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High School Sports Concussions

Lucy, a 15-year-old female is competing in a karate tournament a few hours from her home. She is a black belt and has been working very hard to place in the tournament. While in the semi-final match, she was caught with a round-house kick to her head. She was wearing headgear and she did not get knocked down. Following the match, which she lost, her parents and her sensei noticed that she seemed confused.  She did not remember anything about the match and was starting to have a headache. After having some liquids, she was feeling better and her parents brought her home.

A few days later, she was seen by her pediatrician for evaluation. She had been having a headache, rated 5 out of 10 for the past 2 days, although it was much improved that day. Physical examination, including neurological examination was within normal limits. An ImPACT test (post-injury) assessment was completed. Lucy was noted to have a worsening score on several areas of the test as well as an increase in symptom score, including headache and confusion, after taking the test.

She had a hard time focusing on her homework over the next 2 weeks. She attends an advanced high school program where nearly all of their work and assignments are given through a tablet device.  Scholastic accommodations were provided for a slow return to school work with no strenuous physical activity clearance until symptoms were much improved.

Four weeks later, her symptoms were resolved and she was doing well in school. She was cleared to return to non-contact sports with plans to return to contact sports in the near future.

Discussion

Management of concussion in children has changed drastically over the past 15-20 years. At times in the past, an athlete with a low-grade concussion would have been allowed to return to the game or sport almost immediately. Now, with more research and improved sideline assessments, children are held out of returning to sports until cleared by a certified member of the healthcare team. Recent data suggest that there are over 3 million recreation and sports-related concussions annually in the United States. High school sports concussions make up a significant portion of those who are injured.

There are several sideline assessment tools, such as the Child-SCAT3 (sport concussion assessment tool). In the emergency department, concussions are a common chief complaint, especially if there was a perceived loss of consciousness. Emergency room doctors and nurses can administer a clinical risk score to determine if a child is likely to have persistent post-concussion symptoms.

Additionally, symptoms checklist improvement scores can help to track progress over time:

Clinical features of concussion after head injury in a pediatric patient can differ from adults. Rural urgent care centers or other facilities not frequented by pediatric concussions can use algorithms to assist in the diagnosis.

Post Concussion Syndrome

Post-concussion syndrome is a condition that is typically associated with a head injury. The head injury may be categorized as a concussion or a mild traumatic brain injury. In general terms, post-concussion syndrome, or PCS, is a medical problem that persists for a period of time after a head injury has occurred. This period of time can range from weeks to months.

Causes of Post Concussion Syndrome

In general, post-concussion syndrome follows the occurrence of an injury or trauma to the head. Not all people who suffer mild traumatic head injury experience post-concussion syndrome. This syndrome may be worse in people who have had previous concussions or head trauma. It may also be more severe in those who have early symptoms of headache after injury, or who have mental changes such as amnesia, fogginess or fatigue. Other risk factors include younger age and prior history of headaches.

Diagnosis of Post Concussion Syndrome

Since symptoms can be vague and attributable to other reasons, it can be difficult to diagnose post-concussion syndrome. There is no definitive test for post-concussion syndrome. Diagnosis is mainly based on a history of head injury and reported symptoms. A physical exam, and imaging as indicated, may be done to evaluate symptoms. Other tests may be given to rule out other causes of symptoms, such as infection, bleeding injury to the brain, or poisoning.

Take Home Points

  • Pediatric recreational- or sports-related concussion is a frequent diagnosis, affecting millions of children each year.
  • Proper evaluation and workup can improve return to school functioning
  • Care must be taken to avoid returning to physical contact sports too early. Recent studies have shown that early return to light exercise (i.e. jogging) is more beneficial than staying sedentary
  • Using the algorithms available from The Medical Algorithms Company, members of the healthcare team can better evaluate and manage children with concussion and post-concussion syndrome

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