It’s a grey fall day in Montreal, and 14-year-old Miranda is playing soccer with her teammates beneath a light drizzle of rain. A passionate and talented soccer player, she is proud to be playing at an elite level with the older girls. But suddenly the ball skips in front of her on the wet field. Another player – four years older and larger –misjudges the bounce of the ball and heads Miranda in the chest. Miranda’s head snaps back and she falls to the ground. But she shakes it off, gets up and continues to play. Later that day, she has a headache. A few days later, she has trouble breathing, which lands her in the hospital. She spends two days at the emergency room where specialists and top neurologists tell her family she has a virus. The concussion she has sustained goes undiagnosed for nine months.
Miranda’s mother, Maren Gube describes the concussion trials her teen has suffered as nothing short of “heartbreaking”. “We bounced from doctor to doctor with this ‘mystery ailment,’” Maren says. In the end, her teen lived with post-concussion symptoms for 18 months: “She missed out on so much of her teen-hood and her senior year in high school.”
Miranda eventually healed and moved on to play varsity soccer at a prep school in the United States at age 16. During practice one day, she suffered another concussion. “The coach had me clearing corner kicks, heading them out over and over again within the space of one practice,” says Miranda, now 18. “That night, I had a headache. I figured it was a concussion right away.”
Maren describes Miranda as a grade skipped kid who has always loved school and has a history of good grades. “It’s been very hard for her in the past two years, with the almost constant headaches, difficulties focusing, processing and memory issues.”
Today, any contact sport is out of the question. “She’s looking for a new sport – maybe running or tennis. I am exceedingly grateful that she is healthy, but I see her with a ball, and it’s just a shame.”
A 2013 Statistics Canada survey found that 30,000 concussions or related head injuries were reported annually among 12- to 19-year olds. In the the U.S., the number of people under 19 being treated for concussions increased from 150,000 in 2001 to 250,000 in 2009, according to the U.S. Institute of Medicine and National Research Council. This increase may be due in part to increased reporting. Still, knowledge around recognizing concussions can be as elusive as the concussion itself.
What is a Concussion?
“A concussion is an actual brain injury,” says Laura Leslie, a certified athletic therapist, osteopath and concussion consultant at Concordia Physio Sport Clinic in Montreal. The majority of concussions she sees are the ones that don’t get better in the standard two-week to one-month time frame.
Concussions are sustained in two ways: The first is from direct contact to the head. The second, like with Miranda, is when an indirect force goes into the head and is transmitted to the body, causing a whiplash effect of the neck and head.
“Most concussions are caused in an unexpected environment, meaning that you really don’t see what is coming and therefore you are not prepared to counter that force,” Leslie says. In kids up to 18, as well as any women who have not had experience with contact sports, there is a lack of instinct to receiving the hit. “In general, boys or men who have played all their lives are used to checking over their shoulders, keeping their heads up, being aware of their environment.” While some kids have more athletic experience than others, “Unless you are exposed to that, you don’t always learn that skill.”
Most pediatric concussions happen between ages nine and 16 – a time when kids are growing taller and longer but not getting stronger and there is great variability with an age group of sizes. “We see concussions occur anywhere on any age bracket,” says Leslie. Dr. Scott Delaney, research director in emergency medicine at McGill University Health Centre and McGill Sport Medicine Clinic, posits another reason why women and children tend to be at a higher risk for concussions. He sees more than 100 concussions a year and suggests that, “physically, the neck muscles in a female are not as strong as in a male. As well, a child is thought to be at a higher risk than an adult because there is a larger target, so the head and neck tend to absorb the force. When an adult is prepared for contact they contract their neck muscles – that helps to dissipate a force.”
Not surprisingly, concussions are common in toddlers. “They hit their heads often,” Dr. Delaney explains, reassuring us however, that, “Head injuries in the young age group have no repercussions or ill effects in the vast majority of kids.”
Study after study suggests that an increase in concussions may also be due to playing injured – this is a trend that is becoming evident in girls in particular. Some athletes won’t tell their coach they’re hurt, “because they fear disappointing the coach or they want to make the team, or the playoffs,” Leslie says.
Does my child have a concussion?
Because it’s a hidden injury, a concussion may not be evident. “For young children, we rely on vomiting as an indication,” Dr. Delaney says, “While for other people, balance testing (where the patient will be asked to stand on one leg with eyes closed) is the best thing in terms of a physical examination.”
We need to also be aware that symptoms don’t always occur immediately. “We’ve got this 72-hour window. If you think there is a possibility that a force was strong enough to cause a concussion, even though no symptoms are present, rest the child for three days, and see what evolves,” says Leslie. If there are no symptoms, call the family doctor. “If you suspect a concussion has occurred, go to the hospital right away. ”
Traumatic changes may be occurring in the brain. Leslie describes concussion symptoms as presenting in four main areas:
- Physical: headaches, nausea, vomiting and dizziness;
- Cognitive: poor memory, poor concentration, taking longer to think, and light and noise sensitivity;
- Sleep: (drowsiness, sleeping less or more than usual, hard to fall asleep);
- Emotional/behavioural: irritability, frustration, tearfulness, difficulty waking, sleeping or structuring the day. Personality changes might take place. “Someone who is usually outgoing can be emotional all of a sudden. At that point we get other people involved in the healing process.”
Leslie says that in a pediatric case, you can see depression and anxiety. “These individuals are at a higher risk of having a prolonged healing process.”
Recent studies reveal strong links between concussion and depression particularly in young people. It was previously thought that youth recovered quickly from concussion, but according to the Journal of Adolescent Health (JAH), new evidence suggests symptoms may persist for months or years, particularly after multiple concussions. Post-concussive depression, associated with substance abuse, school failure and suicide, is one of the most concerning. The JAH claims that teens with a history of concussions are three times as likely to suffer from depression compared to those who have never had one.
“There is also the reactive component,” says Dr. Delaney. “Even normally upbeat patients can feel similar to a depressed patient – flat and down. It’s not fun for someone who is active to hear that they have to stop exercising.”
Interestingly, concussions are one of the only injuries that take longer to heal in children than in adults, “which is contrary to everything else in medicine,” says Dr. Delaney. “What’s needed is complete rest.” According to Leslie, 85 percent of concussions get better in two weeks to a month with complete rest. “If you’re straining the brain, it is still utilizing all the resources and depriving the injured area, when it needs to heal and consequently we get into an unbalanced state in the head and then it goes into a crisis. That is when symptoms get worse.”
Patients must calm down in all four areas (physical, cognitive, sleep and emotional) to avoid over stimulating the brain so it can heal, Leslie says. “We know that complete rest in the first 72 hours promotes a faster recovery.”
That can be extremely challenging. JacquelineTomlinson-Sinclair, a Greensville, Ont., mom, the extent to which her daughter had to rest. “No reading. No electronic devices. No cell phone. Nothing too exerting.” While many doctors advise no school, Jacqueline’s daughter was able to attend but her physiotherapist came in to tell the teachers that no homework meant no homework. Another side effect? “Everything changed, her vision prescription for long distance and her teeth moved so she needed new braces.”
As well as complete rest, Dr. Delaney says doctors will often treat neck injury symptoms because they can sometimes be confused with the symptoms of concussion.
There are millions of children playing sports across North America, so we need better methods to assess concussive injuries. Dr. Delaney is currently researching biomarkers: blood tests that would indicate concussion with a simple ‘yes’ or ‘no.’ He also sat on a panel to introduce standard protective headgear for soccer, noting it has been mandated in some American leagues.
Another helpful tool is a system called Im- PACT (Immediate Post-Concussion Assessment and Cognitive Testing). This base-line, neurocognitive test is a computerized concussion evaluation system. The test measures multiple aspects of cognitive functioning in athletes, including: attention span, memory, sustained and selective attention time, problem solving and reaction time. Players are measured before the season and if they suffer a head injury, they get tested again.
Until their post-concussion test results resemble their pre-season baseline tests, players will not be allowed to return to action. “What we would like to see is more formal instruction on concussion, coaching, certification on concussion process structure,” says Dr. Delaney. This is exactly what Leslie’s group does, going into schools and giving lectures to the teachers at the beginning of the year, and offering resources. “The more knowledge people have the better they can make a decision.”
While, more and more organizations want to have information and be more aware about concussions, Leslie worries that this interest remains at the amateur echelon. “Once you get to the elite level there is more pressure to continue playing. “Coaches, teach your players to be fully aware of their surroundings,” Leslie says. “It’s not just about removing the child from play, it’s about all these other elements.”
Miranda’s parting words for players? “Resist the pressure to continue. If you think something is wrong, don’t be afraid of disappointing your parents or your coach and teammates. It’s your future. The sooner you take time off, the sooner you’ll be playing again.”
Heads Up – The 4 Rs of concussion
- Remove from play
- Rest (completely)
- Return to play
Beatrice Ekwa Ekoko is a Hamilton, Ontario mother to three teens, one of whom has a passion for soccer.
Originally published in ParentsCanada magazine, June/July 2014.