About the blog:
Tri Fit for Life is a website to provide information and inspiration to people of all ages and abilities who are interested in maintaining a healthy and fit lifestyle. Topics will range from general health & fitness to endurance sports such as triathlon.
About the author:
Megan Long, M.D. is a Pediatrician and Ironman triathlete with an interest in promoting fitness and wellness for all ages.
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
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
Does my child need a CT or a cat scan? An
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.
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:
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
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
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 video games
-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
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
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.