Between 1997-2007, the number of emergency room visits for concussions doubled in children ages 8-13 who play organized sports.
Part of the reason is greater awareness, according to Mark E. Halstead, MD, pediatric orthopedic surgeon at St. Louis Children's Hospital and assistant professor of orthopedic surgery and of pediatrics at Washington University School of Medicine.
In this segment, Dr. Halstead, shares information for pediatricians on recognizing the signs of a concussion, the appropriate treatment and when to refer to a specialist.
Recognizing the Signs of a Concussion
Featured Speaker:
Learn more about Mark Halstead, MD
Mark Halstead, MD
Mark Halstead, MD focuses his practice on the non-surgical treatment of sports related injuries of the upper and lower extremity in patient 5 years and older. His special interests include nonoperative management of injuries, pediatric/adolescent concussion management, exertional compartment syndrome in the lower extremity, injuries and pain in runners and back pain in the adolescent athlete. Dr. Halstead is consistently recognized in "The Best Doctors in America" list.Learn more about Mark Halstead, MD
Transcription:
Recognizing the Signs of a Concussion
Melanie Cole (Host): Sports-related concussion is a hot topic in the media and in medicine. It’s a common injury that’s likely underreported by pediatric and adolescent athletes. My guest today is Dr. Mark Halstead. He’s a Washington University Pediatric Sports Medicine specialist at St. Louis Children’s Hospital. Welcome to the show, Dr. Halstead. Give a working definition of concussion. What is it?
Dr. Mark Halstead (Guest): Yeah, so it’s an injury to the brain. One of the things that I think gets confused, a lot, about concussions, we don’t want to call it a trouble where there’s bleeding, or swelling, or bruising in the brain. It’s really a functional problem in the brain, and that’s where the symptoms come from, so it’s a traumatic brain injury.
Melanie: What are the most common reasons for a concussion?
Dr. Halstead: Usually, sports take the cake for that, but we certainly see them from falls, we see them from playground accidents, but mostly what I deal with are the sports-related concussions.
Melanie: Who would notice concussion in a student-athlete? Would that be the coach, the parents, the athlete, or maybe the other athletes on the field?
Dr. Halstead: Yeah, I think it could be anybody. Certainly, if the person is at the event and something has happened, usually we hope that the coach would recognize that and the parents there – maybe the parent would notice that the child just doesn’t seem to be doing things normally. They may be slow to get up after a hit, for example. Sometimes the athletes themselves -- although unfortunately, sometimes the athletes don’t even recognize that what they’re experiencing is a concussion. They may think, “Oh, I just have a little bit of a headache,” and then they go on to keep playing, unfortunately, and that can lead to other consequences and a longer recovery. It could be a referee; it could be a medical provider that’s there, such as an athletic trainer or the physician that may be covering the event
Melanie: And Dr. Halstead, as a Sports Medicine specialist, does you see that either students or their parents, or even the coaches might feel that the equipment keeps them safe, and is this myth that the equipment can really protect against concussion?
Dr. Halstead: Yeah, the interesting thing about equipment is that we would assume – let’s put the more protective gear on and that’s going to help keep the injury from happening, but the three most common sports to get concussions are football, ice hockey, and lacrosse when we look at them in male sports. The common denominator there, for all three of those sports, is they’re all helmeted sports, so if the helmet and the protective gear was so great, those should actually not be our three most common sports to get a concussion in, so we get concerned, obviously, when we say, “Let’s go out and buy the newest and greatest helmet, this one’s going to help. Let’s get a headband for soccer, that's going to help.” If a big, hard helmet isn’t going to help prevent from a concussion, a little band of air around a child’s head isn’t going to help either. There’s research to show that really doesn’t make a difference. There’s research also that show that – whether a helmet is a new helmet, whether it’s a refurbished helmet, whatever manufacturer or model is out there, that there’s really not any significant difference of what symptoms that athlete will experience after the concussion, or their duration of recovery, so really, the hard part is preventing the brain from moving in the skull and external devices probably aren’t going to be our answer for that.
Melanie: So what are some of the symptoms and red flags? What are we supposed to notice as parents and what do you want the Pediatrician to know about recognizing these symptoms?
Dr. Halstead: Yeah, so headache is, by far, the most common symptom that we get from a concussion and sometimes it’s getting hyper focused on, as far as a headache alone. When we see athletes for a concussion we have them fill out what’s called a symptom checklist, and there’s 22 different symptoms that we ask about, so they’re not all going to experience those. Athletes may experience them at different degrees of severity. Certainly, headache is the number one, but there are some concussions that happen that don’t even produce a headache. They can have dizziness. They can have difficulty concentrating. They can have a sensitivity to light and noise. They may develop some sleep difficulties. They may be excessively tired or have a hard time to get to sleep. Our red flags always are the worst headache that that person can experience, or progressively worsening headache that’s not improving with rest, episodes of throwing up. Episodes of emesis – I have in my practice what’s called the “two-puke rule,” so if they’ve thrown up more than twice, that’s someone that I think that needs to get evaluated further in the ER.
If they have any focal neurologic findings, so maybe weakness in an extremity, they have numbness and tingling in an extremity after the concussion, those are all signs that something more may be going on than just a concussion and certainly reasons that that person needs to get seen sooner rather than later. Episodes of loss of consciousness – and one of the myths with concussions is that you have to have had a loss of consciousness to have a concussion and that only happens in less than 10% of concussions. If it does happen, especially if it’s a prolonged loss of consciousness – we’re talking minutes at a time – that is definitely somebody that should get evaluated. A very brief, short loss of consciousness that doesn’t have any other red flags probably doesn’t need to get seen immediately.
Melanie: So should parents take kids to the pediatrician if it’s determined on the field by the coach, or whoever, that some of these symptoms are present?
Dr. Halstead: Well, if it’s an athlete, most states now – well, actually all 50 states have a law in place that if they are involved with high school sports and some it applies to other sports – club sports, middle school sports, grade school sports – that there has to be written clearance by a health care professional who is trained in the management of concussions before they can go back to play. That will vary from state-to-state, so you really have to be familiar with your own state laws as far as who is allowed to clear the person and what requirements they have and what levels those written requirements are at. So for example, I’m in Missouri, so right now this just applies to high school athletes in high school sports in the public schools, so other ones don’t necessarily have to get cleared, but certainly we would encourage them to. There’s nothing different about a concussion that happens from club sports, and we certainly want that athlete to be safe and recovered before they go back to play.
Melanie: And when do you think it’s necessary to be referred to a specialist?
Dr. Halstead: I think that’s – for referring to a specialist, I really think that’s a comfort factor for the individual who’s evaluating them. I have plenty of pediatricians in town here who are very comfortable with managing concussions initially and following them to recovery and some that just would rather have a specialist look at them right off the bat. Certainly, I would say if an athlete’s not recovering after three or four weeks, or if they're having real severe symptoms that don’t seem to be getting better with typical recommendations for resting from physical activity, being in school but with adjustments, and those things aren’t really helping the kid improve, I think that is certainly something that should be seen by a specialist. Certainly, I would say, if an athlete has had multiple concussions in their lifetime I think that is also is important for a specialist to evaluate the person and see if there are some particular risk factors or modifiable things that would make that person more prone to get concussions and when is the appropriate time to maybe suggest for that athlete they should stop playing contact sports, as an example.
Melanie: And what would you like pediatricians to tell the parents about returning to play, returning to school, and what they should do while the child is recovering?
Dr. Halstead: Yeah, so for returning to school – first of all, one of the unfortunate things I hear a lot of is pediatricians recommending don’t go back to school until you’re a headache free. That is absolutely not what we want to be recommended to kids. It is perfectly fine to be in school and in fact, there’s research to show that kids that get back into school sooner, but with adjustments in school to help them through the school day, recover quicker and have less symptoms than the kids that are told to stay home and rest. There’s nothing wrong with them being in school. Being in school, making the brain work, doesn't make the concussion worse. The concussion was what happened during the playing time when they had that episode. It might make them feel a little worse, but it’s not worsening the injury, so we can have these kids back in school.
As far as getting back into physical activity and their normal sports – so to be released to full activity, two things need to happen. One is the athlete needs to be feeling back to their normal self, both in and out of school – if they are at a time of the year when school is in session. And then, also, we would recommend them going through what’s called a “Return to Play” progression and the American Academy of Pediatrics – and there are various other organizations out there – have specific guidelines on how that should be conducted, but usually it’s a five-day process of returning to play before they go back to sports. It’s not one-week headache free, and then they can go back. They can start that when they’ve reached a full day feeling their normal selves and then we absolutely put them through that progression, which is a gradual increase in exercise in the demands of that sport to make sure that their symptoms don’t return.
Melanie: And are there any adjuvants to treatment that you’d like to recommend, such as NSAIDS, or anything that the pediatrician can tell the parent they shouldn’t or should use?
Dr. Halstead: Yeah, so as far as medications go, I don’t have any big opposition to parents or pediatricians recommending Tylenol or Ibuprofen. I’m not a fan of recommending scheduled medicines because, number one, I don’t expect most of those medications to help. Most of the kids that we see when we ask them are they really helping, they really don’t make a big difference in their headache because the ibuprofen, Tylenol, doesn’t really make the brain function any better, so it typically doesn’t do anything for concussion headaches. Some of that may get improved with if, with the concussion, the child has an associated neck strain. That’s very common, so I do get very aggressive with sending kids to physical therapy soon after their injury if they have been identified to have any neck component of their injury because that actually can generate some of the headaches too, just from cervicogenic headaches.
Otherwise, we’re not typically recommending a lot of medications for these kids. We do recommend modifications for their school work. We do recommend that they keep on their normal sleep schedule. We try to discourage lots and lots of sleep because once kids get out of their normal sleep cycles, that can actually have an effect on how they feel throughout the day and they may have difficulty with having more troubles with sleep, so we do try to keep kids on normal bed times, normal wake-up times. We do, also, encourage them to keep on their normal nutrition and their normal hydration throughout the day in order to help their recovery.
Melanie: Wrap it up for us, Dr. Halstead, with your best advice for pediatricians on recognizing the signs and the symptoms and when to refer to a specialist in the case of concussion.
Dr. Halstead: Yeah, so I think, again, it’s one of those things that – concussion is a difficult process. Even five, ten years ago, recommendations that we have now are often different than what may have been recommended five or ten years ago. It’s an ever-changing field, and as we learn more about the injury -- I think it’s just important to try to stay current and keep up with what’s being recommended. We don’t recommend locking the kid into a dark room and then keep them in that room until they’re symptom-free. That’s not something that we do. In fact, sometimes we will encourage a little bit of light cardio activity as they start to improve before we get them back into things. It’s really just managing them and evaluating them for a headache, not asking just about a headache alone. I encourage pediatricians to use symptom checklists to help with their clinical assessments with kids, making sure they don’t have any abnormalities on their neurologic exam when they do have their assessment with them, and then definitely making sure that they’re following the appropriate return to play policies.
Melanie: And tell us about your team. Why is St. Louis Children’s Hospital so great to work with?
Dr. Halstead: Yeah, so we have a great team with young athletes. We have actually a group called the Young Athletes Center and so – obviously concussion are a part of what we do there, and so there's several of us who take care of concussions through the Young Athletes Center. Then we have other specialists, including our Orthopedic Surgeons, our Physical Therapists, and then those of us, like myself, who are the non-surgeons in the group, who take care of pretty much everything related to the athlete. We’ve got a great team that helps take care of the whole athlete rather than just one specific injury. We can take car of them from prevention things all the way up through their injury and their recovery and if -- God-Forbid they needed the surgery for their injury from sports, we have people that can help them with that, as well.
Melanie: Thank you, so much, for being with us today. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to StLouisChildrens.org, that’s StLouisChildren.org. This is Melanie Cole. Thanks, so much, for listening.
Recognizing the Signs of a Concussion
Melanie Cole (Host): Sports-related concussion is a hot topic in the media and in medicine. It’s a common injury that’s likely underreported by pediatric and adolescent athletes. My guest today is Dr. Mark Halstead. He’s a Washington University Pediatric Sports Medicine specialist at St. Louis Children’s Hospital. Welcome to the show, Dr. Halstead. Give a working definition of concussion. What is it?
Dr. Mark Halstead (Guest): Yeah, so it’s an injury to the brain. One of the things that I think gets confused, a lot, about concussions, we don’t want to call it a trouble where there’s bleeding, or swelling, or bruising in the brain. It’s really a functional problem in the brain, and that’s where the symptoms come from, so it’s a traumatic brain injury.
Melanie: What are the most common reasons for a concussion?
Dr. Halstead: Usually, sports take the cake for that, but we certainly see them from falls, we see them from playground accidents, but mostly what I deal with are the sports-related concussions.
Melanie: Who would notice concussion in a student-athlete? Would that be the coach, the parents, the athlete, or maybe the other athletes on the field?
Dr. Halstead: Yeah, I think it could be anybody. Certainly, if the person is at the event and something has happened, usually we hope that the coach would recognize that and the parents there – maybe the parent would notice that the child just doesn’t seem to be doing things normally. They may be slow to get up after a hit, for example. Sometimes the athletes themselves -- although unfortunately, sometimes the athletes don’t even recognize that what they’re experiencing is a concussion. They may think, “Oh, I just have a little bit of a headache,” and then they go on to keep playing, unfortunately, and that can lead to other consequences and a longer recovery. It could be a referee; it could be a medical provider that’s there, such as an athletic trainer or the physician that may be covering the event
Melanie: And Dr. Halstead, as a Sports Medicine specialist, does you see that either students or their parents, or even the coaches might feel that the equipment keeps them safe, and is this myth that the equipment can really protect against concussion?
Dr. Halstead: Yeah, the interesting thing about equipment is that we would assume – let’s put the more protective gear on and that’s going to help keep the injury from happening, but the three most common sports to get concussions are football, ice hockey, and lacrosse when we look at them in male sports. The common denominator there, for all three of those sports, is they’re all helmeted sports, so if the helmet and the protective gear was so great, those should actually not be our three most common sports to get a concussion in, so we get concerned, obviously, when we say, “Let’s go out and buy the newest and greatest helmet, this one’s going to help. Let’s get a headband for soccer, that's going to help.” If a big, hard helmet isn’t going to help prevent from a concussion, a little band of air around a child’s head isn’t going to help either. There’s research to show that really doesn’t make a difference. There’s research also that show that – whether a helmet is a new helmet, whether it’s a refurbished helmet, whatever manufacturer or model is out there, that there’s really not any significant difference of what symptoms that athlete will experience after the concussion, or their duration of recovery, so really, the hard part is preventing the brain from moving in the skull and external devices probably aren’t going to be our answer for that.
Melanie: So what are some of the symptoms and red flags? What are we supposed to notice as parents and what do you want the Pediatrician to know about recognizing these symptoms?
Dr. Halstead: Yeah, so headache is, by far, the most common symptom that we get from a concussion and sometimes it’s getting hyper focused on, as far as a headache alone. When we see athletes for a concussion we have them fill out what’s called a symptom checklist, and there’s 22 different symptoms that we ask about, so they’re not all going to experience those. Athletes may experience them at different degrees of severity. Certainly, headache is the number one, but there are some concussions that happen that don’t even produce a headache. They can have dizziness. They can have difficulty concentrating. They can have a sensitivity to light and noise. They may develop some sleep difficulties. They may be excessively tired or have a hard time to get to sleep. Our red flags always are the worst headache that that person can experience, or progressively worsening headache that’s not improving with rest, episodes of throwing up. Episodes of emesis – I have in my practice what’s called the “two-puke rule,” so if they’ve thrown up more than twice, that’s someone that I think that needs to get evaluated further in the ER.
If they have any focal neurologic findings, so maybe weakness in an extremity, they have numbness and tingling in an extremity after the concussion, those are all signs that something more may be going on than just a concussion and certainly reasons that that person needs to get seen sooner rather than later. Episodes of loss of consciousness – and one of the myths with concussions is that you have to have had a loss of consciousness to have a concussion and that only happens in less than 10% of concussions. If it does happen, especially if it’s a prolonged loss of consciousness – we’re talking minutes at a time – that is definitely somebody that should get evaluated. A very brief, short loss of consciousness that doesn’t have any other red flags probably doesn’t need to get seen immediately.
Melanie: So should parents take kids to the pediatrician if it’s determined on the field by the coach, or whoever, that some of these symptoms are present?
Dr. Halstead: Well, if it’s an athlete, most states now – well, actually all 50 states have a law in place that if they are involved with high school sports and some it applies to other sports – club sports, middle school sports, grade school sports – that there has to be written clearance by a health care professional who is trained in the management of concussions before they can go back to play. That will vary from state-to-state, so you really have to be familiar with your own state laws as far as who is allowed to clear the person and what requirements they have and what levels those written requirements are at. So for example, I’m in Missouri, so right now this just applies to high school athletes in high school sports in the public schools, so other ones don’t necessarily have to get cleared, but certainly we would encourage them to. There’s nothing different about a concussion that happens from club sports, and we certainly want that athlete to be safe and recovered before they go back to play.
Melanie: And when do you think it’s necessary to be referred to a specialist?
Dr. Halstead: I think that’s – for referring to a specialist, I really think that’s a comfort factor for the individual who’s evaluating them. I have plenty of pediatricians in town here who are very comfortable with managing concussions initially and following them to recovery and some that just would rather have a specialist look at them right off the bat. Certainly, I would say if an athlete’s not recovering after three or four weeks, or if they're having real severe symptoms that don’t seem to be getting better with typical recommendations for resting from physical activity, being in school but with adjustments, and those things aren’t really helping the kid improve, I think that is certainly something that should be seen by a specialist. Certainly, I would say, if an athlete has had multiple concussions in their lifetime I think that is also is important for a specialist to evaluate the person and see if there are some particular risk factors or modifiable things that would make that person more prone to get concussions and when is the appropriate time to maybe suggest for that athlete they should stop playing contact sports, as an example.
Melanie: And what would you like pediatricians to tell the parents about returning to play, returning to school, and what they should do while the child is recovering?
Dr. Halstead: Yeah, so for returning to school – first of all, one of the unfortunate things I hear a lot of is pediatricians recommending don’t go back to school until you’re a headache free. That is absolutely not what we want to be recommended to kids. It is perfectly fine to be in school and in fact, there’s research to show that kids that get back into school sooner, but with adjustments in school to help them through the school day, recover quicker and have less symptoms than the kids that are told to stay home and rest. There’s nothing wrong with them being in school. Being in school, making the brain work, doesn't make the concussion worse. The concussion was what happened during the playing time when they had that episode. It might make them feel a little worse, but it’s not worsening the injury, so we can have these kids back in school.
As far as getting back into physical activity and their normal sports – so to be released to full activity, two things need to happen. One is the athlete needs to be feeling back to their normal self, both in and out of school – if they are at a time of the year when school is in session. And then, also, we would recommend them going through what’s called a “Return to Play” progression and the American Academy of Pediatrics – and there are various other organizations out there – have specific guidelines on how that should be conducted, but usually it’s a five-day process of returning to play before they go back to sports. It’s not one-week headache free, and then they can go back. They can start that when they’ve reached a full day feeling their normal selves and then we absolutely put them through that progression, which is a gradual increase in exercise in the demands of that sport to make sure that their symptoms don’t return.
Melanie: And are there any adjuvants to treatment that you’d like to recommend, such as NSAIDS, or anything that the pediatrician can tell the parent they shouldn’t or should use?
Dr. Halstead: Yeah, so as far as medications go, I don’t have any big opposition to parents or pediatricians recommending Tylenol or Ibuprofen. I’m not a fan of recommending scheduled medicines because, number one, I don’t expect most of those medications to help. Most of the kids that we see when we ask them are they really helping, they really don’t make a big difference in their headache because the ibuprofen, Tylenol, doesn’t really make the brain function any better, so it typically doesn’t do anything for concussion headaches. Some of that may get improved with if, with the concussion, the child has an associated neck strain. That’s very common, so I do get very aggressive with sending kids to physical therapy soon after their injury if they have been identified to have any neck component of their injury because that actually can generate some of the headaches too, just from cervicogenic headaches.
Otherwise, we’re not typically recommending a lot of medications for these kids. We do recommend modifications for their school work. We do recommend that they keep on their normal sleep schedule. We try to discourage lots and lots of sleep because once kids get out of their normal sleep cycles, that can actually have an effect on how they feel throughout the day and they may have difficulty with having more troubles with sleep, so we do try to keep kids on normal bed times, normal wake-up times. We do, also, encourage them to keep on their normal nutrition and their normal hydration throughout the day in order to help their recovery.
Melanie: Wrap it up for us, Dr. Halstead, with your best advice for pediatricians on recognizing the signs and the symptoms and when to refer to a specialist in the case of concussion.
Dr. Halstead: Yeah, so I think, again, it’s one of those things that – concussion is a difficult process. Even five, ten years ago, recommendations that we have now are often different than what may have been recommended five or ten years ago. It’s an ever-changing field, and as we learn more about the injury -- I think it’s just important to try to stay current and keep up with what’s being recommended. We don’t recommend locking the kid into a dark room and then keep them in that room until they’re symptom-free. That’s not something that we do. In fact, sometimes we will encourage a little bit of light cardio activity as they start to improve before we get them back into things. It’s really just managing them and evaluating them for a headache, not asking just about a headache alone. I encourage pediatricians to use symptom checklists to help with their clinical assessments with kids, making sure they don’t have any abnormalities on their neurologic exam when they do have their assessment with them, and then definitely making sure that they’re following the appropriate return to play policies.
Melanie: And tell us about your team. Why is St. Louis Children’s Hospital so great to work with?
Dr. Halstead: Yeah, so we have a great team with young athletes. We have actually a group called the Young Athletes Center and so – obviously concussion are a part of what we do there, and so there's several of us who take care of concussions through the Young Athletes Center. Then we have other specialists, including our Orthopedic Surgeons, our Physical Therapists, and then those of us, like myself, who are the non-surgeons in the group, who take care of pretty much everything related to the athlete. We’ve got a great team that helps take care of the whole athlete rather than just one specific injury. We can take car of them from prevention things all the way up through their injury and their recovery and if -- God-Forbid they needed the surgery for their injury from sports, we have people that can help them with that, as well.
Melanie: Thank you, so much, for being with us today. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to StLouisChildrens.org, that’s StLouisChildren.org. This is Melanie Cole. Thanks, so much, for listening.