Thursday, October 31, 2013

Traumatic Brain Injury: Concussions, Recovery, and Return to Learn/Play

So, high school football season is coming to a close and professional football season is just gearing up, and I love sports and sports safety (obviously), so I thought a great topic for discussion this time of year would be the topic of concussion. It's not just a football injury, folks! I'm currently doing an elective in Sports Medicine, and I have to tell you, we are seeing 6-8 of these injuries a day! Anyone who experiences head trauma can end up with a concussion. This means everyone is at risk, but the athletes playing football, hockey, lacrosse, and soccer are particularly at risk because they get their heads hit (by other players and by the ball) often. Even horseback riders are at risk because they can fall and hit their heads.

What is a concussion?

To explain what a concussion is, I think we first have to start with the brain. And you
know how much I love the brain and what it can do, which is why I recommend helmets for preventing Traumatic Brain Injury. The brain is special. It is a magical organ that contains neurons and blood vessels and is in charge of our entire body and what it can do. Some have likened it to the soul because so much depends on the brain: emotion, personality, intelligence, learning, memory. It's amazing, right? But what happens when it gets damaged? 

Injury to the brain can be present in 3 main forms:  1. hemorrhage, 2. fracture, 3. concussion. Those are a bunch of fancy medical words, but basically, when you have injury to your brain, you can have an intracranial bleed or hemorrhage, you can break part of your skull bone (fracture), or you can have a good old-fashioned bruise (concussion).

What's the mechanism?

A concussion is in fact a form of Traumatic Brain Injury. It’s an injury to the brain that changes a person’s behavior, thinking, or physical functioning. This injury can be caused by forceful blow to the head or body that causes rapid movement of the head. The brain is encased by a skull, the bones of your head, and when quick movement of the head occurs, the brain moves around within the skull and can get bruised, resulting in a concussion.

Does a helmet protect you? 

No, it actually doesn’t. Not even the new fancy ones that they hoped would help to protect better against concussion. Helmets can protect you against fracture and hemorrhage, but they won’t protect you against a concussion because the mechanism for concussion depends on whether the brain gets knocked around inside the skull, and a helmet does not keep that from happening. Slowing players down or lightening them up so they do not hit each other with as much force (That guy Newton said Force = mass x acceleration, remember? He was a smart guy.) would help lessen the risk concussion. But until we can get our athletes to weigh less, or until we can get them to slow down (Probably unlikely, right?), then we need to know how to handle concussions.

Does my child need a CT or a cat scan?  An MRI?

This is an important question, and it is one that depends on clinical judgment and your child’s symptoms. If there is prolonged loss of consciousness after head trauma, if your child is not acting normally, if he or she is vomiting, if there is something concerning on his or her neurological exam, these are all things that the physician evaluating your child will consider when deciding if a CT or MRI is necessary. Please keep in mind that a CT is a lot of radiation, way more radiation than a simple x-ray, and in pediatrics, we try very hard not to perform a CT or cat scan unless it is absolutely necessary. Most emergency room departments will observe the child for 6-8 hours following the head trauma if there are no focal abnormalities on the neurological exam. An MRI has less radiation than a CT, but it is not a test that can be done emergently. Once your child is out of the first window of danger after concussion, those first 6-8 hours of observation and into the next 24 hours, if he or she is still having the symptoms that we will discuss later in this blog, it does not mean that he or she needs a CT or an MRI. It means that your child has a concussion and needs to be followed clinically by pediatrician or concussion specialist to manage his or her symptoms. An imaging test at that point is not what is needed because the diagnosis can be made clinically based on symptoms.

Do I need to wake my child up to make sure he is not confused after head trauma?

Pediatricians actually recommend that you do NOT do this. This used to be what was recommended, waking the athlete up every few hours and asking them questions to see if they knew where they were, who they were, what day it was, etc. But some confusion after a concussion is possible, and let’s be honest, if someone wakes you up at 3am, do you really know what day it is and where you are, even if you haven’t had head trauma? Some of us are heavier sleepers than others. However, if your child is vomiting, if your child’s pain is worsening, or if she is not acting like herself, then you need to bring her back to the emergency room for additional evaluation, and your ER physician should review these important signs with you before you leave the ER after your first evaluation.

Symptoms of Concussion:

Neck pain
Sensitivity to Light
Sensitivity to Sound
Feeling “in a fog”
Fatigue – needing 12-13 hours of sleep per night, needing naps throughout the day
Difficulty concentrating 
Difficulty remembering
Changes in behavior

Your doctor should be evaluating these symptoms at each visit and whether or not they are getting worse. This is sometimes part of something called Impact Testing which evaluates overall how well you are recovering from concussion; it can help determine when you are ready to start gradually reincorporating some of these activities that use your brain.

What's the treatment for concussion?

The AAP just released a statement on concussion and has based its report primarily on expert opinion as well as adaptation from a concussion management program developed at the Rocky Mountain Hospital for Children, Center for Concussion in Denver, Colorado. 

Most kids recover from concussion in 3 weeks. However, some athletes may take 3 months to recover, depending on history of previous concussion, how severe their symptoms were immediately following concussion, and the progression thereafter. If symptoms are severe, some students may need to stay home from school after a concussion.

The hardest part about having enough symptoms that your child needs to stay home from school is that the reason your child is home is because he or she needs cognitive rest. Cognitive rest is rest for your brain, and resting for your brain is a lot of nothing! This is really hard for most people, but especially for kids. What does rest mean for concussion recoverers? No brain stimulation of any kind. Remember that even while you are sleeping, your brain is still active.
When awake, your brain is constantly working to process the world around you and perform whatever tasks you are doing. So, when you have a concussion, even eating, talking on the phone, texting, watching TV--all things we swear kids do without any thought being used--are activities that work your brain. For this reason, some kids cannot go back to school immediately following a concussion. Depending on symptoms, you may need to stay home and not even play video games (!) which we know to any school-aged kid or teenager seems to defeat the purpose of being home from school, but your brain really does need to rest and avoid stimulation.

So, rest for a concussion is different than rest for your femur fracture or your wrist fracture where you can just not use that appendage. Your brain is an appendage that you use for everything. When your doctor tells you to rest your brain, they really mean:

-no TV
-no video games
-no reading
-no school
-no homework
-no physical activities
-no social activities, i.e. no trick-or-treating for some folks if they are having too many symptoms, no sleepovers because concussion sufferers really need actual sleep

 (Man, concussions really suck!)

This can be so hard for teachers, parents, and coaches to understand, which is why, if you or your child suffers from a concussion, you really need to be followed closely by your doctor, preferably by a Sports Medicine doctor who has experience helping kids recover from concussions. This is a step-wise process, and every concussion, just like every child and every athlete, is different. Some kids who are having few symptoms can return to school on a modified schedule right away, and some need to stay home from school and avoid reading, TV, video games, etc. because all of these things, whether you realize it or not, are actually using a lot of your brain and can be very taxing for someone recovering from brain trauma. Remember, you have a bruise in your brain, and all bruises take time to heal. Healing requires a step-wise progression to returning to all of the activities you did prior to your concussion, not just playing your sport, and it depends on your symptoms and the recommendations of your doctor.

Return to brain-stimulating activities

Your doctor will recommend a schedule for you to return to some of these activities after the first few days of rest, and how fast you return depends again on your symptoms. I guess this goes without saying, but during your REST, you also need to SLEEP. A lot. 12 hours a night is not unreasonable to recover, and a nap after any sort of return to cognitive activity is also recommended. Some kids are even sensitive to light and sound and have to be in a dark quiet room even while awake during the day. If your child is better, and your doctor recommends trying 20 minutes of reading or video games, a nap in the afternoon to recover from that new brain stimulation is warranted. If these activities are going well with no worsening of symptoms, then tutoring at home can be set up in 30-minute to 1-hour intervals, again with naps and rest in between. And once returning to school, partial days and coming home to take a nap is also necessary for recovery.

Return to School or "Return to Learn"

Coaches, parents, and athletes are all often very focused on what they feel is the most important part of recovery from a concussion-Return to Play. However, we are focusing more now on something that is equally if not more important because it is essential to a child's development and also an important step towards Return to Play, and that is cognitive rest and Return to School or "Return to Learn" as it is now being called by some specialists in the field.

When recovering from a concussion, the brain has trouble with tasks that are very important for school and learning. For example, thinking, concentrating, remembering, and processing and retaining new information can be halted to various degrees depending on the severity of the brain trauma. If symptoms are mild or tolerable, the student/athlete may return to school on a half-days schedule with special accommodation. No non-core classes and no activities with the potential for loud noises or for getting hit again – so no gym, no band, no recess. Your child should eat lunch in the nurse’s office or in a quiet place like the library to avoid loud noises and stimulation during the first part of return to school.

Return to Play 
Troy Aikman of the Dallas Cowboys had
10 concussions in 12 NFL seasons.

Most schools now have their own protocols for return to playing sports after concussion. Your doctor will be able to tell you when you are ready for return to play protocol. You should be going to school for full days without symptoms and maybe doing some walks or slight aerobic activity of short duration also without symptoms before you progress to Return to Play. Most of these protocols involve a gradual return to physical activity with close monitoring of symptoms. A plan might be something like: Day 1: bike 20 minutes; Day 2: bike and run; Day 3: non-contact practice with team; Day 4: contact practice with team; Day 5: if no symptoms, ready to return to play. If at any point, the athlete is experiencing symptoms such as headache, dizziness, etc., he or she needs to rest and re-start the protocol when no longer having symptoms.

When to see a specialist:
Your general pediatrician should be able to follow most athletes with first concussions. However, if symptoms are very severe, or if it is taking longer than 3 weeks to recover, seeing a concussion specialist (This usually falls under the category of Primary Care Sports Medicine) is warranted. Also see a specialist if the athlete has had multiple concussions, particularly within a few months or less of each other. IMPACT testing is now done at many schools, which is a baseline test to determine cognitive abilities prior to concussion and then also to follow athletes during recovery from concussion. A specialist will also do these tests to evaluate your child and can send he or she for vestibular therapy (a subset of physical therapy) and/or occupational therapy if these are needed to recover.

Resources for Parents:
From the AAP on slow return to school:

For Schools/Teachers:
Fact sheet by the CDC for Return to Learn strategies:

For pediatricians:
School daze. Students recovering from a concussion often need academic, environmental adjustments. Jessica Pupillo. AAP News 2013; 34:4; doi:10.1542/aapnews.20133411-4.

For the college athlete:
The NCAA, as do pediatricians and the medical community, recognizes concussion as traumatic brain injury. More on concussions from the NCAA:

The AAP is putting out a policy statement in the November issue of Pediatrics regarding Sports Medicine  practices for secondary schools and colleges, so stay tuned.