Mike’s physical education class at Main Street High School was being conducted outside on the school’s new turf field. Mike was playing soccer when he fell and hit his head against the goal post. Although he never lost consciousness, Mike appeared dazed and did not recall the score of the game or that he fell and hit his head.

Suzy was playing in a lacrosse game after school. As she was about to score her third goal an opponent from the other team ran toward her to defend the goal and the two girls collided, head-first. The opponent appeared to be okay, but Suzy complained of a headache, blurry vision and nausea.

Although these adolescents had different signs and symptoms following a head injury, they were diagnosed with having a sports-related concussion. Concussions result from a sudden knock or jostle to the head or body which causes the brain to be moved quickly inside of the skull and changes how the brain functions. Up to 3.8 million recreation and sports-related concussions occur annually in the United States.

In this article, we take a closer look at concussion, including signs and symptoms, complications, management, and education.

Headache is common

The most common symptom after a concussion is headache. Only a small percentage of those who experience a concussion lose consciousness.

Other signs and symptoms of a concussion include one or more of the following: blurred vision, dizziness or difficulty with balance, fatigue, trouble falling asleep, excessive sleep, nausea and/or vomiting, light or noise sensitivity, feeling dazed or “not right,” confusion, and problems with memory and concentration.

Signs and symptoms of a concussion may not appear until several hours or even days after experiencing a head injury. The length of time that symptoms last can vary among individuals, but in most cases symptoms subside within 7-10 days.

Watch for complications

The brain, supporting structures, and muscles are still developing in adolescents, which puts this population at a higher risk for concussions. In addition, an adolescent’s brain responds to the force from an injury differently than an adult. As a result of the differences in development and injury response, adolescents have to experience a force several times greater than an adult to experience symptoms of a concussion, making it vital to monitor them closely for possible complications:

• Post-concussion stress syndrome occurs when the symptoms of the concussion last more than six weeks after the injury. Lingering symptoms can result in school absences and declines in academic performance.
• Chronic post-traumatic headache can affect a person’s concentration, memory, and thinking abilities. Often pain, nausea and vomiting, and light and noise sensitivity accompanies chronic post-traumatic headache and affect an individual’s attention capability and ability to learn. Many times the individual suffering from post-traumatic headache is frequently absent from school and will have difficulty participating in social activities.
• Second impact syndrome is rare and a potentially deadly complication that occurs when a second concussion occurs before the first is completely healed. The brain is unable to regulate blood flow, which leads to cranial edema and a rise in intracranial pressure. Symptoms usually begin with the individual having a dazed appearance, followed by progressive decline to a loss of consciousness, respiratory failure, coma, and even death.

Care and management of concussion

Recent research of sports-related concussion in student athletes have provided a better understanding of risks from a concussion and led to a multifaceted approach to concussion injuries. Schools have established evidenced-based protocols outlining procedures for staff to follow in managing head injuries, and policies that pertain to return-to-play guidelines after concussion.

The Zurich Consensus Statement on Concussion in Sport recommends baseline pre-injury and serial post-injury follow-up neurocognitive testing protocols. One of the commonly used testing programs is the Immediate Post-Concussion and Cognitive Testing (ImPACT). ImPACT is a computer-based program that evaluates multiple aspects of the students’ ability to think and reason, including memory, attention, brain processing speed, reaction time, and post-concussion symptoms. Athletes take a baseline ImPACT test before participating in sports and repeat the test every two years.

The care of the student who has sustained an injury that may result in a concussion is a concerted effort among school professionals, healthcare professional, parents, and students. Initial assessment of acute concussion includes the “ABCs“ (airway, breathing, and circulation) and stabilization of the cervical spine.

Evaluation of symptoms and cognition should be done by a health care professional experience in concussion management along with a neurologic examination using one of available sideline assessment tools such as the Sport Concussion Assessment Tool 2 (SCAT2). The ImPACT test is also given on the sidelines or within 24 hours of the injury, and then again 3, 5, and 7 days after injury.

Restrictions on physical and cognitive exertion are recommended. Activities that require a high level of concentration, such as studying, working on the computer, or playing video games are commonly restricted during recovery. In addition, limitations upon physical exertion such as weight training, cardiovascular training, and physical education classes are recommended. Because concussion affects each student differently, an individualized management plan that is consistent with a written school policy is necessary for each student.

When is it OK to play?

The Zurich consensus statement recommends that a student athlete with post-concussion symptoms should not be allowed to return to play on the day of injury no matter how quickly the symptoms disappear. Physical and mental rest should be maintained.

The consensus statement emphasizes a five-step, graduated exercise program leading to medical clearance by a licensed physician before returning to activity.

Prevention and education

The best way to protect students from concussions is to prevent them. In many schools the school nurse is the primary care provider and plays an important role in concussion prevention and education.

Preventing injuries by ensuring a safe, well maintained, and supervised environment should be a priority. Nurses should teach parents, athletes, and coaches about the importance of recognizing concussion and seeking timely medical attention. The Centers for Disease Control and Prevention (CDC) has created free tools for youth and high school sports coaches, parents, athletes, and healthcare professionals that provide important information on preventing, recognizing, and responding to a concussion.

Despite extensive research and media coverage many parents, coaches, and students still cling to myths and misconceptions regarding concussion. One significant misconception and stumbling block to early detection, accurate diagnosis, and early intervention is that loss of consciousness must occur to be diagnosed with a concussion. Education conducted by the school nurse must dispel the myths that youth are indestructible and that concussion should be “toughed out” and does not necessitate medical intervention.

The school staff should be notified about students returning to school following a concussion. All school staff members should be aware if the student still complains of any symptoms or should monitor the student for any return of symptoms. Education of teachers, counselors, and school administrators of cognitive difficulties that a student experiences following concussion is important. Cognitive rest is recommended to prevent worsening of post concussion symptoms. Students with concussion injuries often have difficulty attending school and focusing on academic work, taking tests, or keeping up with assignments.

A student still complaining of symptoms may require certain accommodations to meet educational needs and goals with the 504 plan from the Rehabilitation Act of 1973 or an individualized education plan. The plans might include measures such as decreased assignments, reduced complexity of assignments, increased time for completion of assignments or tests, creating an outline or instructions for completing tasks, providing a quiet area or area with few distractions, and a progress report to be sent home on a weekly basis. Other activities that require concentration and attention such as driving, playing video games, using the computer, and watching television should be monitored and may need to be avoided.

Nurses’ key role

Sports-related concussion is common in youth, so nurses need to know signs and symptoms and potential complications. Nurses should work to establish evidenced-based protocols outlining procedures for school professional to follow in managing head injuries, and policies for return to play after concussion. An important strategy for the nurse is to provide effective education to the teachers, coaches, parents, and students regarding the importance of recognizing concussion and seeking appropriate and timely medical attention.

Kim Cahill works The Kireker Center for Child Development at The Valley Hospital, Ridgewood, New Jersey; Debi Nickles and Patricia Fonder are employed in the nursing program at Ramapo College of New Jersey.

Selected references

Center for Disease Control and Prevention. Heads up to schools: Know
your concussion ABC’s. http://www.cdc.gov/concussion/HeadsUp/schools.html. 2009. Accessed January 31, 2012.

Halstead M, Walter K. Clinical report: Sport-related concussion in children and adolescents. Pediatrics. 2010;126(3):597-615.

Langiois JA, Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: A brief overview. J Head Trauma Rehabil. 2006;21(5):375-378.

McCrory P, Meeuwisse W, Johnston K et al. Consensus statement on concussion in sport: the 3rd international conference on concussion in sport held in Zurich, November 2008. J Athletic Training 2009;44(4): 434-448.

Piebes SK, Gourley M, Valovich McLeod TC. Caring for student-athletes following a concussion. J Sch Nurs. 2009;25(4):270-281.