Concussion in Children Lecture Summary Sports Medicine Australia

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1 Concussion in Children Lecture Summary Sports Medicine Australia Nicole Pates BSc (Physiotherapy) Postgraduate Certificate in Physiotherapy (Paediatrics) A recent survey of parents of school aged children showed: 51% did not know that head trauma is more serious in children 61% were not aware their child could not immediately return to play after a suspected concussion 37% could not recognise the signs and symptoms of a concussion 90% were not aware if their school/team had a concussion policy NASN School Nurse 2014 Children are not little adults. The most recent international consensus statement on sport- related concussions (Zurich consensus statement) identifies several important differences in the way concussions are diagnosed and treated in children and adolescents. Why do children need to be treated differently? The brain is developing: By age 6 the brain is 90% of its adult size. In the pre- adolescent years there is a large increase in number of brain cells and the connections between the cells, the volume of the brain increases. In the teenage years, pruning occurs of the brain cells and pathways that are not regularly used. During the teenage years there is a prolonged period of plasticity of the frontal areas of the brain as it matures. The parts of the brain that control physical movement, vision and sense mature first, while the regions that control higher thinking, including rational thinking, mature later. So what does this mean for children with concussion? Concussion may have a greater impact on the growing brain cells and connections, resulting in a longer recovery time. Adolescents might not understand the importance of managing concussion due to poor conceptualisation hence I m fine let me play or not reporting symptom's at all.

2 Less than 20% of concussed children are diagnosed. Why? 1. Concussions are not Recognised The fall or incident that results in a concussion is not seen. The child does not report the head knock or symptoms. A prevalent misconception is that loss of consciousness must occur in order to have a diagnosis of a concussion (occurs in <10% of concussions). Children report symptoms differently to adults, assessments designed specifically for children are now available. The signs & symptoms of concussion are not well known/misunderstood. Concussion results in functional deficits, not structural damage. As such, radiological studies, such as CT scans, may not reveal for evidence of injury providing false reassurance that everything is fine. 2. The child is not Removed from play If a concussion is not recognised or suspected, removal from play does not occur. Players often feel a sense of duty to their teammates, coaches, and even parents to ignore these symptoms and return to play either immediately after sustaining a concussion or before their symptoms have completely resolved. Cultural expectations of concussion in Australia. o We often see elite athletes return to play immediately after sustaining a head injury. Elite teams have doctors, physiotherapists and other medical professionals on the sidelines using thorough assessment protocols to ensure player safety, unlike community and school sports teams. o The effects of concussion are not as obvious as those of an injured ankle. In an ankle injury you can observe swelling and bruising but in concussion. The signs and symptoms are not seen as serious because they cannot be seen (see Table 1). Often the you ll be right mentality is exercised as the severity of concussion is underestimated. 3. There is no Referral to a medical practitioner If the concussion is not recognised, or the severity underestimated, the child is allowed to return to play and referral to a medical practitioner does not occur. All players with suspected or recognised concussion must be referred to a medical doctor or emergency department as soon as possible. This referral must happen even if symptoms or signs have disappeared. Ideally, the medical doctor who reviews the player should have experience in the diagnosis and management of sports concussion.

3 Anybody can RECOGNISE a concussion and REMOVE the child from play. A suspected concussion is considered a concussion until proven otherwise by a medical practitioner. REFERRAL is essential to diagnose and determine concussion severity Post Concussion Recovery Macleod (2014) Return to School Usually return to school is quick and the child is back fully participating in 2-3 days. However for the child with persistent symptoms a more indivualised program is required with a team approach. Once symptoms and signs are settled and medications are stopped, the child then returns to activities of normal daily living (school) via a graduated return to school plan. The plan should consider: Extra time and a quiet room to complete assignments and tests. Avoidance of noisy areas such as assembly halls, sporting events and music classes. Frequent breaks during class, homework and tests. Use of a helper or tutor. The use of half days or attendance only at core subjects. They must not perform any exercise during school (recess, breaks) or any organised sport during or after school. The program should also include continual communication between parents, teachers and health professionals. If any symptoms re- occur during recovery, the child may need more complete rest time. If symptoms re- occur they should be reviewed by their medical doctor.

4 Return to Play Children should not return to play until they have received clearance from a medical practitioner. This certificate must be given to the club or school sport master. Because of the different physiological response and longer recovery after concussion and specific risks related to head impact during childhood and adolescence, the Zurich consensus statement recommends a more conservative return to play approach, extending the amount of time of asymptomatic rest and/or the length of the graded exertion for children and teens. The brains of young athletes are still developing, making them particularly susceptible to catastrophic injury if the brain has not healed before a second blow to the head An child who has not yet fully recovered from a concussion, is at risk for second impact syndrome (SIS). SIS is a serious condition involving swelling in the brain. The best way to return to sport is to follow a gradual re- introduction of exercise in a step wise progression known as a graduated return to play programme (GRTP) It is the role of the physiotherapist/sports trainer/ primary carer /nurse to ensure the child is asymptomatic through each phase. The Australian Rugby Union Concussion Guidance Policy outlines an example of a clear, stepwise graduated return to play protocol: Health and Safety/ARU Concussion Guidance 2014.pdf Players 18 years and under cannot return to contact training or playing for at least 2 weeks (14 days) after all symptoms and signs have disappeared training. This guidance applies only to players who have suffered their first concussion in a 12 month period. The guidance does not apply to players with potentially more complex injuries. The following players must see a medical doctor experienced in sports concussion management; 2 concussions in 12 months. Multiple concussions over their playing career. Concussions occurring with less collision force. Concussion symptoms lasting longer than expected i.e. a few days.

5 Recommendations To ensure child safety, minimise effects of concussion on brain development and reduce the risk of legal action, all schools and community sporting clubs should develop and implement a concussion management policy. The sports trainer/physiotherapist/school nurse, here on now known as the primary carer, should be an integral member of the team developing this policy. Sports Medicine Australia have produced guidelines for policy development and created a sample policy as a model (see hyperlinks below). 0Development%20Guidelines.pdf 20Concussion%20Policy.pdf The primary carer should assist in providing education to sporting club/school personnel in the recognition and appropriate management of a concussed child. This may include educating administrators, coaches, parents, and others on concussion prevention, cause, recognition and referral, physical and cognitive restrictions for concussed athletes, return- to- play protocols, and ramifications of improper concussion management. Sports Medicine Australia have developed resources for use within schools, sporting clubs and the community to aid in the recognition of concussion, the removal of the child from play and the referral onwards to a medical practitioner. The resources can be found here: It is important for the primary carer to highlight that concussions do not require the child to lose consciousness and that concussions can happen on the playground, on the sports field, or in the gymnasium. Clear rules and systems need to be in place and enforced by all involved in caring for the child.

6 References: 1. AFL Guidelines The management of concussion in Australian football with specific provision for children 5 17 years can be accessed at 2. Apps J, Walter K, Pediatric and Adolescent Concussion. Diagnosis, Management and Outcomes. 2012: London, Springer Sciences. 3. Doss R, Dentz M, Seaton K, Petronio J, Mills J, Allen J, Kabriaei M. Differences in rate of recovery from concussion in children injured during the school year vs the summer months Childrens Hopsitals and Clinics Minnesota. 4. Field M, Collins MW, Lovell MR, Maroon J. Does age play a role in recovery from sports- related concussion? A comparison of high school and collegiate athletes. Journal of Pediatrics 2003;142(5): Grady MF. Concussion in the adolescent athlete. Curr Probl Pediatr Adolesc Health Care 2010;40(7): Halstead ME, McAvoy K, Devore CD, Carl R, Lee M, Logan K. Returning to learning following a concussion. Pediatrics 2013; Halstead ME, Walter KD, Council Sports Med F. Clinical Report- Sport- Related Concussion in Children and Adolescents. Pediatrics 2010;126(3): Labond V, Barber KR, Golden IJ. Sports- related head injuries in students: Parents knowledge, attitudes, and perceptions. NASN School Nurse 2014 (2) Lebel C, Beaulieu C, Longitudinal development of human brain wiring continues from childhood into adulthood. Journal of Neuroscience, McClincy MP, Lovell MR, Pardini J, Collins MW, Spore MK. Recovery from sports concussion in high school and collegiate athletes. Brain Injury 2005;20(1): McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, et al. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November British Journal of Sports Medicine 2009;43:I76- I McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvorak J, Echemendia RJ, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November Br J Sports Med 2013;47(5): McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported concussion in high school football players - Implications for prevention. Clinical Journal of Sport Medicine 2004;14(1): Moser RS, Schatz P, Jordan BD. Prolonged effects of concussion in high school athletes. Neurosurgery 2005;57(2): Purcell L, Carson J. Sport- related concussion in pediatric athletes. Clinical Pediatrics 2008;47(2): Purcell L. What are the most appropriate return- to- play guidelines for concussed child athletes? British Journal of Sports Medicine 2009;43:I51- I Sim A, Terryberry- Spohr L, Wilson KR. Prolonged recovery of memory functioning after mild traumatic brain injury in adolescent athletes. Journal of Neurosurgery 2008;108(3):