Kids and concussions
Awareness of concussion has risen dramatically in recent years due to news reports of serious concussions from devastating collisions in sport, and tragic events like the one that resulted in Rowan’s Law.
According to a study published in 2014, this awareness has resulted in a dramatic rise in the number of paediatric concussion cases coming into the Emergency Department at London Health Sciences Centre’s Children’s Hospital.
Dr. Rod Lim, an emergency physician at the ED, explains when a patient arrives with a suspected concussion, provincial paediatric concussion guidelines are followed.
“We take into account the how they were injured, what symptoms they’re having that could be consistent with concussion, how affected they are, whether they’re oriented, whether they’re processing things properly,” says Dr. Lim. “We also determine whether they’ve had a previous concussion, because you’re going to have more symptoms if you’ve suffered a previous concussion.”
Behavioral changes are also considered.
“Parents are invaluable in letting us know what’s different from before,” says Dr. Lim. “They know their child best and I often ask them, ‘are they acting normally?’ I want to know, compared to what I see now, is their brain working properly, are they as fast as they usually are, has their personality changed?"
Patients who have significant concussive symptoms, also receive a CT scan to make sure that there isn’t something beyond concussion – for example, bleeding in the brain.
“If they have significant symptoms or we’re worried about a more serious injury causing the symptoms, they would be admitted and they would see someone a paediatric trauma doctor or the brain injury team,” says Dr. Lim.
It is rare for a concussion-only patient to be admitted. Most concussion patients who were admitted had other accident-related injuries that required the admission. For concussion patients discharged from the ED without being admitted, a risk assessment is done to match the patient to the right resource for their recovery.
“If we feel that with good education and with the aid of the primary care physician, the patient’s going to be well cared for, then a referral to a recovery program is not necessary,” says Dr Lim. “If we have an elite athlete who has time pressure to return to sport or who has had a really tough time knowing how to align their sport regimen to their concussion routine, Fowler Kennedy Sport Medicine Clinic can be invaluable.”
Children and young adolescents whom ED physicians predict are going to have a tough time - or who have returned with concussion symptoms that lasting beyond the normal recovery time - are referred to a resource like the Thames Valley Children’s Centre’s Paediatric Acquired Brain Injury Community Outreach Program, where the recovery process is closely guided by a specialized team.
Older adolescents facing a complicated recovery might be referred to the Return to Learn Program at St. Joseph’s Health Care’s Parkwood Institute.
What the research says
Dr. Doug Fraser is a member of LHSC’s paediatric trauma team and sees patients with multiple injuries that can include concussion. He’s also a concussion researcher.
According to the 2014 study he co-authored: “Typically, concussions result in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.”
“Every injury is different because your brain is very different from my brain. The brain has the ability to change – it’s always dynamic and modulates. So, when an injury occurs, it’s going to create symptoms that are very different for every single one of us.”
“Children’s brains have a great deal of plasticity - which can be good from a healing perspective but it can also be bad because they are much more prone to the injury itself,” says Dr. Fraser. “That’s why, for children, it’s imperative that they’re treated appropriately and that you do everything to ensure they don’t have another one any time soon.”
It’s important that parents are aware of this type of injury, since concussions disproportionately affect youth and more than half of paediatric concussions are not related to either sport or recreational activities. The 2014 study cites falls, being accidently struck by or against a person or object, motor vehicle collisions, pedal cycle, and intentional injury as the other leading causes of paediatric concussion.
For instance, 73 per cent of concussions in children under five years of age were caused by falls, with the majority occurring in the home from either ground level or a slightly elevated height like a coffee table.
The good news is that most children respond well to treatment and symptoms usually disappear within three to five weeks with a guided routine through Return to Learn and Return to Play protocols, where a patient gradually increases their tolerance for activity back to normal.
Some athletes going through these protocols benefit from the guidance of LHSC’s Fowler Kennedy Sport Medicine Clinic, which also offers sport-based concussion physiotherapy. Last year, 309 (63%) of the 491 new concussion patients seen by Fowler Kennedy were under 18 years of age.
Dr. Lisa Fischer, Director, Primary Care Sport Medicine at the clinic says patients come to Fowler Kennedy a variety of ways.
“Most referrals are from the LHSC ED, some coaches or parents call saying ‘I think my kid’s concussed.’ Those are the patients with acute symptoms and we try to see them within 24 to 72 hours,” says Dr. Fischer.” Patients referred from family physicians tend to be persistently symptomatic – they were concussed perhaps weeks ago but are still suffering.”
Concussion patients at Fowler Kennedy are examined in similar fashion to the ED. A full history, a neurological exam and physical exam to rule out any other causes for symptoms or that the injury is more serious than a concussion.
Once the extent of the injury and any contributing factors are determined, a recovery plan can be put into place.
“Education on how to recover is a big part of what we do: guiding them through on how to get back to school,” according to Dr. Fischer, who says one of the questions often asked is “how much can I do?”
“One of the big things, is we don’t want people in a dark room and saying ‘you can’t do anything’. That’s old-school,” she says. “We’re really encouraging kids to be active. Twenty-four hours rest and then start doing some stuff. Start reading, start looking at your phone, start going for walks.”
Dr. Fischer agrees that a concussion is similar to any other injury where recovery is taken in steps and shouldn’t be rushed. You won’t be running on an ankle sprain the next day but eventually you start putting weight back on it and strengthening it.
Along with education and correctly pacing the recovery, reassurance is a big factor says Dr. Fischer.
“Some people are terrified of this injury, and they really don’t need to be. Parents come in, their child has had one concussion and they’re worried: ‘that’s it, they’re done.’ So, the reassurance is pretty important,” she says.
Patients whose recovery isn’t straight forward can also have multi-faceted causes for prolonged symptoms in addition to the concussion like: upper neck complications, soft tissue strain, jaw pain, or pre-existing mood disorders like depression or anxiety.
“The acute injury is pretty straight forward. Seventy to 80 per cent of concussions just get better,” says Dr. Fischer. “The ones that are complex or persistent are a different story. However, most people are not in that second group.”
Dr. Fischer explains that it’s a simultaneous rehabilitation. “There is more of a focus on Return to Learn during the school year because when students miss a lot of classes, they get stressed, they get anxious which can lead to headaches, sleep deprivation, and more symptoms – so Return to Learn is prioritized because we want to avoid the secondary loss.”
“We want to ensure that piece is really well-controlled. And while they are doing that, they are exercising, but nobody is allowed contact until they have achieved full Return to Learn and full non-contact exertion.”
She doesn’t see resistance from coaches to this approach. “They’ve really bought into the message “don’t mess with a kid’s brain,” Dr. Fischer says. Many coaches and trainers also use the sideline version of SCAT (Sport Concussion Assessment Tool), a checklist to help assess an injured player.
“With athletes who want to push their return to sport, we deal with that gingerly, educating them on why we are following protocols,” says Dr. Fischer. “We emphasize the short-term and the long-term. For instance, do they really want to feel this rotten for the next few months or even end up losing their entire academic year?”
Dr. Fisher emphasizes that the most important thing for parents is to be aware of what a concussion is and if they suspect their child is concussed, do not let them go back to play that day. See a doctor right away and get it managed properly.
“For young athletes, don’t be afraid that coming to see a doctor means we are going to make you stop playing,” she adds. “We’re just going to make sure you do it safely and we’ll get you back playing as quick as we can.”