By Doctor Q Pediatrics
March 29, 2016
Category: Neurology
Tags: head injury   sports   concussions  

Within the last few years, Neurologists and Pediatricians have begun to measure the ability of children, post-concussion to return to school and work.  Routinely, children need clearance from healthcare providers to resume normal activities.  Below is a summary of the signs and symptoms of concussion and the requirements that must be met for children to resume sports.  Although acute symptoms may no longer be present, a lenghty protocol must be followed to clear our young athletes.  

Over the past decade, general knowledge of and concern about concussion has expanded. When the head is hit, the brain may be shaken around inside the skull.  If there is a brief loss of consciousness, or even an alteration of consciousnss, then a concussion has occurred.  Symptoms of concussion include poor concentration, instability, fatigue, depression, memory problems, headaches, anxiety, trouble thinking, dizziness, blurry vision, and  sensitivity to light.

According to the American Academy of Pediatrics, the current standard of care for returning to sports following a suspected concussion centers around the consensus statement commonly known as the Zurich Guidelines.

These were developed by the Concussion in Sport Group, whose members are international concussion experts from the fields of sports medicine, neurology, neurosurgery, neuropsychology and various other fields involved in the care of sport-related concussions.  The protocol requires athletes to become asymptomatic from their head injury before attempting any return. 

The best current method for quantifying concussion symptoms is to use a symptom checklist.  The most widely used for professionsals is the Sideline Concussion Assessment Tool (SCAT3) and for the untrained, the Sport Concussion Recognition Tool  http://bjsm.bmj.com/content/47/5/267.full.pdf .   This is a good tool to have on the sideline at each game.

An additional method of assessing whether an athlete is at "baseline" is to gather additional information about symptoms or congnitive performance from patents, teachers, athletic trainers, and neuropsychologists before allowing an athlete to return to sport.  In additon to the SCAT 3, an athlete with a head injury ideally should undergo balance and functional testing, the results of which, are compared to preinjury performance.  Commercial products, such as computerized neurocognitive tests and vision tests, claim to aid in detecting concussion, but their routine use for making return to play decisions is controversioal.  Athletes at the high school level are having pre concussion testing routinely in Central Florida so that head injured students can be compared to their baseling congnitive function.

Once the head-injured athlete has returned to his symptom free physical and neuopsychological baseline, clinicians should initate a step by step return to play process.  Each step consists of an increasing level of activity and requires a minimum of 24 hours before proceeding to the next step.

Stage 0: No activity: physical and cognitive rest.  

Stage 1:  Light aerobic exercise: walking swimming, no weightlifting.

Stage 2:  Sport-specific exercise: Noncontact sporting activities, skating, running to >70% max heart rate.  

Stage 3:  Noncontact training drills: Progression to more complex training drills, passing in football, shooting in basketball, may start weightlifting.  

Stage 4:  Full contact practice:  Following medical clearance, may participate in normal training activities.

Stage 5:  Return to normal play: Normal game play.

Patients whose symptoms return while trying to advance though the steps should contact their doctors, rest for at least 24 hours, and return to the last successfully completed step before trying once again to proceed. 

Another recent development is the concept of "return to learn" following concussion.  Cognitive challenges may lead to increased concussive symptoms.  Much like the progrssive steps employed with returning to sports, return to learn protocols have been developed and emphasize a gradual progression of cognitive abilities based on the presence of symptoms, with increasingly more complex tasks.

Lastly, in continued attempts to avoid concussion, the AAP recently adopted a zero tolerance policy for headfirst hits in football.  According to them, teaching young athletes to tackle with their heads up and enforcing rules against illegal headrirst hits can reduce the risks of concussions in youth football.  

For more information about policy as it relates to head injury and concussion symptoms and management go to  http://www.nflhealthplaybook.com/ and http://www.cdc.gov/headsup/index.html

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