Scott Otallah, MD

The increased incidence of sports-related concussion reported nationwide has attracted much media and public attention. Most data about sports-related concussion involve professional, college, and high school level athletes; however, these injuries also affect children and young adolescents.

 This increase in the incidence of concussion may potentially have been caused by an increase in the number of young athletes or increased participation in high-risk sports; however, it has been attributed, at least in part, to increased awareness and reporting by parents, athletic trainers, coaches, and physicians.

Adolescent girls' soccer has the highest reported rate of concussion for girls' sports; this rate is only slightly behind the rate of boys' football. For reasons that are not entirely clear, the rates of concussion for teenage girls' sports are higher than those for comparable teenage boys' sports.

 Some authors have theorized that girls have less neck muscle strength to help absorb impact, that girls are more likely to report concussion than boys, and that sex differences in brain development may be a factor.

Here we will address 3 questions pediatricians must consider when evaluating a child with head injury: Was this a concussion? When can the patient return to play? Can concussions be prevented? To illustrate the difficulty in diagnosing concussion, we will present a case study of a head injury in a young female athlete.

Teenaged Girl With Confusion, Wooziness After Heading A Soccer Ball

A 14-year-old girl presents in the office 3 days after having sustained a head injury in a soccer game. She has been playing on a competitive “travel” soccer team whose practices include drills on heading the ball. During this particular game, she attempted to head a rapidly propelled ball after it had been forcefully kicked by another player. However, the ball came in contact with the top of her head instead of the intended location on her forehead. After the impact, she immediately felt dazed and confused and “saw stars.” She did not lose consciousness but came out of the game and did not return to play. She continued to feel “woozy” after the game while riding home in the back of the family car. Later that evening, she was brought to a local emergency department, where she was reportedly told that “this was not a concussion.” No imaging was performed.

For the past 3 days, she has had occipital headache, which is relieved for a few hours by ibuprofen. She feels as if she is thinking normally and says that she has been feeling better each day since the injury. She can remember the incident clearly.

Findings from her physical examination are normal. On further questioning, the mother reports that the patient had a concussion after a fall several years earlier. She also mentions that 2 other girls on the same soccer team have had “concussions” this season.

Although the precise definition of concussion remains a matter of debate, the recent International Conference on Concussion in Sport (ICCIS) defined it as “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces” that includes 5 major features (

 The fourth major feature emphasizes that concussion may or may not involve loss of consciousness (LOC). It is a common misconception in the general public and even in the medical community that LOC is a necessary component of concussion. This factor may have played a role in this patient reportedly being told that she had not had a concussion. Recent data suggest that LOC occurs in only about 10% of concussions.

 The most common symptoms of concussion are headache and confusion/disorientation. Patients may also feel mentally “foggy” or “slowed down” or complain of nausea/vomiting, difficulty in concentrating, irritability, sadness, mood swings, sleeping more or less than usual, difficulty in falling asleep, balance problems, difficulty in remembering, visual problems, drowsiness, dizziness, and forgetfulness about recent events.

 The most common neurocognitive deficits include reduced reaction times and impaired speed of information processing. The severity and longevity of postconcussion symptoms cannot be reliably predicted by any of these symptoms or deficits; however, their resolution can be monitored with symptom scoring and neurocognitive testing.

Findings that help distinguish traumatic brain injury (TBI). 

The new recommendations from the ICCIS and the American Academy of Pediatrics eliminated the fine distinction between concussion and mild TBI. They also abandoned the use of concussion grading scales, because the grades were arbitrary and did not prove clinically useful. Several factors have been shown to be useful in distinguishing more severe injury. In the case of mild TBI, these include LOC for more than 30 seconds and the presence of amnesia for the event.

 These symptoms may warrant more careful observation. The ICCIS recommends considering neuroimaging only in cases of prolonged LOC, focal neurological deficit, or worsening symptoms. Those who have LOC for more than 30 seconds or significant and persistent amnesia may warrant more careful observation for longer periods or consultation with a concussion expert. Other signs that may indicate trauma that has caused intracranial lesions detectable on neuroimaging include severe and worsening headache, seizures, focal neurological findings on examination, repeated emesis, and significant drowsiness or difficulty in awakening. These signs suggest more severe TBI warranting emergent imaging and treatment.

 Tools that can be used to recognize, evaluate, and manage symptoms of concussion are included in the “Heads Up: Brain Injury in Your Practice” tool kit for physicians developed by the CDC (

www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html

). It offers many free resources for office use. The Heads Up Web site contains valuable information suitable for coaches, trainers, parents, and the athletes themselves. It also provides an example of one of the many symptom scoring tools that have been developed to help clarify whether a concussion has taken place during a sports activity.

The 14-year-old girl in this case has sufficient symptoms, including headache and confusion, to treat her as if she had received a concussion.

The most recent recommendation about returning to play after a concussion for children and adolescents is that the process needs to be individualized and stepwise.

 Generally, each stage in concussion rehabilitation should last no less than 24 hours, so that a minimum of 5 days passes before a full return to competition (

). The first step includes complete physical rest-no sports, physical training, gym class, or recreational activities (such as bike riding) that place the patient at risk for recurrent head trauma-and cognitive rest-no school or decreased school load as well as limiting activities at home, such as computer use and video games, that require attention or concentration. Ensuring that injured athletes comply with this first step requires a team effort by the pediatrician, parents, and education professionals.

If the child is symptom-free for 24 hours, he or she may advance to the next stage. If symptoms recur, the athlete should discontinue the provoking activity immediately. Once asymptomatic after at least another 24 hours, the athlete can resume at the previous asymptomatic level. Athletes should contact their health care provider at any point if symptoms recur.

Some experts feel that young athletes (younger than 10 years) should not begin the process until the child is symptom-free for a longer interval, such as 1 week. It should be emphasized that each stage of this stepwise approach needs to be monitored and enforced by parents and coaches rather than trusting a young person to comply with the plan on their own.

An athlete with multiple concussions or prolonged symptoms (lasting longer than 1 to 2 weeks without significant improvement) may require a longer concussion-rehabilitation program, which is ideally created by a physician who is experienced in concussion management.

 Children with reduced reaction time and impaired speed of information processing after a head injury are more likely to cause themselves further injury if they return to play too quickly. At least one study suggests that as many as 10% of children with concussion have persistent symptoms lasting weeks to months, even years, that will worsen or become more persistent if return to play is too soon.8 These deficits can have significant impact on school performance.

There is concern that athletes who sustain a second head injury before the symptoms associated with the first have fully cleared may experience severe and catastrophic brain injury with cerebral swelling and increased intracranial pressure (second-impact syndrome). It is not completely clear whether this entity exists or simply represents posttraumatic brain swelling caused by a single significant trauma.

 Cases of second-impact syndrome are rare in the literature, and some experts feel that concern for this entity plays too large a role in the guidelines for concussion management. Death after minor head trauma is extremely rare but is thought to be more common in children and adolescents than in adults; thus, increased caution is acceptable when managing head injuries in children.

 The American Academy of Neurology recently released a position statement emphasizing that a concussion represents brain injury.

 It recommended that every child with a concussion be evaluated by a specialist or physician familiar with the management of concussion. It is unclear how this statement will affect the ongoing evolution of concussion management. However, it is meant only to serve as an interim guideline, while their concussion committee prepares evidenced-based, return-to-play guidelines to be released in 2011.

 The results of neurocognitive testing may help determine when a player's cognitive status has returned to normal and when it is safe for the athlete to return to play. Ideally, players can be tested before the season begins so as to establish a baseline for their test performance in a “sports as a laboratory assessment model.” Deviations from an athlete's personal normal can then be assessed more accurately. Several computerized tools to monitor improvement in these areas after injury are commercially available but have yet to be validated by independent studies.

 This type of before and after testing has already become more common and will probably become an even more important aspect of concussion management in the future.

The type of stepwise model of rehabilitation discussed above was recommended for the teenaged girl in this case study. Her symptoms resolved completely within 1 week after a graded return to play. She has had no long-term sequelae; however, no neuropsychological testing was performed.

Education of athletes, families, coaches, trainers, and physicians about the problem of concussion is the best way to reduce the frequency of this injury and to avoid the complications associated with its improper management.

The role, if any, of protective headgear in preventing concussions varies by sport. The mother of the patient in this case asked whether her daughter might benefit from the use of a concussion headband (

). Whether protective headgear can reduce soccer-related concussion remains uncertain, and experts do not recommend such equipment at this time. If this equipment is determined to be effective, it would be desirable in the setting of girls' soccer because of the high frequency of concussion in this sport.

 In ball-to-head impact models, these devices appear to decrease the biomechanical impact of direct collisions. One retrospective survey suggested that headgear in soccer players may decrease concussions caused by head-to-head or head-to-body impact

; however, another study suggested that by increasing the weight of the head, such headgear may actually increase the forces of acceleration and deceleration with a resultant increase in the risk of concussion.

 Use of this headgear has yet to show a decrease in the rate of concussions.

 Figure – The concussion headband on this college soccer player is one of several products developed in an attempt to reduce concussion risk. However, use of these products has not resulted in a decreased rate of concussion. The role of protective headgear to reduce soccer-related concussion remains uncertain.

(Permission to reprint photo of soccer player Lauren Alwine courtesy of Jim Davis, Athletic Director for Media Relations at the University of Virginia.)

Reduction in the risk of concussion by using helmets has been inconsistent in other sports.

 The only sports in which helmet use has been convincingly shown to prevent concussion are downhill skiing and snowboarding. In other high-risk sports, such as football, rugby, and hockey, helmets appear to reduce the risk of skull fracture and face/scalp lacerations; however, they do not clearly decrease the risk of concussion.

Although biomechanical studies performed by helmet manufacturers predicted reduced concussion, these results have yet to be independently validated. This seemingly counterintuitive result is probably related to the fact that helmets largely act to reduce impact forces. TBI is thought to be related more to acceleration-deceleration forces, both rotational and linear. Traditional helmets do very little to reduce these forces. Rule changes (such as limiting head-to-head impacts in football) and increased awareness of concussion symptoms and appropriate rehabilitation are likely to lead to the greatest improvement in incidence and outcomes for all youth sports.

 Although heading the ball, when performed properly, is not likely to be a significant factor in concussion (

), it is important to
minimize the risk of unintentional, unprepared, and improper impacts between a head and a rapidly propelled ball.

 Maintaining a minimum age for teaching heading (generally age 12 years for girls' youth soccer but sometimes as old as 14 years) allows for further development of neck muscles and more fixation of neural pathways. Proper ball size and inflation for age can help reduce the force of impact and is emphasized by youth soccer leagues nationwide. National teaching curricula for youth coaches (such as those provided by the US Soccer Federation) can help ensure proper heading technique.

Heading the Ball in Soccer Not a Significant Cause of Concussion

Although whether repeated, intentional headers can potentially cause brain injury later in life is unknown, existing data are encouraging in that there does not appear to be a correlation. A few early studies suggested that former professional soccer players may have cognitive impairment secondary to headers; however, in subsequent studies that controlled for complicating factors, such as alcholism, drug use, and repeated more severe head injuries, this effect disappeared.13 Biomechanical studies suggest that the force of a standing header is far below the theorized force necessary to cause a concussion.13 In one study, most soccer-related concussions were caused by impact between 2 players; concussions caused by head-to-ball collisions occurred when an unprepared player was accidentally struck in the head with the ball.4 It appears that the routine use of the head for controlling and advancing the ball-when performed properly-is not likely to be a significant factor in concussion and reported cognitive deficits.

 Bakhos LL, Lockhart GR, Myers R, Linakis JG. Emergency department visits for concussion in young child athletes. 

 Halstead ME, Walter KD; Council on Sports Medicine and Fitness. American Academy of Pediatrics. Clinical report-sport-related concussion in children and adolescents. 

 Gessel LM, Fields SK, Collins CL, et al. Concussions among United States high school and collegiate athletes. 

 Boden BP, Kirkendall DT, Garrett WE Jr. Concussion incidence in elite college soccer players. 

 Broshek DK, Kaushik T, Freeman JR, et al. Sex differences in outcome following sports-related concussion.

 McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008.

 Ruff RM, Iverson GL, Barth JT, et al; NAN Policy and Planning Committee. Recommendations for diagnosing a mild traumatic brain injury: a National Academy of Neuropsychology education paper. 

 Barlow KM, Crawford S, Stevenson A, et al. Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. 

 Withnall C, Shewchenko N, Wonnacott M, Dvorak J. Effectiveness of headgear in football. 

 McCrory P. Does second impact syndrome exist? 

 Cantu RC, Voy R. Second impact syndrome: a risk in any contact sport. 

 American Academy of Neurology. Position Statement on Sports Concussion. October 2010. 

http://www.aan.com/globals/axon/assets/7913.pdf

13. Kirkendall DT, Jordan SE, Garrett WE. Heading and head injuries in soccer. 

 Delaney JS, Al-Kashmiri A, Drummond R, Correa JA. The effect of protective headgear on head injuries and concussions in adolescent football (soccer) players. 

 Tierney RT, Higgins M, Caswell SV, et al. Sex differences in head acceleration during heading while wearing soccer headgear.

 Benson BW, Hamilton GM, Meeuwisse WH, et al. Is protective equipment useful in preventing concussion? A systematic review of the literature. 

Br J Sports Med. 2009;43(suppl 1):i56-i67.

Articles

The increased incidence of sports-related concussion reported nationwide has attracted much media and public attention. Most data about sports-related concussion involve professional, college, and high school level athletes

Scott Otallah, MD

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