Understanding the dangers of concussions

CHKD physicians lead the efforts to improve concussion care.

By Greg Raver-Lampman

Sarah Cottrell
CHKD physicians lead the efforts to improve concussion care.

The third time Sarah Cottrell suffered a concussion, she knew it immediately – and she knew what she’d face in the days and weeks ahead. Clutching her head after an accidental blow from another lacrosse player’s stick, Sarah began bracing herself for the splitting headaches, dizziness, anxiety, nausea, fatigue and concentration problems that made sitting through a single 45-minute high school class almost impossible.

Sarah, 17, had also learned enough about the dangers of concussions from Dr. Joel Brenner, medical director of the sports medicine program at CHKD, to realize that her lacrosse days were probably over. Dr. Brenner, a national leader in the push to protect young athletes from repeated brain injuries, was afraid the rising senior at Norfolk Academy would risk permanent brain damage if she kept playing.

“I never really understood the severity of concussions until all this happened to me,” said Sarah, who suffered her injuries in the spring and fall of 2009 and the spring of 2010. “A lot of people think you can just play through it, tough it out. It’s difficult because it’s not an injury you can see. The third time I had one, I didn’t want to admit it. But I felt so bad that I didn’t even want to stand up. I just wanted to sleep all day.”

Over the past year, Dr. Brenner has been working with CHKD neurologist and state Sen. Ralph Northam to help other athletes as well as parents and coaches understand that concussions present special risks to young athletes.

In last year’s General Assembly session, Sen. Northam sponsored legislation requiring school systems to develop standards for identifying and treating sports concussions and educate athletes and parents about their risks.

Dr. Brenner traveled to Richmond to testify on behalf of the legislation, which passed and was signed into law last spring.

The two doctors are now working with the Virginia Board of Education to develop guidelines that will go into effect. Virginia is one of at least 10 states to pass such legislation.

Sarah Cottrell
Sarah’s symptoms were so severe that for weeks she struggled during tests and developed cold sweats and severe nausea trying to take notes in the classroom.

As chair-elect of the American Academy of Pediatrics’ Council on Sports Medicine and Fitness, Dr. Brenner was also involved in the recent publication of AAP’s national guidelines on pediatric and adolescent sport-related concussions, the first pediatric-specific guidelines ever for the treatment of sports concussions.

Nationwide, the Centers for Disease Control and Prevention estimates about 3.8 million people a year suffer some kind of concussion while playing sports; approximately 10 percent of athletes in contact sports have one each season.

Dr. Brenner, the state’s only provider who is board-certified in pediatrics, adolescent medicine and sports medicine, has treated athletes from all sports, although the riskiest tend to be football, basketball and soccer. In peak seasons, he may see 10 or 12 new concussion patients a week.

A concussion can occur after any blow to the body or head that causes the head to whip back and forth. That force slams the brain against the inner wall of the skull. While concussions can range from mild to severe, all temporarily interfere with brain function. Symptoms, which vary widely by person and may not appear right away, can include headaches, dizziness, nausea, memory problems, loss of balance, double vision, anxiety, irritability and sleep disturbances.

Contrary to popular opinion, most young concussion patients don’t ever lose consciousness; in fact, just 10 percent do. Sarah Cottrell, an aggressive defender on her school’s varsity lacrosse team, remembers feeling as if she was in a haze after her first injury, when she collided with another player and fell, hitting the back of her head against the ground.

“It seemed like clouds were all around me, and I was moving very slowly,” she said. “And I wanted to come out of the game, which is totally unlike me.”

After Sarah’s second and third concussions, both caused by blows from lacrosse sticks, her symptoms were so severe that for weeks she struggled during tests and developed cold sweats and severe nausea trying to take notes in the classroom.

Her mother estimates she missed close to 30 days of school, counting days she had to go home early. “Such situations are common,” said Dr. Brenner, who helps athletes get academic accommodations as they heal. “Your brain needs to rest just as much as your body does,” he said. “Unlike adults, the young athlete’s job is to learn in school, and trying to do this while recovering from a concussion can worsen symptoms and prolong recovery.”

Sarah Cottrell
Sarah, shown here in her playing days, has decided to stop playing lacrosse to avoid the risk of future concussions.

In fact, rest is the only way to heal a concussion, although doctors can treat headaches with medication. Most children who suffer concussions can return to play after fully recovering. If athletes return to the playing field too soon, they are at higher risk for a second concussion, as well as for a condition called post-concussion syndrome in which symptoms can linger for months or even years.

“I have seen some athletes who still aren’t completely recovered two years after their injuries,” Dr. Brenner said. “People need to understand that these are traumatic brain injuries, even if symptoms are mild.”

Even worse is the small but real risk of “second-impact syndrome,” when a second head injury happens before an earlier one has healed. This can cause rapid brain swelling, permanent brain damage and even death. Furthermore, doctors are discovering evidence that repeated concussions may, over time, increase the chances of chronic traumatic encephalopathy (a condition similar to Alzheimer’s disease).

Treatment recommendations are evolving as knowledge improves. Not long ago, players who suffered concussions might resume play after 15 or 20 minutes if they reported feeling normal. Virginia’s new law will enforce an updated standard: Players can’t go back into the same game or practice if a concussion is suspected and can’t return without written clearance from a health professional. Before each season, students and parents will have to sign a form stating they have learned about possible short- and long-term effects of the injury.

“We’re protecting people from themselves,” Dr. Brenner said. “Sometimes players aren’t completely honest about how they’re feeling because they want to keep playing. Sometimes concussions go unrecognized or under-treated by coaches, parents and athletes because they’re not always obvious. We just want to help make sure they’re always taken seriously.”

CHKD doctors regularly give talks to coaches and parents in the community, and the hospital is partnering with a growing number of local schools (see page 17) to implement a comprehensive concussion program which includes a diagnostic tool called ImPACT. The non-invasive, computerized ImPACT test precisely records a child’s brain function, including reaction time, attention span, memory and problem-solving ability. If schools get baseline measurements of all athletes, doctors can compare those to results after a head injury.

In the end, though, many families still have to make judgment calls. Sarah’s doctors, coaches and parents – Becky and Ben Cottrell – were cautious about letting her return to lacrosse after her first concussion and especially her second, and Dr. Brenner now believes that she may simply be more susceptible to brain injury for unknown reasons. He and her parents hope she will avoid long-term health problems by sticking to non-contact sports. That means Sarah, who had hoped to play lacrosse in college, will be a team captain next season – but almost certainly will be cheering from the bench.

“We just don’t know what would happen if she played,” Becky said. “Maybe she’d be fine, but maybe she really wouldn’t. Our doctors have made us understand all the risks. It makes all of us sad, but it’s just not worth the risk.”

Drs. Brenner and Northam practice with Children’s Specialty Group PLLC at CHKD.

This story was featured in the fourth quarter 2010 issue of KidStuff, a publication of Children's Hospital of The King's Daughters. Click to read more patients' stories.