Posted on: October 14, 2014
Concussion Management. Assessing the Symptoms.
By Dr. Eric Small
While a headache is among the best-known and first symptoms of a concussion, there are often delayed symptoms that indicate ongoing mild brain damage and require treatment. Ten percent of symptoms don’t present for a week or more.
For this reason, it is essential that parents and teachers as well as emergency room physicians and pediatricians recognize the need to monitor a young injured athlete for the full spectrum of possible symptoms. In my experience, when the athlete gets over the initial headache, or perhaps never experiences this symptom, parents and youngster often push for a quick return to all activities. But that can put a young person at serious risk.
Today’s best concussion management involves assessing all symptoms – early and late, including many that can seem unrelated to the injury — to determine the proper timing of an athlete’s return to play and also to learning, that is, the resumption of a full academic load.
Often-overlooked symptoms of a concussion include sleep disturbances and personality changes, in which, for example, a very sociable teen becomes quiet. It’s also important to know that post-injury cognitive impairment often causes academic difficulties to emerge over time. For example, an A student in math becomes, two or three months later, a B student. I particularly advise parents to keep an eye on their child’s performance in math and foreign language. As both subjects require doing multiple mental tasks simultaneously, and rely heavily on memory, they are usually the most affected. When I see a young athlete who appears fine after a concussion, I ask two targeted questions: First, “How are you sleeping?” And always – “Are you having problems with math?”
Be aware that cognitive symptoms may not surface until triggered by a heavy cognitive stress, such as back-to-back tests in school – and that this delay in symptoms can lead to dangerously delayed treatment. A little-known fact about this type of injury is that an untreated concussion can keep getting worse.
Another surprising fact to most people is that a broken nose or broken tooth suffered during sports can also cause head trauma, causing the same set of often-delayed symptoms. This is why I strongly advise that even a symptom-free child see a doctor within 48 hours of the injury, and that visits continue as the child is watched for late-arriving symptoms.
It is now recognized that proper concussion rehabilitation often involves not only physical rest and rehabilitative therapies – but rest and rehab for the brain. Ideally, a physician prescribes personalized guidelines for modifying physical and mental activities. The guidelines typically encompass texting and computer screen time, both of which can add visual over-stimulation to the stress of cognitive processing.
For day one post-concussion, I typically recommend that the student go to school a few hours late. If they tolerate that, day two is a full day. But during non-core classes, such as gym and music, I recommend they rest in the nurse’s office. And no tests. Similarly, a return to play might start the student off with a little jogging, then add push-ups. What you don’t want is the old method of rehab where the athlete stays out of school for a period of time and then returns to a full regimen. A gradual progression is a must.
Editor’s Note: Dr. Eric Small is a past chairman of the AAP committee on Sports Medicine and is active in creating national policy regarding children and sports. He has been named Sports Medicine Best Doctor in New York Magazine and Westchester Magazine since 2007, and has over 20 years of experience with athletes.
For more information on concussions, visit www.cdc.gov/concussion