Go Conservative With Youth Concussions

ACEP News
September 2009

By Bruce Jancin
Elsevier Global Medical News

KEYSTONE, COLO. -- No athlete under the age of 18 who experiences a concussion should ever be allowed to return to play on the same day, according to recent consensus recommendations arising from the Third International Conference on Concussion in Sport.

This position is solidly based in incontrovertible evidence that the still-developing brains of adolescents and children are slower to heal from concussions, Michael W. Collins, Ph.D., said at the annual meeting of the American Orthopaedic Society for Sports Medicine.

"The younger you are, the longer it takes to recover from the injury. The data [are] unquestionable that kids are different. The only cases of second-impact syndrome have happened in adolescents and young adults, the point being that the developing brain is more vulnerable," explained Dr. Collins, assistant director of the University of Pittsburgh Medical Center Sports Concussion Program.

The guidelines state that athletes under age 18 years must be carefully monitored with their activities restricted until they have fully recovered from their concussion. That means no exertion--physical or mental. No video games, no text messaging, no cramming for tests, and perhaps even, for a time, no school. Neurocognitive testing while the young athlete still is symptomatic is recommended in the guidelines as useful in assisting physicians in planning regarding school and home management (J. Clin. Neurosci. 2009; 16:755-63).

The concussion conference, hosted by FIFA (the Federation Internationale de Football Associations, sponsor of soccer's World Cup) took place in Zurich late last year. The consensus guidelines urge moving away from concussion severity grading scales, a proposal enthusiastically endorsed by Dr. Collins.

"We know the grading scales are not effective," he said. "You will never hear a grade of concussion come out of my mouth. It doesn't predict anything in terms of prognostic outcomes."

Similarly, it's time to abandon some of the traditional phrases intended to provide reassurance to athletes, parents, and coaches that a concussion is minor or insignificant, such as "Don't worry--you just got your bell rung," or "He merely got dinged."

"Those terms need to be replaced by 'What symptoms are you having? Are you having headaches, feeling dizzy, fatigued, nauseous, photophobic, foggy?' " Dr. Collins continued.

The consensus report states there is little role for neuroimaging except when a structural lesion is suspected, a view shared by Dr. Collins.

"Concussion is not a structural brain injury, it's a metabolic crisis. You can't see it on CT or MRI," he stressed.

This metabolic crisis involves injury-induced increased neuronal energy demand at the same time cerebral vasoconstriction causes decreased energy delivery.

The consensus report introduces the Sport Concussion Assessment Tool 2 (SCAT2), designed as a practical aid to physicians in evaluating injured athletes in the emergency department, office, or on the sidelines. However, the report's authors note that the SCAT2 has yet to be formally validated, and they name that as a research priority.

 

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