Watching Children for Concussions

Possible concussions in young athletes may need professional evaluation

(RxWiki News) Concussions can happen when children play sports. When an athlete returns to the game after a concussion, the coaches and trainers may rely on the child to report their symptoms.

A new study showed that many cheerleaders with concussions reported having no symptoms. Many of these cheerleaders who reported no symptoms had impairment, including memory problems, when they were checked by a standard neurocognitive test.

This study suggests that instead of relying solely on the athlete to report symptoms, a neurocognitive test may be needed.

"Have your child evaluated if you suspect a concussion."

Mark Lovell, PhD, from the Department of Neurology at the University of Pittsburgh, and Gary Solomon, PhD, from the Neurological Surgery and Vanderbilt Sports Concussion Center at the Vanderbilt University School of Medicine, led this study to compare the effectiveness of neurocognitive tests in patients reporting their symptoms after having a concussion. The study considered whether symptom reporting is enough to clear an athlete to play sports.

The researchers recruited 138 junior high and high school cheerleaders. All participants were female. Cheerleaders with any prior neurological disorders, seizures, learning disabilities or chemical dependencies were excluded from the study.

Cheerleaders were chosen because cheerleading carries a high risk for injuries, including concussion-related injuries.

The cheerleaders were divided into groups based on their positions: flyers, bases/spotters and tumblers.

The researchers used the Immediate Postconcussion Assessment and Cognitive Testing (ImPACT) to evaluate the girls before injury. The ImPACT is a computerized test commonly used to evaluate injury, symptoms and neurocognitive function (bodily function related to the central nervous system and brain).

ImPACT measures symptoms, verbal and visual memory and processing speed. ImPACT is divided into sections.

The first section measures symptoms on a scale from 0 to 6, with 0 being no symptoms and 6 being severe symptoms. The second section is on verbal memory and is scored from 0 to 100 based on correct answers to word recognition questions.

In the third section, visual memory is scored from 0 to 100 based on correct answers to questions using symbols, colors and design to test memory. Fourth, processing speed is measured by number of correct answers to questions asking the test subject to remember symbols and numbers. Finally, reaction time is measured in 1/100th of seconds.

The assessment was administered again within one week of a possible concussion injury. The average time from injury to ImPACT testing was 3.9 days.

The researchers defined concussion as a “traumatically induced alteration in mental status with or without a loss of consciousness.” Symptoms were described as headache, dizziness, balance problems and nausea.

A medical professional, such as physician, athletic trainer or school care official, diagnosed the cheerleaders’ concussions.

The researchers then compared the scores pre-injury to post-injury.

Only 62 percent (85) of the cheerleaders with confirmed concussions reported increased symptoms such as headache, dizziness, nausea and trouble sleeping, within seven days of injury, compared to normal.

Among the cheerleaders who did not report symptoms, 33 percent (20) had at least one section of the ImPACT test score that showed lowered cognitive functioning, including memory problems, compared to their score before the injury.

On the verbal memory section, the cheerleaders scored, on average, approximately 2 percentage points lower post-injury than pre-injury.

On visual memory, the cheerleaders lost three percentage points when retesting after their injury, getting fewer correct answers compared to before the injury.

The cheerleaders lost two points on average on the processing speed section of the ImPACT, meaning they got two fewer answers correct than pre-injury.

The cheerleaders' reaction time on the ImPACT increased around 0.04 seconds post-injury, as they were slower to react than before the injury.

The study did not find a difference between the ImPACT scores based on the cheerleaders’ positions (flyer versus base/spotter versus tumbler).

The authors noted that athletes are usually cleared to play based mostly on the athlete’s self-reports about their symptoms.

According to the Centers for Disease Control and Prevention (CDC), it is important that patients with brain injuries, including concussions, are not returned to recreational activities too quickly in order to allow proper recovery and avoid reinjury.

The authors note reported cases of athletes falsely claiming to feel better to return to play sooner. They stated that treating physicians should be careful about letting athletes return to play without neurocognitive testing.

Nancy Chiaravalloti, PhD, Director of Neuropsychology and Neuroscience and TBI Research at the Kessler Foundation, told dailyRx News that this study is important because it shows that concussions are common not only in contact sports.

"This study highlights a popular female, non-contact sport — cheerleading — as presenting a concussion risk," Dr. Chiaravalloti said.

"Interestingly, many of the concussions documented in this study occurred during practice — not competition! Additionally, no significant differences were noted in concussion risk based on position on the  squad," she said.

"These are important findings for parents and coaches to consider in that it indicates that a concussion can happen to anyone, at any time. Baseline testing prior to the start of the season is important in many sports — not just football — and should be seriously considered in cheerleading. Additionally, the application of return to play guidelines to other sports, such as cheerleading, should be seriously considered," she said.

The authors noted several potential weaknesses of their study. For one, the athletes were not chosen randomly, but instead by convenience. Also, because the study occurred after the injuries occurred, the researchers were unable to control the timing of the post-injury ImPACT testing.

Another potential weakness was that the researchers did not have information about prior concussions among the athletes in their study.

Furthermore, the study used only female athletes, so it is possible that male athletes would have had different results.

Finally, the statistical analysis the researchers used was quite rigid and may have left out many mild concussions from being considered for the study.

According to the authors, this study suggests that relying on cheerleaders to report their symptoms accurately may not be enough. The authors recommend using a neurocognitive assessment to make sure the cheerleaders have returned to normal before returning to competition.

This study was published August 12 in the Journal of Pediatrics.

Dr. Lovell created the ImPACT test, which was used in the study to measure cognition. Dr. Solomon reported no conflicts of interest. No information was provided about funding for this study.

Review Date: 
August 26, 2013