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Concussions

  • If you’re a fan of any professional sport, you've probably heard about someone suffering a concussion and having to sit out the next play, the rest of the game or even the remainder of the season. But did you know that concussions happen to plenty of non-athletes, too … and that they affect millions of children every year in the United States alone?

    Concussions are traumatic brain injuries that result from the brain going into a spinning motion. This is most often because of a direct blow to the head, but can also be caused by a blow to the body that snaps the head forward or backward.

    Sometimes, a concussion causes an immediate loss of consciousness, but a child can also appear fine at first and then have symptoms develop later.  Symptoms of a concussion usually include:

    • headaches
    • difficulty falling or staying asleep (insomnia) or excessive sleepiness
    • nausea
    • dizziness
    • confusion
    • difficulty concentrating
    • difficulty remembering things
    • problems with balance and coordination

    These symptoms can last anywhere from a few minutes to a few weeks after the injury. All concussions cause some disruption to the brain, and call for an exam by your child’s regular doctor as well as careful monitoring.

    The good news is that most concussions don’t cause any lasting effects, and most children make a complete recovery with physical and mental rest. Even when concussions lead to complications, advances in concussion diagnostics and treatment make the majority of cases very treatable.

    How Boston Children’s Hospital approaches concussions

    Children’s has a long and distinguished history of caring for children with complex diseases and disorders of the brain, spine and central nervous system. Clinicians in our Department of Neurology and Department of Neurosurgery are regarded as international leaders in treating conditions that range from rare syndromes to relatively common injuries like concussions.

    In addition, Children’s Division of Sports Medicine is at the forefront of advocating for greater understanding of – and better treatments for – concussions and other head injuries sustained during athletics. Student-athletes are playing at higher levels of competition (and facing more pressure to return to play) than ever before. Recognizing that student-athletes of all ages are at elevated risk for concussions, the Division has established a Sports Concussion Clinic that:

    • uses a team approach to treat each child, involving specialists in sports medicine, neuropsychology, neurology, and neuroradiology
    • works with school districts across the Boston area to:
    • provide screenings
    • raise awareness of concussion symptoms and risk factors among coaches, athletic trainers, parents and the athletes themselves

    Here in the Sports Concussion Clinic, we use a computerized test called ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) to obtain baseline evaluations of neurocognitive functioning (thinking, memory, concentration and information-processing abilities) in children who have sustained a concussion.

    Through our state-of-the-art assessment tools, relationships with schools and coaches and multidisciplinary team approach, Children’s Hospital Boston provides an essential medical perspective and outlines measurable steps for athletes, coaches and families. 

    Tackling concussions head on

    Watch Children's live webcast on pediatric concussions.

     

     

    News Stories

    Evidence shows cognitive rest aids concussion recovery

    Skip the homework if you've got a concussion

    Children's concussions and brain rest

    Concussion recovery delayed by mental activity, study shows

    Concussions: Reviewed by Alyssa Lebel, MD and William Meehan, MD
    © Boston Children’s Hospital ; posted in 2011

  • In-Depth

    While recent news coverage has focused extensively on the issue of concussions in professional athletes, the fact remains that kids get concussions, too – and not only from sports.

    A concussion is a traumatic brain injury that:

    • is most often caused by a direct blow to the head, but can also result from body blows that snap the head forward or backward
    • sends the brain into a spinning motion 

    What happens when a child gets a concussion?
    Concussions usually cause:

    • headaches
    • difficulty falling or staying asleep (insomnia) or excessive sleepiness
    • dizziness
    • nausea
    • fatigue
    • difficulty concentrating, remembering and paying attention
    • problems with balance and coordination 

    How are concussions treated?
    Rest (both physical and mental) is usually the best treatment for a concussion, and symptoms typically improve within a few days and are gone within a month. After symptoms have cleared up, children can resume their normal school, home and sports routines as long as they have been evaluated and given the ok by their doctor.

    How do I know if my child needs to see a specialist?
    It is possible that a child with a concussion will need more specialized treatment. If your child is not getting better – or is actually feeling worse – after the first few days, you should ask for a referral to a specialist. 

    Rarely, a child with a concussion will experience serious complications. You should seek immediate emergency care if your child:

    • has blood or fluid coming out of her nose or ears
    • has a seizure
    • loses consciousness
    • has worsening headaches
    • vomits repeatedly
    • experiences difficulty breathing
    • has trouble walking or standing
    • experiences a change in pupil size (one is bigger than the other, or both are abnormally enlarged)
    • starts slurring her speech or experiencing difficulty speaking
    • develops noticeable bruising or a large bump anywhere on her head

    Why is there such a focus on concussions in student-athletes?
    While children frequently sustain concussions for other reasons – falls or car accidents, for example – student-athletes are at particular risk. According to the U.S. Department of Health and Human Services’ Centers for Disease Control and Prevention, as many as 3.8 million concussions happen each year in the U.S. during sports or recreational activities. This is especially troubling because:

    • an athlete who has had a concussion is at increased risk of suffering another
    • athletes can develop second impact syndrome if they sustain another concussion before a prior concussion has fully healed. This is a rare but severe syndrome that can cause swelling in the brain, brain damage, coma and even death.

    Here at Children’s Hospital Boston, we treat concussions with a multidisciplinary approach – combining our clinicians’ expertise in sports medicine, neuropsychology, neurology, and neuroradiology. Our experts are fully equipped to assist your child – and each member of your family – at every step of the way. 

    Children’s neurosurgeon pushes for concussion safety
    New legislation has gone before Massachusetts lawmakers that would make concussion education a requirement for all athletes who participate on public school teams, as well as parent volunteers, school medical personnel and coaches. Learn how Children’s neurosurgeon Mark Proctor, MD, is advocating for this essential bill.

    Causes

    What causes a concussion?
    A concussion is caused by the brain going into a rapid spinning motion. This most often happens because of a direct blow to the head, but it can also happen if the head is snapped forward or backward by a blow to the body (for example, a hit to the chest or facemask during sports).

    Signs and symptoms

    What are the symptoms of a concussion?
    Most children with concussions will have headaches and difficulty falling or staying asleep (insomnia). They can also experience:

    • dizziness
    • excessive sleepiness
    • nausea
    • fatigue
    • confusion
    • memory loss
    • difficulties concentrating
    • problems doing their schoolwork
    • difficulty with balance and coordination

    All of these symptoms should start to improve after a few days of rest and refraining from any strenuous physical or mental activity.

    It’s important for parents to recognize possible symptoms, because younger children don’t always realize that what they are experiencing could be linked to a concussion. Parents should watch for any evidence of their child:

    • being slow to acknowledge or respond when spoken to
    • struggling with balance and coordination
    • looking or acting “spaced-out”
    • appearing “glassy-eyed”

    If you suspect your child may have sustained a concussion, you should always seek treatment from a qualified medical professional right away. Even if the trauma your child experienced appeared very minor – for example, a collision during a game that he quickly got up and walked away from – and his symptoms don’t seem “serious,” it’s essential that he be evaluated by a doctor.

    FAQ

    Q: Will my child be OK?
    A:  Most likely, he will be just fine. The vast majority of children who have sustained a concussion make a complete recovery with no complications. However, it’s crucial that a child with a concussion is diagnosed and treated properly, and that he avoids physical and mental exertion for the period of time recommended by his doctor.

    Some children with concussions do develop more serious complications. It might be months before they regain normal brain function and feel “like themselves” again. This is especially true of children who experience a second concussion when they have not fully recovered from their first.

    If your child has suffered a possible concussion, the most important thing you can do to maximize his chances of a full recovery is to seek immediate medical treatment. Always follow prescribed recommendations for rest, monitoring and follow-up care. And, if your child plays sports, be sure to adhere to the restrictions and gradual schedule for return to play outlined by his doctor.

    Q: Is a direct blow to the head the only way of getting a concussion?
    A:
    No. Concussions occur when the brain is sent into a sudden "spin," which can also happen when there's a blow to the chest or torso that causes the head to snap forwards or backwards.

    Q: Which sports carry the highest risk of concussion?
    A: Football tends to attract the most attention in the media, but ice hockey players are just as likely – if not more likely – to suffer sports-related concussions. And virtually any sport or physical activity can result in concussions: here at Children’s, we have seen patients with concussions sustained during baseball, softball, rugby, wrestling, lacrosse, soccer, basketball, field hockey, horseback riding and even swimming!

    Q: Is a concussion always obvious right away?
    A: Most of the time, warning signs show up shortly after the initial impact. However, it’s also possible that symptoms won’t emerge until later  (or that they will be subtle enough to be overlooked, especially if the child has also suffered a more visible injury like a fracture or laceration).

    For this reason, it’s a must that – even if your child has received immediate treatment from a coach, athletic trainer, school nurse or EMT, or in the emergency room – he also see his regular doctor as soon as possible. He should be monitored closely for the next few days.

    Q: Is there any way to prevent concussions? Can’t helmets and mouthguards stop them from happening?
    A:
    Nothing can prevent a concussion altogether. Helmets were designed to guard against catastrophic brain injuries, not concussions (and mouthguards, although very good at protecting the mouth and teeth, don’t lower the risk of concussions, either.)

    Neck-strengthening exercises can likely reduce the chance of your child’s head snapping forward or backward if he sustains a blow to the body. Talk to your doctor about recommended exercises for your child’s age, size and (if applicable) the sport he plays.

    Finally, if your child has already suffered one concussion, the best way to prevent another is to make sure he has recovered fully (getting plenty of mental and physical rest) and has been cleared by a doctor before returning to his normal routine, including athletics.

    Q: What is chronic traumatic encephalopathy? Could my child develop it as an adult?
    A:
    Chronic traumatic encephalopathy is a relatively new diagnosis. It is a rare syndrome that has been observed in some former athletes – most notably, football players – who suffered multiple concussions during their sports careers, and went on to experience severe mental health and memory problems later in life. Autopsies have revealed changes in their brains that are very similar to the changes caused by Alzheimer’s disease.

    Doctors and researchers believe that sustaining repeated concussions on the playing field may have caused irreversible brain damage in these athletes. However, since the disease is so newly discovered, and research is still in the very early stages, it is entirely possible that other factors beyond multiple concussions were involved.

    Q: What is second impact syndrome and is my child is at risk?
    A:
    Second impact syndrome happens when someone who has not completely recovered from a prior concussion sustains another blow to the head, even a minor one.  For reasons that doctors do not fully understand, some of these individuals experience massive brain swelling that can lead to a coma or even death. 

    Although second impact syndrome has received widespread news coverage, it is a rare phenomenon. It can be avoided by reporting concussions, and being honest with medical personnel.  It’s always essential that a child who sustains a concussion is given plenty of time to heal and rest – and gets formal clearance from his doctor before returning to playing sports and the rest of his daily routine.

    Q: Does my child need to give up sports if she’s suffered a concussion?
    A:
    Most likely, no. Nearly every student-athlete who experiences a concussion can eventually return to sports – but only gradually (after getting the prescribed amount of rest), and only with a doctor’s explicit permission. Talk to your child’s doctor about the approach that will work best for her. 

    Concussions: Heads, you lose
     At every level of competitive sports, coaches, athletes and parents are rethinking when it’s appropriate for athletes return to the game. As Children’s Hospital Boston’s William Meehan, MD, director of the Sports Concussion Clinic, writes in this article, the days of an athlete “having his bell rung” and then jumping back in to the game are gone.
  • Tests

    How is a concussion diagnosed at Children’s Hospital Boston?
    Typically, we will first perform a neurological and physical exam of your child and obtain a full medical history. We will also conduct a standardized assessment of his balance and coordination, and use computerized tests to measure any effects on his neurocognitive functioning – how well his brain works when processing certain kinds of information.

    If your child plays sports, ideally he will have had a baseline test performed before his injury that we can use for comparison after a concussion. Here at Children’s, we use a system called ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) to track a child’s progress as he heals. The goal is to get him to a point where his scores match what they were before his concussion.

    Because this type of testing is so precise, and gives such a clear picture of a child’s neurological and cognitive functioning after a concussion, we strongly recommend that any child or adolescent who plays sports – particularly high-concussion-risk sports like ice hockey, football, rugby and soccer – be tested. Learn more

    When to return to play
    Watch these video clips for advice from Children’s neurosurgeon Mark Proctor, MD, on returning to athletics after a concussion.

    Concussions and CT scans
    Lise Nigrovic, MD, MPH, of Children’s Hospital Boston co-led a study suggesting that the frequency of CT scans can be reduced by over 50 percent by allowing an observation period after minor head blunt trauma, such as a concussion. Learn more about this study in the Children’s newsroom.
  • What to expect after a concussion
    Michael O’Brien, MD, director of our Sports Concussion Clinic, and Marilou Shaughnessy, PsyD, sports psychologist from the Sports Medicine Division, offer some advice.

    What are the treatment options for a concussion?

    Rest
    The main part of any concussion treatment plan is rest – both physical and mental. Rest allows the brain to heal and gradually return to its normal level of function. 

    This means, for the time duration specified by her doctor, your child must:

    • remain quiet, undisturbed and stress-free
    • get plenty of sleep
    • stay away from the computer (avoid video games and marathon text-messaging sessions!)
    • (if applicable) avoid driving cars, riding bicycles or ATVs, or operating any type of machinery

    Depending on the severity of her symptoms, your child may need to stay home from school for a few days. (Most children and teens will start to feel better within a couple of days, and nearly all will make a full recovery within a month – but some will take longer.) She should not read or do homework, as well as anything else calling for intense concentration, until given permission by her doctor.

    If your child plays sports, she will be taken out of practice and games for a designated period of time (and she will have to sit out phys. ed. class and recreational exercise, too). Only when her doctor has examined her and given her the “all clear” should she resume her normal school, home and sports routines. Read more in our “Returning to sports” section below. 

    Medication
    Although no medication can “cure” a concussion, your child's doctor may prescribe medication to help manage her symptoms, such as headaches or difficulty sleeping.

    Always follow the exact dosages and instructions you are given. If you have questions about any medication, or are concerned that your child may be experiencing side effects, never hesitate to call or see your doctor right away.


    Complications

    The most common complication of a concussion is a delayed or lengthy recovery. If your child's symptoms aren't getting any better after the first few days – or if they are becoming worse – he should see a doctor. 

    Rarely, a child with a concussion will experience serious complications.You should seek immediate emergency care if your child:

    • has blood or fluid coming out of her nose or ears
    • shows symptoms of a seizure
    • loses consciousness for several minutes
    • has worsening headaches
    • vomits repeatedly
    • experiences breathing difficulty
    • has trouble walking or standing
    • experiences a change in pupil size (one is bigger than the other, or both are abnormally enlarged)
    • starts slurring her speech or experiencing difficulty speaking
    • develops noticeable bruising or a large bump anywhere on her head


    Returning to sports

    If your child is involved in sports, it's essential that she not resume practice or play until her symptoms have resolved, balance has been re-established and her pre-concussion brain functions have been restored. Doctors can assess her brain functions at multiple stages of recovery with neurocognitive testing, like the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) system used here at Boston Children's Hospital. 

    Returning to sports after a concussion is a gradual process that takes place over a series of steps, and should always be directed and observed closely by your child's doctor. The process typically looks something like this: 

    1. A period of absolute rest from any and all physical activity, until all concussion symptoms have disappeared. (This may take anywhere from a few days to several weeks, depending on your child's individual symptoms and circumstances.) 

    2. Clearance to start light aerobic activity, such as walking or riding an exercise bike. 

    3. Clearance to resume warm-up activities related to the child's sport (for example, jogging on a training track or swimming laps). 

    4. Clearance to take part in non-contact training drills. 

    5. Clearance to resume resistance training, gradually upping the level of difficulty with each session. 

    6. Clearance to return to full-contact training/practice.  This can only begin after a doctor has deemed it safe.  

    7. Clearance to take part in games or meets. 

    If concussion symptoms re-emerge at any time during any of the steps, your child should see her doctor immediately. She may need to go back to the previous step (or several previous steps) until symptoms subside and her doctor gives the OK. 

    It's critical that your child not rush to get back to the playing field before her brain has healed; returning too soon will increase her risk of suffering another concussion. And although second impact syndrome – caused by a concussion sustained while the brain is still recovering from a prior concussion – is rare, it can be life-threatening. Your student-athlete is undoubtedly passionate about her sport and her teammates … but nothing is more important than protecting her health.

    Caution and patience are vital, and you are your child's greatest advocate as she progresses in her healing. If your child's coach, trainer or fellow athletes are pressuring her to return to play, refer them to the Centers for Disease Control (CDC) website on concussion, or remind them of Massachusetts State Law, which prohibits the return to athletics after a concussion until written clearance from a doctor has been obtained. 


    Monitoring and follow-up

    How often your child will need to see his doctor for follow-up care after recovering from  a concussion – and how long he will need to be monitored – depends on his individual circumstances (such as his age, the severity of his concussion, whether he plays sports) and the exact symptoms he experienced.

    Some children will need only standard annual check-ups, while others may require ongoing assessments and neuropsychological testing. Ask your doctor for detailed follow-up recommendations.

    Are concussions an “invisible epidemic”?
    Recent news headlines have people asking if testing for a concussion can involve equipment as simple as a hockey puck. Read more.

    Coping and support

    In addition to the clinical information provided on this webpage, Children's offers several other resources designed to give your child and family comfort, support and guidance. 

    Resources at Boston Children's Hospital

    • Children's Center for Families is dedicated to helping families locate the information and resources they need to better understand their child's particular condition and take part in their care. All patients, families and health professionals are welcome to use the center's services at no extra cost. The Center for Families is open Monday through Friday from 8 a.m. to 7 p.m., and on Saturdays from 9 a.m. to 1 p.m. Please call 617-355-6279 for more information. 
       
    • Children's Behavioral Medicine Clinic helps children who are being treated on an outpatient basis at the hospital—as well as their families—understand and cope with their feelings about:
      • being sick
      • facing uncomfortable procedures
      • handling pain
      • taking medication
      • preparing for surgery
      • changes in friendships and family relationships
      • managing school while dealing with an illness
         
    • The Experience Journal was designed by Children's psychiatrist-in-chief, David DeMaso, MD, and members of his team. This online collection features thoughts, reflections and advice from kids and caregivers about living with a variety of medical conditions, the “befores” and “afters” of surgery and going through many other medical experiences.
       
    • Children's Department of Psychiatry offers a free booklet, “Helping Your Child with Medical Experiences: A Practical Parent Guide.” (Adobe Acrobat required to view and download) Topics in the booklet include:
      • talking to your child about her condition
      • preparing for surgery and hospitalization
      • supporting siblings
      • taking care of yourself during your child's illness
      • adjusting to life after treatment
          
    • The Children's chaplaincy is a source of spiritual support for parents and family members. Our program includes nearly a dozen clergy members—representing Episcopal, Jewish, Lutheran, Muslim, Roman Catholic, Unitarian and United Church of Christ traditions—who will listen to you, pray with you and help you observe your own faith practices during your child's treatment.
       
    • Children's International Center is a resource for patients and families from countries outside the United States. The center can provide assistance with everything from reviewing medical records to setting up appointments and locating lodging. Contact the center by phone at 01-617-355-5209 or via e-mail at international.center@childrens.harvard.edu.  
    General guide for patients and families
    Read our guide to essential information across the hospital.


    Helpful links

    Please note that neither Boston Children's Hospital, the Department of Neurology nor the Division of Sports Medicine at Children's unreservedly endorses all of the information found at the sites listed below. These links are provided as a resource.

    Did you know?
    Children's has an Integrative Therapies Team, offering services like therapeutic touch, massage therapy, Reiki and more.
  • At Boston Children’s Hospital , our care is informed by our research, and our discoveries in the laboratory strengthen the care we provide at each child's bedside. Children’s scientific research program is one of the largest and most active of any pediatric hospital in the world.

    In particular, our neurology, emergency medicine and sports medicine researchers are yielding crucial insights into the causes and development of concussions, paving the way for the promising new treatments.

    Study finds CT scans are frequently unnecessary after head injury
    Overall, roughly half of U.S. children taken to hospital emergency departments (EDs) for a head injury receive a head CT scan, often to ease worried parents’ concerns. Yet true traumatic brain injury is uncommon. A multi-center study of more than 40,000 children with minor blunt head trauma, co-led by Children’s Hospital Boston, shows that allowing a period of observation can reduce the use of head CT by as much as half without compromising care – and without exposing children to ionizing radiation. 

    Kids who receive neuropsychological testing after concussions are sidelined longer
    When computerized neuropsychological testing is used, high school athletes suffering from a sports-related concussion are less likely to be returned to play within one week of their injury, according to a study in The American Journal of Sports Medicine co-authored by Children’s clinicians William Meehan, MD and Pierre d'Hemecourt, MD.  

    A link between head injuries and epilepsy?
    As doctors re-examine many of the basic assumptions and long-held understandings about concussions, research by Children’s neurologist Alexander Rotenberg, MD, PhD, is shedding light on what happens on a molecular level during brain injuries. 

    Clinical trials

    Children’s is known for pioneering some of the most effective diagnostic tools, therapies and preventive approaches in pediatric medicine. A significant part of our success comes from our commitment to research—and to advancing the frontiers of pediatric health care by conducting clinical trials.

    Children’s coordinates hundreds of clinical trials at any given time. Clinical trials are studies that may involve:

    • evaluating the effectiveness of a new drug therapy
    • testing a new diagnostic procedure or device
    • examining a new treatment method for a particular condition
    • taking a closer look at the causes and progression of specific diseases 

    Children’s is involved in several multi-site clinical trials and studies. While children must meet strict criteria in order to be eligible for a clinical trial, your child may be eligible to take part in a study. Before considering this option, you should be sure to:

    • consult with your child’s treating physician and treatment team
    • gather as much information as possible about the specific course of action outlined in the trial
    • do your own research about the latest breakthroughs relating to your child’s condition 

    Taking part in a clinical trial at Children’s is entirely voluntary. Our team will be sure to fully address any questions you may have, and you may remove your child from the medical study at any time. 

    In the News

    Dr. William Meehan speaks about his new study about concussions in children on WGBH.com's "The Pressure To Win And New Concussion Research"

  • Maggie Hickey was a star athlete and scholar. But after hitting her head, she couldn’t exercise or study without coming down with crippling headaches and other mysterious symptoms. “My whole life was falling apart,” Maggie says. “I thought, ‘This just can’t be normal.’”

    She was referred to Children’s Hospital Boston, where the Hickeys were startled to learn that Maggie’s problems were due to the after-effects of a severe concussion. Read more. 

     

    More Stories on Thriving

    How to help your teen return to school after a concussion
    Subconcussive blows and soccer: what’s the headache?
    Are low-tech (and cheap) evaluations the future of on-field concussion testing?


     


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