Concussions in Kids: Lessons From The Pros

As sure as the sun rises and sets every day, resistance from sports parents and young athletes with return to play recommendations, especially when it comes to concussions, is something I’ve come to expect in my work as an urgent care pediatrician. This is one of the biggest uphill battles we face as pediatricians but one we can’t afford to lose without resulting in dire consequences for an athlete and a family.

For concussions, Boston Bruin’s Patrice Bergeron’s story and his cautious, step-wise slow return to play when he returned to the ice in early 2009 the exact play book we need to follow when handling concussions in athletes of ages, and is consistent with current recommendations from the American Academy of Pediatrics as explained in the January 2009 Pediatrics with a hot off the presses Clinical Report released in the September 2010 Pediatrics.

Bergeron sustained his second concussion on December 20, 2008, the having occurred on October 27, 2007 after playing only ten games during that season. On January 4, 2009, two weeks post-injury, Boston Bruins General Manager Peter Chiarelli reported that Bergeron was starting light exercises because his symptoms were progressing well. Bergeron continued his slow, step-wise return to play until his return to the ice January 11, 2009 but was not cleared to play a game until January 27, 2009. His health was the driving factor; not playing in a game.

The currently accepted, step-wise return to play protocol involves starting with rest and progressing slowly as follows:

Step 1: No activity with rest.

Step 2: Light aerobic activity

Step 3: Sport-specific exercise

Step 4: Noncontact drills; progressive resistance training

Step 5: Full contact training after medical clearance

Step 6: Game play

Like with Bergeron, we have to be very cautious with concussions in young athletes and follow a similar plan. Returning to play too quickly and skipping steps can result in either catastrophic neurologic events resulting in permanent issues or death. In addition, we must recognize that one concussion increases the chance that more concussions will occur. We must recognize that the symptoms of a concussion are variable and can be as obvious as headache and loss of consciousness to as subtle as feeling “out of it” or being moody. We must be realistic that most athletes fail to report their own symptoms in order to keep playing, putting them in harm’s way. And, we must be willing to recognize when a player has had too many concussions to make some sports safe to play at all. This is where a medical team and neuropsychological testing can be very helpful.

Parents and coaches need to be educated on this step-approach to concussions, but so, too, do the athletes if we are to keep our teams truly safe. Everyone needs to be on board with how the system works and why youth sports teams need DL’s just like the pros. For the players, it is imperative that they understand that a concussion is a guaranteed, nonnegotiable spot on the DL. They each only have one lifetime brain; this is the only way to keep that brain safe and healthy during high risk sports.

Put another way, playing one more game in the setting of a concussion is like playing Russian roulette. So ask your self, is the risk really worth it?

(Originally posted March 2009; Updated September 2010)

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