My child has a concussion — now what do I do?

By David Bertone, P.T., DPT, OCS

The incidence of concussion in youth sports continues to rise, and parents are often left with trying to navigate the process on their own. According to the Centers for Disease Control, there are between 1.6 and 3.8 million sports-related concussions in the United States every year. In addition, a 2012 study that analyzed 20 high school sports found that concussions accounted for 13 percent of all injuries reported, with two-thirds occurring during competition and one-third in practice.The highest incidence rates occur in football, boys’ ice hockey, girls’ soccer and boys’ lacrosse.

Unfortunately most parents get their first piece of education about the concussion process in the local emergency room, which is not always the best place to go following a mild head injury.The ER is often loud, bright and hectic, which is over stimulating to the concussed athlete and can make the symptoms of headache, dizziness and irritability even worse. But the ER gives parents the much-needed piece of mind that nothing “serious” is going on and they are placed at ease.There are, however, several red flag signs that require an immediate visit to the local emergency room. They are headaches that worsen, seizures, slurred speech, repeated vomiting, weakness or numbness in legs or arms, unable to recognize people or places, worsening confusion or irritability, severe neck pain, and difficulty awakening your child.

In the far majority of situations after a mild head injury or concussion, quiet rest is the most important treatment.This allows the brain to heal during a vulnerable time. Our internal system that regulates blood flow to the brain gets impaired during a concussion, so when the brain needs increased blood flow to provide healing nutrients, it actually gets less. If the brain is stressed during this healing time with concentration tasks, memory functions, visual and auditory processing and exercise or activity, the healing process gets interrupted, which can delay the recovery process.The key concept when your child is resting is to allow them to sleep and avoid any stimulating activities such as reading, television, video games, computer tasks and exercise. It is also important to not wake your child while they are sleeping, but instead check for normal breathing to confirm they are not in any distress. Sleep is good and will improve healing.

So now your child completes a few days of quiet rest, sometimes called cocoon therapy. Now what do you do? A visit to the pediatrician is often the next step. However, the pediatrician does not always have any objective testing available to make a decision on readiness for return to school or safe return to sports. This is where a healthcare practitioner that is involved in all aspects of concussion management is important.A physical therapist with extensive experience in this area can improve the process of return to play by objectively measuring your child’s balance, neurocognitive function, as well as eye movement speed and processing. These are important factors that are compared to preseason baseline testing values, or in the case when no baseline testing is available, compared to normative data. This information is forwarded to your pediatrician with recommendations based on the results. If deficits exist in any of the areas, quite often a short course of vestibular rehabilitation is recommended with monitoring by a physical therapist specifically trained in concussion management. Sometimes your child has balance problems and dizziness that appears to linger.A study performed in 2010 by authors at the University of Pittsburgh found that a few simple vestibular or balance exercises can significantly reduce the complaint of dizziness. In addition, residual symptoms such as headache and neck pain can be treated with manual therapy.

In the instances when extended rest is required for symptom control and recovery, your child will often become deconditioned and must undergo a supervised retraining program before return to any sports.This will required a progressive exertional therapy program with monitoring of heart rate and symptoms, as well as program modification and progression based on their response. Eventually your child is progressed through a graded return to play protocol, which includes nonimpact activities and agility with advancement to return to sports and impact over a six-day period of time. This can occur only if their symptoms are absent and they do not return during any part of the rehabilitation process.

There is much more available for concussion management than just waiting around for someone to give you direction and safely return to sports.A key component of the process is to get a comprehensive baseline assessment that includes cognitive, balance and eye motor processing.This data can be essential for comparison in case of future head injury. I often hear from parents who have had difficulty navigating the system post-concussion:“We wish were had our child baseline tested before the head injury occurred.” Unfortunately, partial baseline testing at some high schools does not tell the entire story post injury. Most high schools offer the athletes baseline ImPACT testing, which is a type of neurocognitive testing.This only tells a partial story post-concussion. It is important to also have the balance and eye-tracking component to use for post injury comparison.

Dr. Bertone is an adjunct instructor at Rutgers, The State University of New Jersey, teaching the doctoral physical therapy students all aspects of concussion management. He is the founder of ConcussionRxcare at db Orthopedic Physical Therapy, providing baseline concussion testing and post-concussion rehabilitation. Dr. Bertone is available to educate youth sports groups, coaches and parents about recommended concussion procedures and designing baseline testing programs. He can be reached at info@dborthopt.com or at 732-747- 1262. For more information, go to www.concussionRXcare.com.