by Kathie Sutin
High school athletes may joke about getting their “bell rung” when they knock heads. But any blow to the head—even when the athlete is wearing a helmet—should be treated seriously, say guidelines released on August 30,2010 by the American Academy of Pediatrics (AAP).
“Getting dinged or getting your bell rung is a concussion,” the study’s lead author, Mark E. Halstead, M.D., told Parent USA City.
And young athletes are especially vulnerable because their brains are still developing, he said.
The treatment that AAP stipulates is unequivocal. Children and teens should not return to their sport until all their symptoms have cleared up completely, no matter how long this takes.
St. Louis Children’s Hospital and assistant professor of orthopaedic surgery and of pediatrics and director of Washington University in St. Louis’ Sports Concussion Program. The guidelines, which Dr. Halstead co-authored with Kevin D. Walter, M.D., and the AAP’s Council on Sports Medicine and Fitness, are published in full in the September 2010 issue of Pediatrics, the AAP’s official journal.Dr. Halstead is a sports medicine physician at
A new study whose results are reported in the same issue cites evidence that even athletes in middle and elementary school may increasingly be suffering from concussions.
Emergency room visits for concussions among young athletes playing team sports have more than doubled over a 10-year period, and 40 percent of these injuries have been sustained by children ages 8 to 13.
Whether concussions are on the rise, or awareness of concussions has grown so that parents bring their kids to the emergency room more often, or it’s a combination of both, concussions in young athletes are serious business.
MRIs, other tests don’t reveal concussions
What exactly is a concussion?
Experts in the field from around the world meeting at three international congresses on the topic couldn’t come to complete agreement, said Jay Noffsinger, M.D., professor of pediatrics at St. Louis University School of Medicine and director of pediatric sports medicine at SSM Cardinal Glennon Children's Medical Center.
“The problem with concussions is that we really don’t know what we’re talking about because there aren’t any ‘no question about it’ physical findings, and there certainly aren’t any lab or radiologic findings,” Dr. Noffsinger told Parent USA City. “That’s part of the definition—that there’s supposed to be no evidence of any structural problem.
A concussion, he said, can be described as “some kind of transient abnormality in brain function, not accompanied by structural abnormality, which usually improves and resolves over time.”
Dr. Halstead defines a concussion as an injury to the brain caused by a hit to the head or somewhere else on the body that causes a reflexive impulse or rotational force to the head without causing structural damage.
While there are multiple definitions of concussions, all include the fact that there are no structural abnormalities from the injury, Dr. Noffsinger said.
“If you did a CT or MRI of the brain, or any other test in the book, they should all end up being normal—because if they’re not normal, the diagnosis wouldn’t be a concussion,” he said. “It would be something else.”
Parents often want tests when it’s suspected their child has a concussion, but tests only disclose structural problems “like the skull breaks or there’s bleeding that goes on inside the brain,” Dr. Halstead said. “That’s not a concussion. That’s a totally different problem in the head.”
Concussions are diagnosed by their symptoms, not with tests, Dr. Halstead said.
The person may have a headache or be sick to their stomach, sensitive to light or sound, dizzy and confused, he said. They may not know where they are. They may have problems with remembering events before and after their injury. Some may have trouble with balance. Symptoms can be almost immediate or can be delayed for several hours, Dr. Halstead said.
Unconsciousness not always a symptom
A common misconception is that a person needs to be knocked out or lose consciousness to have a concussion. But that’s not the case, Dr. Halstead said.
In fact, less than 10 percent of people who suffer concussions lose consciousness.
And you don’t even need to be hit in the head to get a concussion, he added.
“A kid can get a concussion just from getting hit somewhere else in the body, and then their head really quickly shakes back and forth,” he said. “It doesn’t have to be a specific blow to the head. That’s why protective gear by itself is not as effective.”
Concussions inevitable in contact sports
Data show that high school athletes are involved in 3-4 million reported sports-related concussions each year, Dr. Halstead said. The numbers are actually believed to be higher because concussions are not always reported.
“There’s no way of preventing a concussion in sports short of not participating in that sport,” Dr. Halstead said. “Sports have an inherent risk for injuries, and concussion happens to be one of those things.”
Athletes can get concussions by being hit with balls, other equipment, or other players. Basketball players can receive concussions “just falling and landing on a hardwood floor,” he said.
Even the use of protective equipment can’t protect against concussions.
“As concussions go, there’s not a single protective gear that prevents someone from getting a concussion,” Dr. Halstead said.
Although helmets can’t prevent concussions, Dr. Halstead said, “Helmets are very good for reducing skull fractures and significant bleeding in the brain.” In fact, he said, helmets are so good at reducing those kinds of injuries that doctors don’t see those injuries among athletes very much any more. Athletes should continue to wear helmets because they do protect the wearer from other serious head injuries.
Concussion—or something else?
The reason for concern in the initial hours after the injury is that the head injury may turn out to be something else, Dr. Noffsinger said.
He cited the case several years ago when he was the team physician for a high school football player who seemed to have a concussion at an away game.
When the boy’s symptoms did not improve in 20 minutes, Dr. Noffsinger sent him to the local hospital, where a CT scan revealed nothing. Although the boy was doing better, he still had symptoms, so the doctor told the coaches he needed to be free of symptoms for a week before being physically active.
Back home, the boy spent a night in the hospital for observation and his family doctor cleared him. “By Wednesday of the next week, he was in an intensive care unit with a subdural hematoma,” Dr. Noffsinger said. “He never should have been allowed to go back in (to play) because he was never without symptoms.” The boy apparently continued to suffer a headache for days after his injury, he said.
“If your headache doesn’t go away, you’re not okay,” Dr. Noffsinger said. “Remember he did have a CT scan. I wonder retrospectively if someone went back and looked at it carefully, they might have seen evidence of the beginning of a bleed.”
The deadly “second impact syndrome”
While in this case Dr. Noffsinger believes the problem was from the injury days earlier, there is a danger of a catastrophic event called “second injury syndrome” or “second impact syndrome,” he said. This follows a significant initial blow.
“Let’s say you were out for a week but didn’t follow the advice and still did have some symptoms,” he said. “Then you get another hit but it this one is very insignificant, like a bump that doesn’t seem that bad at all. Your brain suddenly swells and you collapse and die.”
In such cases, the autonomic nervous system controlling dilatation and constriction goes awry, he said. “You get a little bump and the blood vessels for no particular reason decide to dilate. When they dilate, they take up more space and you get increased pressure in your head.”
Treatment: Stop playing until fully healed
While experts may not agree on the definition of a concussion, they agree on what should be done when one occurs.
“There’s one definite (thing) that everybody will agree with—‘thou shalt never send somebody back into their physical activity while they still have symptoms,’” Dr. Noffsinger said.
“There’s no place any more for going back into the game after 15 minutes.”
Getting bonked on the head means sitting out the action for at least the rest of the day, Dr. Halstead said—even if there are no immediate symptoms.
“Athletes should never return to the same game and they shouldn’t play at all that day,” he said.
Dr. Noffsinger recommends that parenting styles be proactive here—that parents take a close look at the way their child’s coach pays attention to the team members’ wellbeing and reacts to head injuries. “When the coach is more interested in winning than the health and wellbeing of the athletes, that would not be a good situation,” he said.
Sometimes it may take days, weeks, or even months until it’s safe to go back. The AAP’s guidelines recommend a graded return to physical activity over five to six days as ideal.
“They should not return to sports until all their symptoms have gone away,” Dr. Halstead said. “They should feel normal both without doing physical activity and with doing physical activity.
“Sometimes they feel fine when they’re not getting their heart rate going, but when they exercise again, their symptoms come back. That would mean they haven’t cleared up their concussion yet.”
As the AAP guidelines insist, “The phrase, ‘When in doubt, sit them out!’ is paramount in the management of a pediatric or adolescent concussion.”
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Kathie Sutin is an award-winning freelance journalist based in St. Louis, Missouri. She specializes in writing about medical issues, travel, parenting, education, business, food and people. She has three children.
© Football and soccer photos by Jim Boardman | Dreamstime.com ● Photo of Dr. Halstead courtesy of Washington University in St. Louis ● © Headache photo by Margreet De Groot | Dreamstime.com ● © Basketball photo by Cynthia Farmer | Dreamstime.com