Soccer Concussions Rise, With Treatment Less Certain
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The aftermath of concussion
One recent study analyzed what happens when adolescent athletes continue to play with sports-related concussion symptoms. The study compared recovery time and related outcomes between athletes who were immediately removed from play and athletes who continued to play with a concussion.

Neurocognitive and symptom data were obtained at baseline, 1 to 7 days, and 8 to 30 days after the injury. The subjects who continued to play took twice as long to recover and were nearly nine times more likely to recover more slowly than expected. The subjects who played through their concussion recovery also showed significantly worse neurocognitive performance than those who were suspended from play.

Another study, published recently in JAMA Pediatrics, has found that health-related quality of life in children and adolescents can be adversely affected long after concussion symptoms subside. Researchers enrolled about 1,700 children ages 5 to 18 who presented to the emergency department with a concussion. A third of these had persistent post-concussion symptoms after one month. These children had lower health-related quality-of-life scores than the subjects whose symptoms had abated. But even the patients without persistent symptoms had lower quality-of-life scores than published norms. The researchers write that such deficits "may persist for months even in children whose symptoms have resolved.”

Complicating matters even further, previous studies have shown that a person’s perception of their concussion severity actually increases the risk of enduring persistent symptoms. So it is vitally important to be optimistic when discussing recovery from concussion with children and adolescents.

Sit them out?
Now, a JAMA prospective study has found that engaging in physical activity early after concussion is associated with a lower rate of persistent symptoms in children. Researchers surveyed 2,400 children ages 5 to 18 years with acute concussion, as well as their parents, at three stages: in the emergency department, and at 7 and 28 days post-concussion.

Physical activity within 7 days, compared with no physical activity, was associated with significantly lower rates of persistent symptoms at 28 days (29% vs. 40%). For those with symptoms a week in, rates of persistent symptoms at 28 days were lower in those who engaged in early physical activity at any level, as compared to no activity. This includes not just light aerobic activity but moderate and full-bore physical activity.

Given the results of the prior research, how can this be? It turns out that these findings may not conflict with the above-mentioned studies as much as you might first perceive.

For example, this may mean that immediate return to play is indeed always associated with worse outcomes, but return to play within 7 days may (with a few major caveats) be healthy—for one thing because waiting too long to return to play may influence a child’s perception of concussion severity and therefore produce worse recovery outcomes, as the earlier study found.

And in the study that found quality-of-life scores to remain low and persist longer in the aftermath of concussion than we previously thought, could sitting out for too long have been one reason for this? In other words, are we misidentifying the cause of lower quality-of-life scores and moving in the wrong direction, away from return to play, only to make outcomes worse? It’s possible, but far from certain at this point.

In the case of the findings that saw worse symptom persistence in adolescents who “played through” their concussion healing process, it seems the large unknown in establishing return-to-play policy is precisely when youth ought to be allowed to begin active recovery. Clearly, immediately returning to play is not necessary nor presently recommended, given that the JAMA prospective study’s positive associations with return-to-play were observed during a 7-day post-concussion window.

Indeed, young athletes take longer to recover from concussions than older athletes, and so even if return to play turns out to speed recovery, it also puts them at increased risk of so-called “second-impact syndrome” and repeat concussions if they return too soon. Hence the caveats mentioned earlier: among them, risk of reinjury to the head surely limits activity type, regardless of intensity. Yet evolution of concussion management continues, as there is more compelling evidence that we may be wrong to recommend that all children with concussions observe strict physical rest until symptom-free.

It’s clear that official school and league guidelines are not sufficient to determine when your child is ready to return to play. These seemingly conflicting studies establish that we have not yet found a surefire treatment protocol that can be universally applied, as well as reinforce the idea that there is a range of concussion severity and symptom-recovery stages that require close physician monitoring throughout recovery.

Before it happens
In the meantime, there are steps to take before a child ever endures their first closed-head injury on the field:

  • Know the very latest concussion management and return-to-play recommendations and policies, while acknowledging that these are not sufficient, but a good first step.
  • Research concussions. Know the symptoms of the three grades of concussion to better spot them right away.
  • Make reporting blows to the head policy among young players. Be sure to emphasize that such blows should be reported even in practice, where most concussions occur.
  • Limit heading the soccer ball: Prohibit heading for children under 11 and limit it until children reach age 14.

Pediatrics, 2016, Vol. 138, No. 4, http://pediatrics.aappublications.org/content/138/4/e20160346

Pediatrics, 2016, Vol. 138, No. 3, http://pediatrics.aappublications.org/content/138/3/e20160910

JAMA Pediatrics, 2016, Vol. 170, No.12, http://jamanetwork.com/journals/jamapediatrics/fullarticle/2569451

JAMA, 2016, Vol. 316, No. 23, pp. 2504-2514, http://jamanetwork.com/journals/jama/fullarticle/2593568

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