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Children and Concussion: Return-to-Play Guidelines Welcomed by Parents, Coaches

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Written by Tara Leonard

Healthy Living - Healthy Living

SANTA CRUZ (December, 2010) – When Johanna Epps' daughter got a concussion while playing soccer at a San Jose tournament, the Santa Cruz mother was understandably worried. Adding to her stress was a lack of clarity about when it was safe for 16-year-old Helena to return to play. Because Helena had lost consciousness, she was diagnosed at a nearby emergency room. Nonetheless, "she wanted to play later that day," Epps recalled. "And the hospital staff wasn't specific about how long she should wait. They told her she should 'give it some time,' but I think it was less than a week before she was back at practice."
There have been many recent studies, surveys, and news articles on head injuries. Yet like many parents, Epps was not aware of return-to-play guidelines for young concussed athletes. The September edition of the journal Pediatrics spells them out, giving parents, coaches and healthcare providers an important tool in determining when it's safe for concussed players to get back in the game.
Concussion can be caused by a direct blow to the head, face or neck, or less frequently, by a blow directed elsewhere on the body with significant force transmitted to the head. The result is mild traumatic brain injury, affecting memory, judgment, speech and coordination. However, common misconceptions about concussion can interfere with appropriate diagnosis and treatment.
"There are still a lot of people who think if a kid gets his bell rung and seems OK, he can play the same day," said Dr. Greg Whitley, a sports medicine specialist and emergency room medical director at Dominican Hospital "We know better now. There's a lot of evidence that the brain can have long-lasting effects from concussion. It's really important to let the brain heal before we send them back in."
Scott Hamill, certified athletic trainer for Soquel High School has a plan in place to deal with concussions. He uses the IMPACT concussion management tool to get a baseline measurement of his athletes' cognitive ability, memory and reaction time before they ever get injured. "We test every one of our football athletes before the season starts," he said. "Then if they're concussed, we can compare their current values to the baseline measurements."
"I'm at every football game, home and away," Hamill said. "You watch for the hard hits. You watch the player get up. You watch him the next few plays."
If a player does show signs of concussion, Hamill uses the Sports Concussion Assessment Tool or SCAT2, a standardized method of evaluating athletes on symptoms including headache, nausea, dizziness, blurred vision, confusion and balance problems. Those who show signs of concussion are recommended for further evaluation by a medical professional.
"If he's concussed, he doesn't return until we've put him through the return-to-play progression," Hamill explained. "They have to meet or exceed their previous measurement before they can take the field."
Return-to-Play Protocol
The return-to-play protocol recommend by the American Academy of Pediatrics progresses in a step-wise fashion beginning with (1) complete physical and cognitive rest. Once the athlete has stopped showing any symptoms, he or she can progress to (2) light aerobic activity. Provided symptoms don't return, activity increases to (3) sport-specific exercises without head impact, (4) more complex non-contact drills, (5) full-contact practice and, finally, (6) normal game play. Each step should take at least 24 hours. If the symptoms return, it indicates inadequate recovery, and the athlete should wait an additional 24 hours before attempting the previous step again. Symptoms generally resolve within a week to ten days, but athletes with persistent symptoms should be reevaluated by a doctor.
"What's new about this protocol is that you tailor the return to play to the child's symptoms," Whitley explained. "That wasn't always the case."
Dr. Jim Bennett of Capitola Pediatrics agrees. "You really have to respect the step-wise, gradual increase in activity rather than a one-size-fits-all time frame," Bennett said. He has seen patients with classic concussion symptoms rest a day or two and then jump right back into normal activities. "Clearly the general public doesn't understand the step-wise return. We really need to educate parents about this."
“Kids are different than grown-ups,” Bennett continued. “In most illnesses, children tend to recover more quickly than their adult counterparts. But in concussion it’s just the opposite, probably because they’re neuro-developmentally less mature. They seem to need longer recovery time compared with college-aged or professional athletes."
Potential Long-Term Complications
One reason return-to-play guidelines are so critical is that the long-term effects of concussions in children can be considerable. Post-concussion syndrome is defined in the Diagnostic and Statistical Manual of Mental Disorders as “Three months’ duration of three or more of the following symptoms: fatigue; disordered sleep; headache; dizziness; irritability or aggressiveness; anxiety or depression; personality changes; and/or apathy.”
Children are also more susceptible than adults to a rare but potentially deadly condition called Second-Impact Syndrome. This occurs when a child who has sustained a head injury experiences a second head injury before the initial symptoms have disappeared. The result is uncontrolled brain swelling and death. According to the journal Pediatrics, “There is no question that pediatric and adolescent athletes seem to be at the highest risk of this rare condition, because all reported cases are of athletes younger than 20 years.”
“Second-impact syndrome is extremely rare and controversial,” said Whitley. “However, that’s part of the worry about sending kids back in too soon.”
More common are athletes who sustain a series of concussions over time. Studies have shown that athletes with three or more concussions are more likely to have numerous post-concussive symptoms, including amnesia and confusion.
“The more concussions you have, the less well you do on intelligence testing,” Whitley said. “You may even be predisposed to mental illness later in life.”
So What's a Parent to Do?
Don't panic, but know the risks associated with your child's chosen sport.  Among high school sports, football has the highest reported concussion rate. The journal Pediatrics puts it at .47 to 1.03 injuries per 1,000 athletes, followed by girls' soccer (.36), boys' lacrosse (.28 to .34), boys' soccer (.22) and girls' basketball (.21). (Reliable data are not available for individual sports such as skateboarding, snowboarding or mountain biking.)
Second, make sure your child wears appropriate headgear and follows the rules of the game. "We've come a long way in football in terms of tackling technique," said Hamill. "Make sure your kid's not hitting with the top of his head. The point of impact should be his shoulder, the front of his body, or his hands. The rule is see what you're hitting."
Third, err on the side of caution when deciding when a concussed athlete should return to play. When in doubt, sit the child out.
Finally, educate others. "We treat concussion very differently now than when we played sports," Whitley said. "Parents should expect that coaches understand the seriousness of concussion and act accordingly."
As for Epps, she's relieved to have an assessment tool that puts parents, coaches and doctors on the same page. "Of course, athletes just want to play," she said. "This information will be really helpful in determining when it's physically safe for them to do so."