trauma. How is CTE different from a concussion?

CTE results from tau protein [a protein that helps stabilize neurons in the brain] building up in the brain in a unique pattern. It’s associated with accelerated “aging” of the brain. We only know it’s there after someone has died, and scientists can examine the brain tissue. Because of this, we don’t know how many people have CTE. The hypothesis is that many obvious concussions or unrecognized “sub-concussions” can lead to tau deposits in this unique pattern. Abnormal behaviors and moods, memory loss, and confusion are thought to be associated with CTE and many other brain diseases. There are still a lot of unknowns about the link between childhood head injury and CTE. Boston University does a lot of research in this area, so I recommend this site.

What else do you think it’s important for young athletes and their caregivers to know about concussions?

You get one brain in this life - use it well! We are here to help with your injury recovery and get you feeling better as soon as possible. We understand how frustrating having an "invisible injury" can be, and we'll walk you through the treatment steps. Our goal is to safely return as many young athletes as possible to their prior sport and activity level.