Sports: benefits and risks to children
A focus on concussion, a brain injury
My opening note
I am a retired physician and no longer in clinical practice. Hence, this particular article shall be taken as a general backgrounder should you witness a child or an adolescent, perhaps your own, suffer a concussion injury from sports-related or non-team related activity or accident. It is important that you promptly seek medical attention for that child so that prompt evaluation, diagnosis and management by a practising physician are done.
First, benefits and risks
Commendably, girls and boys by the thousands participate in sports. They reap the health benefits of exercise, develop self-discipline and self-confidence, and they have fun while learning some leadership skills. At the same time, they are at medical risk of acute and chronic injuries. One such injury is concussion.
On balance, the benefits outweigh the risks, particularly if players and amateur athletes play by the rules of the game.
Pediatricians opposed to boxing
We all know, however, of one sport activity – boxing – which “encourages and rewards deliberate blows to the head and face;” hence, participants are “at risk of head, face and neck injuries, including chronic and even fatal neurological injuries.” Thus, both the Canadian Paediatric Society and the American Academy of Pediatrics “vigorously oppose boxing as a sport for children and adolescents.”
Indeed, pediatricians recommend alternative sports. While alternative sports such as basketball, football, soccer, hockey, skiing, horseback riding and others, including bicycling and playground activities, have also been associated with injuries resulting in concussion, intentional blows to the head and face are not the central focus as they are in boxing.
Concussion and children
Medically, concussion is defined as “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces, and resulting in the rapid onset of short-lived impairment of neurological function that resolves spontaneously.” Simply put, it is a type of brain injury due to trauma. Although the definition ends with the clause, “short-lived impairment of neurological function that resolves spontaneously,” the condition should still receive the serious attention of all concerned. Caused mostly by a direct blow to the head, face or neck, it may also be caused “by a blow somewhere else on the body which transmits an impulsive force to the head.” Hence, it may be sustained by children and adolescents engaged in organized sports and recreational activities or following an accident such as a fall or a car crash. Fortunately, loss of consciousness is not common in concussion – less than one in ten – and, when it occurs, only lasts seconds.
The state of science on sports-related concussion continues to evolve. To keep all family physicians and pediatricians updated on current thinking, their medical associations periodically issue position statements and guidelines with certain specific recommendations on the topic, namely, the need for:
- medical examinations before engaging or considering certain sport activity, in some instances;
- sport organizations to provide medical presence or coverage at certain sports events;
- appropriate and timely medical care when injuries happen; and
- regular testing and examination of certain bodily functions following a certain type of injury.
Such position statements or guidelines also help ensure physicians are updated and their patients and their parents, health caregivers, teachers and coaches/trainers are adequately educated about medical risks associated with any kind of sport activity and how they are best managed.
Dr. Laura K. Purcell of the Healthy Active Living and Sports Medicine Committee of the Canadian Paediatric Society recently reported, based on the newest data and expert opinion, on the current recommendation with respect to sports-related concussion in children and adolescents, that is, “that the management of concussions should be individualized based on an athlete’s (participant’s) symptoms and recovery rather than on classification of severity, which can only be determined in retrospect after symptom resolution, cognitive recovery and passing a graduated exertional return-to-play protocol.”
Manifestations of concussion
A medically well informed coach/trainer, teacher, parent, health caregiver, parent and older child can correctly suspect or a medical doctor can make a clinical diagnosis of concussion if a child following an injury as described above manifests, singly or in combination, the following: headache, nausea or vomiting, balance problems, difficulty concentrating or remembering, answers questions slowly or repeats questions, dizziness, fuzzy or blurry vision, fatigue, sensitivity to light or noise, feeling mentally “foggy,” irritability or more emotional, sadness, nervousness or anxiety, sleeping more or less than usual, and difficulty falling asleep.
While these symptoms and signs neatly fall into four categories, namely, (1) physical signs, (2) changes in emotion and behaviour, (3) impairment of cognition or thinking and (4) sleep disturbances, diagnosis can still be missed, even by medical doctors. For example, stomach pain or upset can be the manifestation in younger children. Also, development of symptoms and signs may take hours and until the next day. While symptoms usually resolve in 10 days, they may last months. In fact, concussion, particularly if repeated, may have adverse impact on the ability of pediatric patients to do school work.
Evaluation and investigation
Immediately stopping the sport activity and removing the suspected concussed child from the game or game practice are a must and call for medical help must be done promptly. The medical doctor and the trained health caregiver would then assess the injured child. If the injured is unconscious, injury to the cervical spine must be assumed and extreme care and caution should be taken to protect the neck and ambulance transfer to the hospital emergency room should be done.
If the injured child is conscious and any of the manifestations is shown, concussion should be suspected and appropriate management initiated. The child should be closely observed through the night for any sign of worsening and “should be re-evaluated immediately in an emergency department” if any signs of deterioration occur. If in doubt, call the doctor again.
Since concussion is a functional, not a structural, brain injury, do not be surprised if the usual skull x-rays, computerized tomography [CT] scans, and magnetic resonance imaging [MRI]) are not routinely recommended; they usually are normal. What is important is repeated clinical assessment of the injured child.
Rest is key to management and includes both physical rest from such activities as exercise, bike riding, or even wrestling with siblings – and cognitive rest. The latter includes rest from “reading, texting, watching television, computer work and electronic games.” Modifications may have to be made to their schoolwork, including a gradual return to full-time. If symptoms persist for more than two weeks, they should see their doctor again for a full re-assessment and, if need be, a referral to a specialist.
No double-blind prospective study evaluating return-to-play (RTP) guidelines in pediatric concussed athletes has yet been published. Thus, the decision regarding RTP following concussion remains a most difficult area in concussion management. Be that as it may, there is consensus among experts on the following individualized approach:
- A pediatric athlete with a concussive injury should not be allowed to return to activity until all signs and symptoms have resolved and he or she has been cleared to do so by a physician;
- Children and adolescents should not be allowed to return to play the same day;
- Once children and adolescents have been symptom-free for several days, they should then follow a medically supervised stepwise exertion protocol;
- Each step should take a minimum of 24 hours
- As long as symptoms do not return, athletes may progress to the next step.
- If symptoms recur, athletes should rest for 24 to 48 hours before trying to progress again, and starting with the last level where they were asymptomatic.
Should you have any questions, please call your own doctor. This column is a backgrounder.
Dr. Rey D. Pagtakhan, former lung specialist and Professor of Pediatrics, Parliamentary Secretary to Prime Minister Jean Chretien and senior federal minister, is widely published and lectured in Medicine and Politics and has been the recipient of several awards and honours, including the honorary degrees Doctor of Laws and Doctor of Science, the Philippines’ Presidential Citation Pamana ng Pilipino Award, and the Governor-General Queen Elizabeth II Silver, Golden and Diamond Jubilee Medals.