7 Concussion Myths

As the country is focusing more on concussions, I've seen a lot more kids come in after head injuries, many of which are concussions. Even some kids who went to an ER after a head injury get incorrect information about return to play sometimes.

Source: CDC Heads Up

Common myths and misinformation about concussions:

1. A normal head CT means no concussion and a full return to play is okay.

Concussions are not diagnosed by CT. Brain bleeds and masses can be seen on CT, but the damage done to the brain during a concussion is not seen on a CT. Concussions are diagnosed based on symptoms, such as headache, confusion, lack of coordination, memory loss, nausea, vomiting, dizziness, ringing in the ears, sleepiness, and excessive fatigue. Not all symptoms need to be present to make the diagnosis. Some symptoms develop over time and are not present at the time of injury.

A CT scan is usually not needed with head injuries. They involve radiation so are not without risk themselves. Unless there are signs of a possible bleed in the brain, skull fracture, or the type of injury suggests the need for a CT, a CT scan is not needed in the evaluation for concussion.

2. A minor hit to the head never causes concussions.

The force of a hit does not determine the severity of the injury. Some people with more significant problems initially also seem to heal more quickly than others with more mild injury. It is very hard to predict how long it will be until all symptoms are resolved. The most important thing is that if you have symptoms of a concussion, your brain needs rest.

3. After two weeks you can return to play without further testing.

Sadly I've had more than one patient who was given this advice from a medical professional, whether on the sideline at a game or in an emergency room or urgent care. Although most concussions resolve within 2 weeks, not all do and returning to play before the brain is healed can lead to a more serious condition called "second impact syndrome." Second impact syndrome is a very rare condition in which a second concussion occurs before a first concussion has properly healed, causing rapid and severe brain swelling and often catastrophic results, including death.

After a concussion clearance to return to play should only happen when the child, teen, or adult is re-examined and found to be symptom free. Returning to play is done in a stepwise fashion, with each step lasting at least one day and only progressing to the next step if symptoms don't resume. This starts with light exercise when there are no symptoms at rest, then progresses to moderate activity followed by heavy activity without contact, then full practice with contact (if the sport is a contact sport) and finally full competitive play if each step can be done without return of symptoms. If symptoms return, you back up to lighter activity.

Returning to play too quickly can prolong healing time and even lead to long term consequences. Do not return to any activity that causes symptoms to worsen!

4. If a coach doesn't recognize the concussion, it's minor enough to return to play.

Coaches cannot see everything that happens on a field. If you had a head injury, tell your coach. Even if you are the star player. Really. You will do your team a favor if you take time to heal and can play again versus stay in the game and get more severely injured and are out for good. See these real stories of concussion survivors.

Someone who is trained in concussion evaluation should do a sideline evaluation. If there is any chance of concussion, you should not return to play at all that day or until you are cleared by a doctor who understands concussions.

5. IMPACT testing is necessary.

IMPACT testing is a computerized test that measures neurocognitive functioning. Ideally a baseline is done prior to the season (or at least every 2 years) and then testing is repeated if a concussion is suspected. The results of the current test are compared to the person's baseline and can be repeated at intervals until the person is back to baseline and able to be cleared to return to play. It is one tool to help manage concussions and determine when it is safe to return to play, but at this time concussions are diagnosed based on symptoms and physical exam.

6. Complete bed rest until all symptoms are gone is best.

Bed rest for the first day or two can help enforce brain rest and allow healing, but may not be required and prolonged bed rest is specifically not recommended. Prolonged bed rest can increase stress in children who miss substantial amounts of school. This stress is thought to possibly prolong healing. Depression is more common if bed rest is enforced beyond 48 hours. Socialization with friends and family can help provide emotional benefits that aid in healing. This does not mean that people should participate in all social settings. They will likely need relative quiet, so even going to a sporting event to watch can lead to return of symptoms.

7. Concussions only impact sports.

Concussions take kids out of play, but other activities should also be limited until they are tolerated. Lights, sounds and even smells can trigger symptoms after a concussion. If anything leads to worsening of symptoms, it should be avoided. Things that take focus or a lot of brain work may cause symptoms to worsen. These include reading, watching television, or playing video games. Initially a child might need total restriction from these activities, and then can slowly add them back in small increments as tolerated. Many kids need to have breaks during school, a decreased work load, and shouldn't take standardized tests until they can focus for a prolonged time. If computers are used for school, it might be necessary to use paper books and worksheets and to limit computer use until it can be tolerated.

For more information:

• Heads Up is a free resource for parents, athletes, coaches, and medical professionals
• Acute Concussion Evaluation (ACE) Care Plan has all the typical symptoms of a concussion, general guidelines to healing, plus return to school and sport templates
• Dr. Mike Evans has two great concussion videos:

• Concussion 101

• Concussion management and return to learn

Play it Safe!

As the Spring sport season approaches, it is a good time to review the importance of playing safe to prevent injuries.  Parents want their children to grow up to be well rounded academically and physically.  A great way to be physically fit is to participate in sports, but often kids do too much too soon or play with an injury- which can lead to worsening the injury and removal from the game.  Unfortunately by 13 years of age many kids leave sports due to feelings of inadequacy or burnout.  They lose the many benefits of athletics, including physical exercise, mental well being, drug abuse prevention, and more.  Most young kids should not play at an elite level.  Not all will be natural athletes, but all can and should participate in life long sports to varying degrees.  Emphasizing having fun while improving performance can help kids feel less pressure to win and be the star athlete, but even the star should emphasize fun at younger ages!

In general there are two types of injuries: acute and overuse.  Overtraining syndrome is a mental as well as physical issue that can lead to decreased performance and sports burnout. Acute injuries are commonly recognized, and include things such as sprained ankle, wrist fracture, or concussion.  Overuse injuries are less often identified and are more difficult to diagnose.  They occur subtly over time from repetitive trauma to the bones, joints, and tendons.  Examples include little league elbow, gymnast wrist, or stress fractures.

Acute Injuries:  Although not all injuries can be prevented, you can decrease the risk of acute injuries  by adhering to the rules of the sport and the sport-specific safety measures recommended.  If injury is suspected, removal from the sport until injury is healed is important to prevent further injury.

Overuse Injuries:  In the child and adolescent, overuse is the cause of up to half of all pediatric sports injuries.  It is bone, muscle or tendon microtrauma caused by repetitive stress without adequate healing time.  It begins with pain after activity, then pain during activity without affecting performance, followed by pain during activity that affects performance, and finally pain even at rest.  Children are at increased risk because of their growing bones and inability to recognize or describe symptoms.



Overtraining Syndrome (“burnout”) is the psychologic, physiologic and hormonal changes that lead to decreased performance.  Symptoms include chronic muscle or joint pain, personality changes, increased heart rate at rest, decreased sports performance, fatigue, lack of enthusiasm, and inability to complete usual routines.  Prevention includes encouraging a variety of sports throughout the year, making workouts interesting and fun and having athletes take 1-2 days off per week, plus 2-3 months off per year for other activities.  Overtraining can lead to burnout in the early years, which can cause a child to end participation in sports altogether, which may cause inactivity and contribute to the obesity epidemic in our country.

In general, injury prevention begins with making sure your child is playing in a safe environment with a knowledgeable coach and well fitted safety gear.  My favorite tips:

• Remember that many coaches are volunteers with little (or no) specific training.  Don't assume the coach knows how to prevent or treat injuries... you should ask what their experience is!  Be sure there are always at least 2 adults around (this is abuse prevention... another topic entirely, but important!) 
• Encourage athletes to take the time to warm up and cool down.  
• Make sure athletes drink plenty of water, especially in warm weather. 
• Be sure they are playing at a level that meets their skills. 
• Let them know that they should enjoy playing for the fun of the game, not to win.  
• Be sure to remind them that you enjoy watching them play ~ not watching them win!  
• Have kids take time off a favorite sport to try something different for a season.  This not only keeps the game fun, but it works different muscle groups and improves overall fitness.  
• I am also a firm believer in sleep for kids of all ages! Sports practices and games can interfere with an appropriate bedtime and adequate sleep, so make sure your child doesn't suffer from sleep deprivation. 

American Academy of Pediatrics Guidelines and Recommendations Include:

• Athletes should take 1-2 days off per week from competitive athletics and competitive practice to allow physical and psychological recovery.
• Athletes should be a member of only one sport per season.
• Athletes should take at least 2-3 months away from a specific sport during the year.  During this time another fun activity can be done to prevent loss of skills or conditioning.
• The focus of participation should be fun, skill acquisition, safety, and sportsmanship.
• Weekly training time, number of repetitions or total distance should not increase by more than 10% per week.
• Watch for possible burnout if the athlete complains of nonspecific muscle or joint problems, fatigue or poor academic performance.  Consider time off at that time to allow physical and psychological recovery.
• Use caution for younger athletes who participate in multiple games during a short time period.
• Children should participate in a sport at a level consistent with their ability and interest.
• Single sport specialization should be avoided before puberty.  Young athletes who participate in different sports at various seasons have less burnout and fewer overuse injuries.
• Parents should be aware of the coach’s knowledge of proper training techniques, equipment and training of a particular age group.  Parents should encourage organizations to mandate coach training in these areas.
• Never allow an injured athlete to participate in activities until completely healed or cleared by a physician.
• Children are more at risk for heat injury.  Proper hydration should be encouraged.  Avoidance of prolonged activity in moderate temperatures or any activity in extreme temperatures should be enforced.  
• Ensure proper nutrition:         

Proper caloric intake is based on body size and growth rate in addition to calories burned.  Monitor for signs that the athlete is trying to lose weight to benefit performance (to the detriment of overall growth).

Balance nutritional elements based on the Food Guide Pyramid.

Adequate iron is needed.  The amount of iron needed in the diet is highest during the growing years and sports may contribute to iron losses.  Athletes need adequate iron to bring oxygen to tissues in the body.

Calcium intake is important for normal bone growth and possibly to help prevent and heal stress fractures.

Resources and References:


PEDIATRICS Vol. 106 No. 1 July 2000, pp. 154-157, AMERICAN ACADEMY OF PEDIATRICS:  “Intensive Training and Sports Specialization in Young Athletes.”  Committee on Sports Medicine and Fitness.


PEDIATRICS Vol. 119 No. 6 June 2007, pp. 1242-1245, “Overuse Injuries, Overtraining and Burnout in Child and Adolescent Athletes.”  Joel S. Brenner, MD, MPH and the Council on Sports Medicine and Fitness.

Stop Sports Injuries

Concussions in Athletes

Concussions in athletes has been the subject of many headlines over the past couple years.  For as much as we know about concussions, there is still much more we need to learn about head injuries and their healing. While most kids recover from concussions within days to weeks, there are some who suffer for months.  This can disrupt not only sport participation, but also reading, concentration, and the ability to learn.

What we know:

• We know that children's brains are still developing and are more at risk with concussions than mature brains. 
• We know that many athletes attempt to hide symptoms of a concussion so they can continue to play. (Bad idea!)
• After a concussion -- even serious ones that affect the daily activities of a teen -- kids are often eager to return to the game that puts them at risk for another injury.
• Symptoms of a concussion range from mild to severe.

• headache
• nausea or vomiting
• slurred speech 
• dizziness 
• ringing in the ears
• trouble concentrating
• sensitivity to light or noise
• sleep problems
• balance problems
• memory loss  

Treatments:

• There are no specific treatments for concussion.
• Rest is important. This includes not only avoiding activities that increase the risk of another injury, but also brain rest. Some kids need quiet time in bed without lights, sounds, television, computers, or books.
• Headaches can be treated with pain relievers and sometimes migraine medications.
• Memory and thinking problems are treated with rehabilitation and memory devices (like a calendar or planner).  Occasionally stimulants (the medicines used for ADHD) are used temporarily.
• Depression and anxiety should be managed by someone experienced in dealing with post-concussion syndrome.

Return to play is a gradual process, in which the athlete progresses in a step wise manner.  If any symptoms return during the stepwise process, the athlete must stop activities and return to a medical practitioner for evaluation.

Step 1: Light aerobic exercise 5-10 minutes without weight lifting, resistance training or other exercises

Step 2: Moderate aerobic exercise 15-20 minutes of running at moderate intensity without a helmet or other equipment.

Step 3: Non-contact training drills in full uniform. May begin weight lifting and resistance training.

Step 4: Full contact practice.

Step 5: Full game play.

Kansas has a new Concussion Law effective July 1, 2011, that requires the State Board of Education and the Kansas State High School Activities Association to provide information about the risks of head injury to coaches, athletes, and parents and guardians of the school athletes. This information should include the risks of playing or practicing with a concussion.  Under the new law an athlete may not participate in a school sport or practice unless the athlete and the parent/guardian have turned in a signed head injury release form each year.  Any school athlete who is suspected of having a concussion or head injury will immediately be removed from play or practice and will be allowed to return to play only after a health care provider gives medical clearance to return to play.

Athletic trainers are available at many local schools to help identify the athletes at risk of concussion. They will be testing kids with various methods, and at this time there is still a lot of variability in what each school program is doing.  It is best to have baseline testing done BEFORE any brain injuries (ie the start of the season) to compare to testing done after a suspected concussion.

If your child is suspected of having a concussion, bring any available test results (both from before and after injury if possible) to your appointment with a healthcare provider.

Prevention is still the best medicine!

• Wear proper gear at all times.  
• Be sure helmets are in good condition and fit properly. 
• Wear mouth guards at all times.  
• Follow the rules of the game. 
• Sit out if injured.  
• If you suspect someone might have a concussion, speak up!

To read the Kansas State High School Activities Association Recommendations for Compliance with the Kansas School Sports Head Prevention Act and Implementation of the National Federation Sports Playing Rules Related to Concussions, click here.