With sports-related concussions making front page news on an increasingly regular basis, public concern is at any all-time high for the safety of athletes. As physicians, we see this injury occur across the age spectrum -- from the pros and college to high school and younger -- but there's a question as to how each case should be managed. Should we handle adolescent or pediatric concussions any differently? The answer is yes. The young brain is still developing, and we don't really know the long-term effect of a concussion on a developing brain. We need to be much more conservative in treating these cases.
The internationally recognized guidelines for concussion management were updated during the Fourth International Consensus Conference on Concussion in Sport held in Zurich in 2012. The consensus recommended a concept called "cognitive rest" during the early, concussed period of time. Because a cognitive demand on the concussed brain can actually delay recovery, this recommended cognitive rest means no computers, no texting, no video games, no television, no reading or studying. Students may also need to have school tests delayed or they may require extra time in completing exams.
The recommendations were made to correspond with early concussion symptoms, such as headaches, dizziness, memory-loss, sleep disruption and mood swings, all of which can impact the day-to-day activities of a concussed youth in the following ways:
- Taking longer to perform or having difficulty understanding homework;
- Compromised memory of school material or events before or after the concussion (i.e., reading the same page repeatedly because he/she can't remember what was just read);
- Losing his/her train of thought in mid-sentence when communicating with parents, friends and teachers;
- Word searching or having difficulty finding the right words to express his/herself, with resulting frustration making symptoms worse;
- Inability to complete tests in the allotted time since the concussion.
The recommended period of cognitive rest is relatively short, with experts believing that it has a maximum effect in the first week or so, but may also be extended, depending on severity of the symptoms.
Any concussed person also needs to reduce physical activity during this period. This means he/she should not participate in games, practices, weight training or conditioning. Physical activity, which may cause flare-ups of symptoms such as dizziness or headaches, may also delay recovery.
Proper physical and cognitive rest can also help prevent another, potentially fatal condition to which young people are more susceptible. Known as Second Impact Syndrome (SIS), it involves the sudden, dramatic swelling of the brain when a patient suffers a second concussion before having the chance to recover from the first concussion. The first concussion confuses the brain. The second, superimposed concussion may cause the brain to lose its ability to regulate its own blood flow, with the result of brain swelling and death. While a second, superimposed concussion does not guarantee SIS, the risk and potential outcome are too great.
Dr. Robert Cantu, a noted concussion authority and member of the international concussion panels, fielded a question about how difficult it is to keep a 12-year-old still and quiet.
"I know it is difficult," he said. "If the child is improving, you can let them play a video game for 10 minutes. If this worsens their symptoms, then they must continue the cognitive rest. If the child tolerates this, then you can try 10 minutes per hour, and if all goes well you can gradually lengthen the time and activities."
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