It is not something that any parent wants to happen to their child, but having active children invariably means that they are going to be at risk for a head injury. Whether your child just sustained a concussion or you are getting educated for the future, you can use this blog as a quick reference guide to everything about childhood concussions. In this blog, we are going to discuss the best practices when it comes to treating a child with a concussion and when it is safe for them to return to school and sports, and discuss the long-term implications of having a concussion during adolescence.
A concussion is a type of brain injury that is caused by mechanical forces that are transmitted from the body and/or head into the brain. This force on the brain causes a “shaking” of the brain within the skull and leads to dysfunction of the brain cells, or neurons, after the initial impact.
A concussion is not a structural injury but rather a functional one. There is no actual damage to the brain structures, but there is a reduction in the function of the connections of the brain that leads to the symptoms that we normally associate with head injuries.
The shaking of the brain within the skull cavity leads to an initial over-activation of the neurons, which causes a subsequent energy deficit within the brain that can last for up to 30 days after the initial injury. This lack of energy availability to the cells of the brain reduces the rate and efficiency at which the brain cells can communicate with each other. This is why mental and physical activities can quickly overload the reduced functional capacity of the brain and worsen symptoms.
The good news is once the brain energy levels return to normal, there are no long-term consequences of single mild traumatic brain injuries on brain health and function.
There are 3 main categories of concussion symptoms, and children may experience any combination of symptoms during their recovery process. These categories are physical symptoms, emotional symptoms, and cognitive symptoms.
Physical symptoms include headaches, nausea, vomiting, dizziness and sleep changes.
Emotional changes can include increased irritability, trouble regulating emotions, anxiety, depression, and other emotional symptoms.
Cognitive symptoms include feeling “in a fog,” feeling overly tired or sluggish, having difficulty concentrating or remembering, and confusion.
Having any one of the clinical manifestations of pediatric concussions after a blow to the head is enough evidence to diagnose a concussion confidently.
The vast majority of concussions, when treated correctly, do not have any long-term impacts on cognitive function, but they should still be taken seriously. Multiple concussions within a short period of time (30 days) increase the risk of long-term and possibly permanent brain damage because of the stacking effect of head injuries.
Generally, a single mild traumatic brain injury will recover on its own and is not something to be overly worried about, but sustaining a second (or more) brain injury while still recovering from the first puts your child at risk of developing more serious intracranial injury and potentially life-threatening conditions. This is why it is of utmost importance that anyone, but especially a child, is removed from sport and play when a concussion is suspected because it is always better to be on the safe side rather than putting your child’s long-term health at risk. We like the pneumonic, “When in doubt, sit out.”
Even if that means they miss a few practices, games, or days in the classroom. If there is a suspected concussion, your child should be removed from school and sports activities until brain healing has been completed.
One important note is that symptom resolution may occur before healing in the brain has fully completed, so it is essential that your child follows all of the steps of returning to sport and school in the correct order to ensure that they are safe to return to their normal activities.
There are 2 main things that you want to do if your child sustains a traumatic brain injury before anything else:
The single biggest worry after a child sustains a head injury is sustaining an additional head injury in short succession. The second head injury can cause something called second impact syndrome and this can be a serious and life-threatening condition. It stems from the fact that the brain is in an already vulnerable state after the first traumatic brain injury, so even a mild head injury before the brain has had a chance to heal can lead to worsening of symptoms and a significant increase in the risk of long- term brain injury. Therefore, if a child has sustained a mild traumatic brain injury, they need to be removed from all activities that increase their risk of sustaining a second head impact. This includes sports, unsupervised recess, gym class, etc. Remember, it is not just contact sports that can lead to concussions! The second most common mechanism of injury is a fall where the head makes contact with the ground, which can happen during seemingly “safe” activities.
Research has shown people who see a healthcare provider within the first 7 days after sustaining a concussion recover on average 20 days faster than those who don’t seek care until after 14 days. This is important because they can rule out more serious health conditions, provide education on the best practices for concussion management, and help guide you through rehabilitation and return your child to school and/or sports as early as possible. They are an invaluable resource for answering your questions, easing you and your child’s concerns, and guiding your child to resume their normal activities.
Healthcare providers should include your primary care provider and any other healthcare professional trained in concussion rehabilitation, including physiotherapists, chiropractors, occupational therapists, nurse practitioners, athletic therapists, etc.
There are no specific tests that need to be conducted to diagnose a concussion. As mentioned earlier, a concussion is a functional problem in the brain rather than a structural one. Therefore, imaging tests such as CT scans and MRIs are not going to show any structural brain damage after a concussion.
If there is a serious mechanism of injury (fall from a height >10ft, high-speed car accident, etc.), or there are severe symptoms such as those listed below, there may be a recommendation for a CT scan or MRI, but that is to check for diagnoses in addition to the concussion such as bleeding within the brain or skull fractures.
After your child has sustained a head injury, there are some signs that you should be attentive to that would indicate that you should seek immediate medical attention as they are signs of a more severe head injury.
These include:
You should monitor for these symptoms for at least the first 48 hours after a suspected concussion injury.
In short: (probably) yes.
In the vast majority of cases, concussions will heal on their own, given time. How long the healing process takes depends on the individual but you can generally expect that concussions are fully healed between 7-30 days. However, this notion has been recently challenged by a study looking at uncomplicated concussion patients who simply received educational materials at discharge from the emergency department. At 6 months post-injury, 56% of these individuals still had incomplete recovery that was significantly interfering with their lives (e.g., work, social life, sport, etc…). (1)
As mentioned previously, one of the most important things that you can do for your child after they have sustained a mild traumatic brain injury is to get them assessed by a concussion-trained healthcare provider, as research has shown people who are assessed in the first 7 days after a head injury return to sport and school significantly faster than those who don’t. (2)
For a more in-depth look at the common treatments for concussions, please see our other blog post here.
Overall, treatment for concussions is based on giving the brain the time and environment to complete the healing process on its own. This means taking a break from sports and school, limiting activities at home to those that do not significantly worsen symptoms (i.e., symptom-limited activity), and not engaging in any activities that increase the risk of additional head injuries.
In terms of speeding the recovery process, there are many things that you can do to help the process along. This includes helping your child move through a step-wise return-to-learn (RTL) and return-to-play (RTP) process. This includes ensuring that they get lots of overnight sleep, and adequate hydration, providing them with a well-balanced diet that is low in refined carbohydrates and high in omega 3’s, and being a source of support and optimism to maintain their mental health through the process. Napping during the day is fine if your child feels like they need to, but napping too frequently can disrupt overnight REM sleep. Therefore, try to limit napping to 1 nap per day, for 30 minutes or less, and before 3pm.
Your healthcare provider may also suggest adding some individualized rehabilitation exercises that can help improve eye, ear, and neck function if they were also affected by the injury. For example, one study showed that early prescribed sub-symptom aerobic exercise can reduce the risk of developing persistent concussion symptoms (PCS) by 48% in adolescents! (3)
Whether or not your child can still attend school is largely up to your child and how they feel while they are at school. Because concussions vary widely in their symptom profile and severity, it is going to vary from child to child how much mental stimulation they can handle during the day, and this is going to change over time. A concussion-trained healthcare provider can help walk you through this process, and an in-depth overview of the return-to-school protocol can be found here.
Your child should generally start with 48 hours of recovery time at home, where physical and mental loads are minimal. Then, they can progress through the following stages: light cognitive activity at home, school-like activities at home, part-time school at a light load, part-time at school with a moderate load, full-time at school with a moderate load, and then back to full-time.
To progress to the next stage, your child must have no worsening of symptoms in the previous stage and complete each stage for at least 1 full day. In the best case scenario, there is a minimum 7-day period between the time of the concussion and when your child can return to full-time regular school activities. If you progress to a stage with increased symptoms, return to the previous stage for at least 24 hours. Your concussion specialist will be able to guide you through this process with more individualized detail.
If your child is experiencing concussion symptoms, or has been diagnosed with a concussion, they should not attend their regular sporting activities and should follow the return to sport protocol. This is because symptoms can resolve before complete healing has occurred, and your child may still be at an increased risk if they sustained a second head injury. However, this does not mean they cannot do any physical activity or other non-contact sports-related physical activity, depending on where they are in their recovery process. A concussion-trained healthcare provider can help walk you through this process, and you an in-depth overview of the return-to-sport protocol can be found here.
In general, your child should start with 24-48 hours of recovery time at home, where physical and mental loads are symptom-limited and at a minimum. Then, they can progress through the following stages: light physical activity at home, sport-specific exercise with no contact, non-contact practice, full contact practice, and following clearance by an appropriate healthcare provider, back to full sport participation. Your healthcare provider can help walk you through the stages and determine the correct level of exercise for their given condition using specialized tests such as the Buffalo-treadmill test or Gapski-Goodman Test.
To progress to the next stage, your child must have no worsening of symptoms in the previous stage and complete each stage for at least 1 full day. In the best case scenario, there is a minimum 7-day period between the time of the concussion and when your child can return to full-time regular sports activities. If you progress to a stage with an increase in symptoms, return to the previous stage for a minimum of 24 hours. However, the best-case scenario of 7 days is dangerous due to the metabolic energy deficit of concussion. (4) Recently, NFL quarterback Tua Tagavailoa is an excellent example of the risk of returning too early, where he experienced a second concussion the game after returning. The average RTP time across sports is 21 days (5). Athletes, parents, and coaches must know that “symptom recovery (especially at rest)” does not equate to clinical recovery and “safe to return to sport.”
A thorough RTP process that looks at symptoms, physical, and neurocognitive metrics at rest and with dynamic exertion is important for safe decision-making.
This is a very common myth and is actually not true. In fact, less than 10% of concussions result in a loss of consciousness (6) Not only can you sustain a concussion without losing consciousness, you don’t even need to be hit in the head. Any impact to the head or body that is hard enough to “shake” the brain within the skull cavity is capable of causing a concussion, whether someone loses consciousness or not.
A “bell-ringer” is an outdated term that was used to describe a condition that was actually a concussion. Just because there are only a few symptoms after a collision doesn’t mean there was no impact on the brain. There are only two criteria that need to be met to diagnose a concussion:
That means that if your child got hit and had ANY symptoms, even if it is only mild dizziness, that is a suspected concussion, and they should be removed from play. Letting them stay in the practice or game puts them at a significantly higher risk of developing a more serious brain injury that can have permanent consequences.
As mentioned above, the mechanism of injury for a concussion is less about where the impact occurs and more about how much force the head, neck, and brain feel. Concussions are acceleration-deceleration injuries of the brain, so any impact that quickly changes the direction of force the brain feels is enough to cause injury. The most common mechanism of injury that does not involve a blow to the head is a whiplash-type injury from getting hit in the body when moving in the opposite direction to the impact or landing hard or awkwardly when falling to the playing surface.
It is an understandable sentiment of every parent to want to check and make sure that their child is okay frequently, but disrupting your child’s sleep after they have sustained a concussion is likely not going to help them recover any faster. The current recommendation is to ensure your child doesn’t sleep in the first 3 hours after the injury. After that, it is prudent to check on them every 3-4 hours, though you do not need to wake them unless there is a concern about a decline in their status (e.g., changes in breathing). (7,8). Sleep is an essential part of the concussion recovery process, and we want to encourage our children to sleep as much as they feel they need to aid the recovery process. The first night of delaying sleep and monitoring your child is to ensure that you are not missing any red flags that would warrant an ER visit.
If you are concerned that your child may have a more serious underlying condition, you should get them seen by a concussion-trained healthcare provider who can help rule out some more sinister conditions that can accompany head injuries.
While you do want to decrease the amount of physical and mental activity of your child immediately following head injuries, they do not not need to be in a completely dark and quiet room, and they do not need to remain there until their symptoms completely resolve. In fact, removing all stimulation can actually prolong concussion recovery and increase the severity of their symptoms when they try to return to their normal activities like school and sports.
You want your child to have “relative rest,” which means resting as much as they need to limit their symptoms. However, their symptoms do not need to be zero, and they can complete light mental and physical activities as long as it does not significantly worsen their symptoms. We generally guide patients to use the 2/10 rule, where your child can do any activity (within the limits of your current stage of recovery) that does not increase their symptoms more than a 2/10 from baseline. So, for example, if your child had a 2/10 headache after waking up and having breakfast, they could do some light reading until their headache reaches a 45/10, and then they should rest and let their symptoms settle. This rule was affirmed in the latest Amsterdam Concussion Consensus defines “mild” symptom flares as no more than a 2pt increase on a 10pt scale that lasts no longer than 1hr. If symptoms are >2pts or last >60min, we should alter the activity moving forward. We aim to keep symptom flares mild during recovery as we move towards normal activity. (9)
Sport-related concussions can occur in any sport, even individual sports where there is no contact between participants. While it is more common in high-contact sports, research has shown that the second most common cause of concussion in sports, after player-to-player contact, is player-to-surface contact. Therefore, even in individual sports, if there is a risk of falling and contacting a hard playing surface, there is still a risk of concussion. In addition, being hit in the head by a ball, such as in soccer, volleyball, or basketball, is another common mechanism of injury.
There are many different associations and organizations that have a wealth of knowledge on managing concussions, returning to school and sports, and what symptoms to look out for. They also provide you with referral networks to find healthcare professionals that are trained in treating mild traumatic brain injuries.
https://completeconcussions.com/
Complete Concussions is a global network of trained and experienced concussion clinicians and clinics that can provide various concussion services, including concussion treatment and baseline testing, and they have a wealth of information through their online blog.
Parachute Canada strives to create a safer Canada by preventing serious and fatal injuries through evidence-based solutions that advocate and educate. They have many guidelines on best practices for concussion management.
CanChild is a non-profit research and educational centre located within the School of Rehabilitation Science at McMaster University in Hamilton, Ontario, Canada. Our research focuses on improving the lives of children with a variety of developmental conditions and their families over the lifecourse.
https://www.cdc.gov/headsup/index.html
Heads Up is an initiative by the CDC to provide evidence-based research and education on concussions and concussion management. They have various resources for everyone from coaches to parents to athletes and school teachers.
https://www.concussioninsport.gov.au/
Concussion in Sport Australia is a trusted and evidence backed resource for the management of sports-related concussion for all Australians, regardless of the sport, location or level of participation. The Concussion in Sport Position Statement is a collaboration between the Australian Institute of Sport, the Australian Medical Association, the Australasian College of Sport and Exercise Physicians, and Sports Medicine Australia.
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