Parents Play Important Role In Child’s Recovery From Concussion
The subject of sports concussions has been a hot topic in the news for about a decade, but, even after years of coverage, the important role parents play after their kids suffer concussions is often overlooked or misunderstood.
The fact is that an athlete’s parents, along with teachers, coaches, school nurses, psychologists, and athletic trainers play a crucial role in a child’s treatment and recovery from a suspected concussion.
But what, exactly, is the parent’s role? Here’s a 10-point checklist.
1. Regularly and closely monitor athlete immediately after injury.
- While all concussions should be taken seriously, the potential always exists for a life-threatening head injury Because delayed onset of symptoms during the first 24 to 48 hours is possible (and more likely in children), parents – or another responsible adult – should closely and periodically monitor the athlete during this time. Ideally, parents should be provided with information in written form to take home on what to watch for, as is set forth in the SCAT3 and Child-SCAT3.
- Even if an athlete has been removed from a game or practice because of a suspected concussion (as is required by law required by law in every state – at least at the high school level), he or she should not be left unattended or sent to the locker room alone, and should never be allowed to drive home.
- It is a good safety strategy to take away an essential piece of playing equipment to avoid an ‘inadvertent’ return to the game.
- The traditional rule has been to wake up a concussed athlete every 3 to 4 hours during the night to evaluate changes in symptoms and rule out the possibility of an intracranial bleed, such as a subdural hematoma. The new thinking is that there may be more benefit from uninterrupted sleep than frequent wakening, which may make symptoms worse. As a result, waking up your child during the night to check for signs of deteriorating mental status (see #2) is no longer recommended. Indeed, if level of consciousness is a concern, says experts, the athlete should undergo a CT scan or MRI. and observed in a hospital setting. Otherwise, sleep is restorative and your child should be allowed to sleep.
2. Immediate hospitalization if condition deteriorates. If your child experiences any of the following signs of deteriorating mental status, take her to the hospital immediately:
- Has a headache that gets worse and does not go away
- Has persistent or increasing neck pain
- Is very drowsy or can’t be awakened (woken up)
- Can’t recognize people or places
- Has nausea or vomiting
- Behaves unusually, seems confused, or is irritable
- Becomes increasingly restless or agitated
- Experiences convulsions or seizures (arms and legs jerk uncontrollably)
- Has weakness, numbness or tingling in arms, legs or face
- Is unsteady walking or standing
- Has slurred speech
- Has one pupil which is larger than the other
- Loses consciousness (even briefly)
- Will not stop crying/cannot be consoled
- Has difficulty understanding speech or directions, or
- Their symptoms get worse.
3. Use acetaminophen (e.g. Tylenol®) or codeine for headache. Do not give aspirin or non-steroidal anti-inflammatory medicine(NSAIDs)(e.g. Ibuprofen/Advil®). An ice pack on the head and neck is okay as needed for comfort. A 2010 clinical report from the American Academy of Pediatrics’ Council on Sports Medicine and Fitness notes that, because no studies have actually documented any harm from use of aspirin or non-steroidal anti-inflammatories (NSAIDS) after a sport-related concussion, the common recommendation against their use is based more on a theoretical risk. The new 2013 position statement from the American Medical Society for Sports Medicine takes the same stance. A dim, quiet environment may help with headache, as well as symptoms of sensitivity to light and sound often experienced by student-athletes with concussion. Headaches that continue as part of a post-concussion syndrome (symptoms lasting longer than 4-6 weeks) often require a multi-disciplinary approach.
4. No drugs, alcohol, or sleeping pills: Warn your child about the dangers of drinking alcohol engaging in recreational drug use, or using any other substance that could interfere with cognitive function and neurologic recovery. While disturbed sleep is a common and important symptom experienced throughout the course of a concussion, and immediately after a concussion, your child may experience either difficulty falling or staying asleep, or sleep longer, in either case, sleep issues should be addressed without medications, and with particular attention to good sleep hygiene. If sleep difficulties persist (e.g. your child is diagnosed with post-concussion syndrome), then medical and cognitive therapies may be considered.
5. No driving until symptoms have cleared. While an athlete is experiencing concussion symptoms – such as sensitivity to noise or light or dizziness, inability to detect quick movements of the head, sleep problems, problems with memory or concentration, or anxiety, even a narrowing of their field of vision – he should not be driving. If symptoms persist, it may even be advisable for the athlete to be undertake a more formal evaluation to determine whether it is safe for him to resume driving a car.
6. Normal diet: Limited information is available regarding the recommended diet for the management of concussion. A normal well-balanced diet that is nutritious in both quality and quantity should be maintained to provide the needed nutrients to aid in the recovery process. Avoid spicy foods.
7. Physical and “cognitive” rest:
Treating young athletes after a concussive event is uniquely challenging, because their brains are still developing, and their recovery is usually slower than that with adults.
Avoiding strenuous activity until the athlete has no post-concussion symptoms at rest is still advised if it makes symptoms worse and such activity has the potential to delay recovery. While bed rest is not recommended, there is some evidence to suggest that a limited amount of physical activity may actually help in recovery, and, while the effect of physical activity on concussion recovery has not been extensively researched, there is general consensus among concussion experts on reducing the amount of physical activity after concussion, including:
- the sport or activity that resulted in the concussion
- weight training
- cardiovascular training (light aerobic exercise is okay)
- PE classes
- sexual activity
- activities such as bike riding, street hockey, and skateboarding that risk additional head injury or make symptoms worse.
Until recently, the cornerstone of concussion management of young athletes has been complete mental rest until symptoms clear (or are at least tolerable), a gradual return to a full academic workload, and completion of a 5-step graduated exercise program leading to medical clearance and return to play.
But, in a remarkable about face, the trend over the last several years has been for concussion experts to recommend that it may actually better for a student-athlete to return to school, at least part-time, after one or two days of rest at home; and, because complete mental rest (no reading, homework, online activity, video games, text messaging and staying home from school for an extended period of time) can lead to other problems reduced reading, less homework, working less online, and text messaging less may be all that is required.
While a recently-published study in the journal Pediatrics found that student-athletes who reduced their cognitive activity the least took from 2 to 5 times longer on average to recover from concussion than those who limited cognitive activity, researchers also found, that while limiting cognitive activity was associated with a shorter duration of symptoms, complete abstinence from cognitive activity didn’t help speed recovery and may be unnecessary.
Most recently, a group of concussion experts meeting in October 2015 at a conference at the University of Pittsburgh Medical Center concluded that strict physical and cognitive rest beyond the first few days after a concussion was not necessary.
“Exercise is a way of treating this,” Dr. Javier Cardenas, a neurologist at the Barrow Concussion and Brain Injury Center in Arizona, told the Pittsburgh Post-Gazette at the time of the conference. “Many times, we see patients who are completely restricted from any physical activity. As one of the major sources of this injury is sports and athletics, for those who are involved in athletics, this is actually a punishment. They become depressed. They become anxious. So allowing them to participate in physical activity – while keeping them out of harms’ way, of course – is actually a rehabilitation method.”
Another concussion expert who believes that complete cognitive rest may be over-prescribed is Dr. Elizabeth M. Pieroth, a clinical neuropsychologist with North Shore Medical Group in Chicago and a consultant to a number of Chicago professional sports teams, including the Bears.
Like Dr. Cardenas, Dr. Pieroth sees many of the same downsides to keeping concussed athletes out of school for more than a few days after injury, including social isolation, depression, and an unhealthy focus on symptoms instead of recovery.
Dr. Christopher Giza, a pediatric neurologist and director of the UCLA Steve Tisch BrainSPORT Program, agrees. Kids who are cut off from their friends after concussion, Giza says, “quickly start to worry about keeping up in their classes, losing social status and, if they are athletes, whether they will lose their place on the team. It’s important to ease them back into their social circles quickly, and that might mean being a little more permissive when it comes to social media and screen time.”
The American Academy of Pediatrics, mindful of the fact that it is difficult for parents to constantly be monitoring their child and to enforce strict limits on texting, video gaming, computer and TV use and of the relative lack of research in this area, suggests that the most important thing is for a parent to take a common sense approach about their child’s level of cognitive activity, having the child avoid activities that seem to make their symptoms worse.
If symptoms are severe, academic accommodations may be needed. It is reasonable for a child to miss a day or two of school after concussion, and shortening of the athlete’s school day, reduction of workloads in school, and/or allowing an athlete more time to complete assignments or take tests, may be necessary.
Taking standardized tests while recovering from a concussion should be discouraged, because lower-than-expected test scores may occur and are likely not representative of true ability.
8. Graduated, individualized, conservative return-to-play. All recent position and consensus statements on sport-related concussion strongly recommend against – and most of the new state laws prohibit – same day return to play in case of suspected concussion, under any circumstances.
Before returning to full contact, student-athletes should first:
- be off all academic accommodations (or temporary “adjustments,” in the new nomenclature suggested by the AAP in its 2013 clinical report on return to learn);
- be symptom-free;
- have returned to baseline on neurocognitive, balance, and visual tests, and
- have successfully completed a 5-step, symptom limited exercise program – which will usually take about a week to complete, with each stage taking 24 hours or longer; if symptoms recur with exertion or at rest at any stage, the athlete returns to the previous stage and tries again 24 hours later.
Parents need to remember that concussion management is not one-size, fits all and needs to follow an individualized course tailored to their child’s unique situation, as each athlete will recover at a different rate (especially for athletes with a history of multiple concussions).
However, as a general rule, because a number of studies have shown that younger athletes take longer to fully recover cognitive function than college-aged or professional athletes, a more conservative approach is recommended in deciding when a pediatric and adolescent athlete can return to play, even if they show no symptoms of concussion, with the 2012 Zurich consensus statement stating that it “is appropriate to extend the amount of asymptomatic rest and/or length of the graded exertion in children and adolescents.”
Indeed, SmartTeams expert sports concussion neuropsychologist, Rosemarie Scolaro Moser, Ph.D., recommends in her book, Ahead of the Game: The Parents’ Guide to Youth Sport Concussion that children and teens be held at least three weeks before returning to sports.
9. Further testing/management. Until about 12 years ago, concussions were “graded” based on severity, with the concussion grade, the number of concussion suffered, and whether the athlete suffered a loss of consciousness or amnesia determining return to play. Over the last decade, however, concussion grading scales and one-size-fits-all, cookie-cutter return to play guidelines have been abandoned in favor of a much more individualized approach.
The Zurich consensus statement calls for consideration of so-called “modifying factors,” the presence of any of which may suggest the need for more sophisticated, multi-disciplinary concussion management strategies, such as examination by a specialist, more sophisticated testing, and a longer recovery time. These factors include:
- Lingering symptoms. In most cases, obvious symptoms of concussions clear within a week. The presence of post-concussion signs or symptoms lasting more than 7-10 days, or symptoms that reoccur with exercise, suggest a more serious concussion;
- Prolonged LOC or amnesia. An athlete who experiences concussive convulsions or prolonged loss of consciousness (LOC) (one minute or more) or amnesia at the time of injury should be treated more conservatively (although a 2013 study suggests that amnesia is not a risk factor for prolonged recovery from concussion);
- Multiple concussion history. If the athlete has suffered one or more concussive events in the past, especially where the injuries appear to be recurring with progressively less impact force (e.g. a minor blow) or takes longer to recover after each successive concussion, a longer recovery time, or even a recommendation against returning that season or to that sport in the future may be warranted; and
- Other neurological disorders present. A concussed athlete with learning disorders and/or attention deficit hyperactivity (ADHD) or a history of migraines may require different concussion management that takes these conditions into account.
10. Trust your instincts. Be as involved in the management of your child’s concussion as your instincts tell you to be. Don’t be afraid to ask your child how he is feeling, or take him to his pediatrician or a specialist if you suspect something is wrong, or you notice a change in his/her personality (he is solemn or unusually subdued), appetite (eating more or less than usual), sleep patterns, or that he is, for lack of a better word, “off.” Remember: you know your child better than anyone. Because there is a lot medical science does not know about concussions, a common sense approach makes – in a word – sense.
As Dr. Robert Cantu observes in his 2012 book, Concussion and Our Kids, while parents shouldn’t attempt to diagnose concussions – that’s the job for physicians trained to manage head trauma – that “doesn’t excuse moms and dads from the important job of studying children for signs.” He recommends using “every tool in the parental toolbox,” including a series of simple tests that can be given at home:
- short-term memory: A common concussion symptom is a deficit in short-term memory, which can be easily tested by a parent posing a series of questions about recent events, or giving a child a list of unrelated words such as objects or colors and then asking the child to repeat the list back immediately and again in three or four minutes.
- balance: poor balance is common among concussed athletes. Can your child stand firm with their feet together, in heel-to-toe tandem position, and on one foot, eyes open and then closed; with hands on hips, eyes open and then closed?
- open-ended questions about how he is feeling: As Dr. Cantu observes, “it’s a question that occurs so naturally to a parent that it hardly needs to be recommended.” But, in the case of concussion, answers to questions like “‘Are you having trouble with memory? Have you noticed issues with concentration? Is your homework taking longer? Is doing homework causing a headache that it wouldn’t normally? When you study for longer periods, does the headache get worse?'” may suggest that there is either no need for further evaluation (because the child “sails through the evaluation without a sign of a deficit”) or raise serious concern (a question about yesterday’s game, for instance, stumps your child, and they struggle to keep their balance with eyes closed). Dr. Cantu’s view is that “a child should be seen [by a concussion specialist] if he is trying as hard as he can yet struggles to complete cognitive or balance tests.”
“[P]arents should be acutely aware of [concussion] symptoms, potential differences between girls and boys, and alert coaches and healthcare workers to behavioral changes,” advises Dr. Susan A. Saliba, an Assistant Professor at the Curry School of Education; Physical Medicine and Rehabilitation at the University of Virginia, and the co-author of a 2010 study on concussions among high school athletes.
“Parents have the ability to observe the athlete longer and can perceive changes that may affect the outcome. Any lethargy, continued headache, or change in behavior or affect can be concussion symptoms, especially if agitation or difficulty in concentrating are present. Many times the parent cannot identify a specific symptom, but should nevertheless alert someone that the athlete is ‘not him or herself.’ Early return to play during this time presents the most danger,” she says.
An athlete’s school and coaches should maintain regular contact with his or her parents to update them on their progress.
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