Practical Dad

A PracticalDad Look at Concussions

Guns don't kill people, 90 mph free kicks kill people.

  Poster on door of Middle's bedroom

It was during the second half of a mid-season Division II college soccer game with the ball rolling free in the visiting team's penalty box.  Both Diane,a forward, and a defending fullback raced from opposite directions towards the ball and the defender reached it in stride about two steps ahead of Diane.  The fullback cleared the ball with a strong kick and it traveled perhaps five feet before it collided solidly with Diane's face, connecting squarely in the forehead.  Diane dropped flat onto her back, propelled torso backwards by an object kicked with sufficient force that it instantly - violently - eliminated all of her own forward momentum.  According to her teammates, the coach was on the field and running towards her as soon as she hit the turf; after several minutes on her back - conscious the entire time - Diane left for both the remainder of the game and the season.  The subsequent diagnosis from the university's medical staff was that Diane suffered a major concussion.

While it isn't a certainty that it will occur, there's a respectable chance that any active kid will suffer a concussion either through organized sports or the simple *boom* of an accident from hard play.  But what exactly is a concussion and what should you expect to see if your child suffers one?  And as a full disclosure, the PracticalDad household has had first-hand experience with the injury.

A concussion is the common term for a brain trauma, a sudden event in which the brain is jarred or shaken severely enough that there's an acute injury to it.  The design of a person's head is - like the rest of the human body - a wonderful bit of engineering.  This crucial organ is housed within the helmet-like skull, but there's actually no contact between the brain and the skull.  Between the brain and the skull is a thin layer of fluid which cushions it from the movements and shocks of everyday activity.  But a concussion can occur when the body undergoes a physical that overwhelms the cushioning capacity of the fluid and the brain is severely shaken or actually comes into contact with the skull itself.  In Diane's case, getting pounded by a 430 gram ball kicked around 60 mph is clearly beyond the body's natural absorption capacity.

We used to call a concussion getting your bell rung and the old treatment was taking a few minutes to clear your head before returning to the practice or game.  But the bright light of publicity that began years ago with the tragedy of former long-time Steelers center Mike Webster and progressing most recently to San Diego's Junior Seau have brought greater awareness to the insidious damage to the brain caused by concussions, especially if they're repetitive.  The long-term toll of concussions is now being given greater attention so that there are improvements both in terms of treatment as well as prevention.  What the medical community is now aware of is that the risk of long-term brain damage rises with a person's number of concussions.

Concussion Rates: Who and How Often?

For all of the attention being focused on football, a male sport, the reality is that females will suffer a significant number of concussions as well.  At the high school level, girls' soccer players reported the next highest number of concussions for any sport after football and girl basketball players suffered concussions at almost the same rate as their male counterparts.  For soccer however, girl players suffered concussions at almost twice the same rate as their male counterparts; it's unclear as to why but the prevailing opinion is that it's primarily physiological as the female heads are lighter - lending credence to the many fathers' thoughts that boys are boneheaded - and have weaker neck muscles to support the head when it's hit.  The other thought is that culture plays a role as boys are taught to "suck it up" while girls are more likely to say when something is wrong.

For a chart of the concussion rates per common youth sports, by gender, see here.

Additional research has shown that the incidence rate for concussion is several times higher for those who have already had a concussion; the fact that there's already been trauma creates a lower threshold for a concussion than if the individual had never had one in the first place.  In Diane's case, this was her third concussion over a three year period.

There are two upshots here.  The first is that your daughter-athlete is as much at risk for a concussion as your son-athlete.  The second is that if your child has already suffered a concussion, there's a lower threshold for suffering another from a head trauma than another child-athlete who has not yet had a concussion.

Concussion's Symptoms and Diagnosis

What makes a concussion difficult to diagnose is that there can be interior damage to the brain even if there's no actual sign of exterior damage to the body, such as a bruise or laceration.  This is compounded by the fact that the interior damage might not be immediately evident; while Diane was visibly groggy in the immediate aftermath of the injury, she never lost consciousness and two decades ago, might even have been allowed to re-enter the game if she appeared to have been able since there doesn't have to be loss of consciousness with a serious concussion.

The symptoms that arise from a concussion can be classified into four different categories.

Thinking/Memory

  • Inability to concentrate
  • Inability to retain new information
  • Inability to think clearly ("fuzziness")
  • event amnesia, i.e. inability to remember what occurred for a period of time around the trauma
  • demonstrably slower thinking time
  • Physical

  • headache
  • impaired vision
  • nausea/vomiting
  • sensitivity to light and noise
  • issues with balance
  • dizziness
  • fatigue
  • Sleep

  • altered sleep pattern from usual
  • inability to fall asleep
  • Emotion and Mood

  • greater irritability and/or anxiety
  • periods of sadness
  • flat aspect to personality for period after the trauma
  • The takeaway for parents with active kids is this: if you child is struck in the head - by a ball or bat (been there on both), a hard impact with wall or ground (been there, too) - then there's the prospect of a concussion.  Because there might not be an immediate sign, it's best to begin the watch for these symptoms and that watch can last for days.  It's not easy and the child's age can make it more difficult, especially if they're younger.  For small children - kindergarten or younger - take it as a sign of possible concussion if he or she is showing signs of a regression in skills that you might have considered already mastered beforehand.

    If you notice any of these, immediately contact your physician.  There are objective cognitive tests that can be performed and don't be surprised if a scan is ordered to ascertain if there's overt damage to the brain, such as bleeding inside the skull.  But even if there's no overt sign on the scan, the cognitive tests can help ascertain if the child has been concussed.  The only objective examination that can help ascertain the severity of the concussion would be if the child had a pre-injury baseline impact test such as used by professional and college sports teams; it might sound far-fetched for a child - actually a teen - but more middle and high schools are having their student athletes undergo them prior to the season's start.  The online test can be performed on youth as young as 11 years of age if they're involved in sports and can be performed at the office of any medical professional which offers it.  In our case, Youngest - a baseball player - took an impact test a year ago at a physical therapy practice which offers the test and the results are now available to serve as a baseline for future reference.  After a concussion was suffered, periodic test re-takings would serve as waypoints on recovery when compared to the original baseline examination. 

    Treatment of Concussions

    There's no overt treatment regimen - physical therapy, medication - for a concussion and the only help is what was once called the tincture of time.  That said, the tincture can be aided by a simple regimen of true rest; this is rest not only from strenuous activity or exercise which might continue to shake the brain, but also rest from the single activity that preoccupies the majority of the waking time of most adolescents, electronics.

    When the brain is concussed, the purpose of the recovery period is to avoid any physical stressors to the brain.  That certainly includes minimal physical activity and more sleep but what most don't realize is that there are other stressors and these include light, noise and the constant input of watching the flickering of any kind of electronic screen.  When I spoke with Diane's father, he commented that he was surprised to find that the treatment regimen for his daughter included as little screen time as possible as the flickering, combined with the constant eye movements, were stressors that aggravated the brain and actually lengthened the recovery period.  Other aspects of the treatment regimen included the wearing of sunglasses and a visored cap when outside to shade the eyes and the absolute minimum of traveling so that she couldn't even attend away games with her team, if only to stand on the sideline.  In other words, she was to avoid any movement and sensory stimuli that typically cause the brain to work.  This treatment regimen was to continue for as long as she had symptoms and in Diane's case, the symptoms continued for a full six weeks before she was finally cleared to return to play and by that point, the season was finished.

    The upshot for parents is this.  What provides the greatest entertainment for youth today - electronic media - is one of the activities that has to be minimized, if not completely avoided, if the kid is going to recover both the most fully and in the shortest time possible.  The small upside is that the kids at greatest risk of concussion are the athletes and are probably on the screens less that the six hour daily average.  Yet the kid will still have to avoid the screens as much as possible for the recovery and the stress in the household will be greatly elevated as parents have to take into account the mood and temperament of a child who not only suffers from concussion symptoms, but can't even find respite in those activities which were previously entertaining.

    A concussion is a frustrating injury for parents.  It requires vigilance from parents to maintain the rest regimen for a full recovery but it cannot be easily judged as to how it's progressing.  Likewise, the child should be kept away from the typical favorite pastimes and the stage will be set for potential conflict between child and parent.  The other issue for parents is that in their youthful sense of invincibility, the kids don't always understand that they're at an increased risk of reinjury when compared to their uninjured peers and many will balk at the notion that they might not be able to play their favorite sport again.

    Comments

    Dr. Cantu also made a very important point about girls scoecr and the neck strength, i.e., the girls necks are too weak to absorb perturbation .strengthen the neck in any sport where ..the neck is on the line .  all levels of football, hockey, scoecr, wrestling, all contact or semi contact sport training should include the 42 muscles that control the neck.

    By Mallick on February 22nd, 2015

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