David squirms on the couch. You can tell that the tall, 15-year-old boy is used to action, not sitting.Last April, a relative punched him in the face, giving David a concussion. David (his name has been changed to protect his identity as a minor and the confidentiality of his medical case) didn't pass out, but suffered from headaches and felt dizzy. The worst symptoms hit their peak two days after the hit. In the light, "everything came on": sound sensitivity, irritability, headache. But after two weeks, David felt better and returned to normal activities. Back in a school class, he played dodgeball, then later worked out with the school's football team. Something happened during those activities that caused his concussion symptoms to reappear and worsen. David is not exactly clear about what happened -- another hit or just too much activity too soon. What is clear is during football practice, David started acting "not right." He almost passed out, his pupils weren't dilating and he was wobbly. For the next three or four weeks, "everything revolved around bed," Davidsaid. David had suffered from a concussion, maybe two. FEW STUDIES OF CHILDREN Data from Flagstaff Medical Center show 403 concussions for youth aged 18 and younger for the years 2010 and 2011. In general, concussions have received a lot of press. Some professional football players who have received repeated blows to the head are beginning to show signs of dementia. Veteran NHL players have also shown these symptoms. "The boxer, Muhammed Ali, has had so many blows to the head he now has developed dementia pugilistica," said Dr. John Zarske, Flagstaff neuropsychologist. Dementia pugilistica is known among boxers and other head-hitting sports, and is characterized by gait ataxia (lack of coordination), tremors, slurred speech and cognitive decline. Concern with concussions may have started with professional sports, but as Amy Flory, physical therapist and co-owner of CoreBalance, points out, there are very few studies on the long-term effects of concussion on children's brains. And with children, where there is activity, whether it is at home, in the car, on a bicycle, on the playground or in sports, there is a chance for concussion. While concussions do heal, they need to be taken seriously. "Concussions are called mild traumatic brain injuries or TBIs," said Katie Pierce, physical therapist with CoreBalance. "But they are not a mild injury. Concussions can set off cognitive, emotional and physical system effects." According to statistics compiled by the Centers for Disease Control and Prevention (CDC), each year an estimated 1.7 million people sustain a TBI. Around 75 percent of those TBIs occurring each year are concussions or a different form of mild TBI. Annually, about half a million emergency department visits for TBI are made by children from birth to 14 years old. In all age groups, TBI rates are higher for males than for females. Yet, in a survey of nine sports, concussion numbers and rates were highest in football and girl's soccer. 'A METABOLIC CRISIS' During a concussion the brain, which floats in fluid within the skull, can twist or stretch, or even hit the skull. Damage to the brain often isn't seen in a traditional MRI or CT scan unless there is bleeding in the brain. Part of the damage is in how the nerve cells communicate with each other. Information in the brain travels through nerve cells or neurons. At the end of each neuron is a branched axon. Axons send information to other neurons across gaps, or synapses, to other axons. A concussion disrupts this process. Axons and small blood vessels are damaged. Chemicals are released. "It is a metabolic crisis," Flory said. "When the brain is injured (during an impact) the energy exchange is disrupted. Nerve cells are not getting the energy they need as fast as they need it." Added Flory: "The brain is starving." This "metabolic crisis" is represented in a concussion victim through the classic symptoms: difficulty in thinking clearly, feeling slowed down, memory problems, headache, blurry vision, nausea, dizziness, light or sound sensitivity, balance problems, feeling tired, irritability, sadness, anxiety, sleeping more, sleeping less. David found he was light sensitive to the extreme. He lay in bed with the curtains drawn, wearing goggles and sunglasses. He was also sensitive to sounds, had headaches and vertigo. "Riding in the car was almost impossible," said his mother, Susan. REMOVE FROM ACTIVITY Anyone suspected of having a concussion needs to be removed from activity and be seen by a health care professional who is trained in dealing with concussions. Arizona SB1521 mandates procedures for interscholastic athletes who are suspected of having suffered from a concussion: they are to be removed from play and evaluated by a trained health care professional. If the athlete has a concussion, they need written consent that they are cleared for play from either a physician, athletic trainer, nurse practitioner or physician assistant. Varsity high school athletes have the benefit of an athletic trainer and a battery of diagnostic procedures. "I have a bazillion tests," said Eric Freas, athletic trainer, Coconino High School. He looks for physical signs of a concussion: balance problems, disorientation and pupil activity. He also asks about symptoms or what the victim is feeling: headache, ringing in ears, nausea. He evaluates the player's cognition or thought processes by asking questions: What sport are you playing? What did you have for dinner last night? Vital signs, such as pulse and blood pressure, are also checked. "Athletes try to deny symptoms," said Tom Lyle, athletic director at Flagstaff High School. "We learn ways to ask more questions." Serious concussions are sent to the hospital right away, otherwise, athletes are monitored with some of the same questions and tests to see if conditions worsen. Parents are given a concussion informational sheet that also notifies them that their athlete will need clearance from a doctor before being allowed to play again. When athletes return depends on the severity of the concussion, the doctor's orders and other factors. "Athletes (who have suffered from a concussion) undergo exertional testing, then are re-tested to see if it provokes symptoms," said Lyle. Athletic trainers implement a "graduated return to the sport," he added. "[After a concussion] the brain needs cognitive and physical rest." Flory said. "Thinking and moving require more energy than the brain has. Any activity can prolong the recovery time." According to the CDC, most people with concussions recover quickly and fully. But, symptoms including memory loss, visual problems, dizziness, headaches, can last for months.
Zarske explained concussions have been broken into three grades established by the American Academy of Neurology in 1997:-- Grade 1, mild concussion, no loss of consciousness, symptoms may include confusion, clears up in 15 minutes; -- Grade 2, moderate concussion, no loss of consciousness, symptoms include headache, dizziness, symptoms last longer than 15 minutes; -- Grade 3, severe concussion, loss of consciousness, brief or prolonged symptoms. The problem with this system is some people who have had concussions with no loss of consciousness can have lingering symptoms, while some people who have had concussions with loss of consciousness recover quickly. "It has to be looked at individually," Zarske said. Also, as Zarske explained, concussions affect your safety awareness. "If you have a concussion, there is a higher risk for another concussion, about four times the risk, within a couple of months," Zarske said. Secondary-impact-syndrome concussions that cause the brain to swell and can result in death are extremely rare. As for prevention, "There is no such thing as complete prevention of concussions, necessarily," Freas said. TAKING THE IMPACT TEST He then listed efforts that high school coaches implement to limit concussions: limit hitting during football practice, possible padding for soccer players, diving into water with hands first. Football coaches instruct their players on the safest ways to tackle to avoid head and neck injuries. Also as part of the compliance with SB1521, all student athletes need to complete the Arizona Interscholastic Association Brainbook concussion education course online. Students can also get baseline testing of cognitive skills. At CHS it is highly recommended that students take the ImPACT test to determine their baseline. At FHS, athletes in football, diving, cheerleading, basketball, soccer and wrestling are required to take the Axon Sports baseline cognitive test (paid for by the Mayo Clinic). For all other sports it's optional. If an athlete gets a concussion they can take the test again to determine the effects of the concussion. Flagstaff Bone and Joint offers ImPACT baseline testing for $20 for ages 10 through 80. HELMETS NOT OPTIONAL In 2009, Flagstaff passed an ordinance requiring all children aged 18 and younger to wear a bicycle helmet when riding a bicycle. The City of Flagstaff, Safe Kids Coconino County, Flagstaff Biking Organization, Dr. Alice Berger and Anthony Quintile, Absolute Bikes, were instrumental in getting this passed. "We can fix a broken arm," said Heather Taylor, Safe Kids Coconino County Coordinator. "Brain injury is much trickier." Each year Safe Kids distributes 8,000 order forms for $10 Bell bicycle helmets to all schools and homeschool organizations. Interested individuals can also contact the County to order a helmet. According to Taylor they conducted a survey that noted fewer than 50 percent of Flagstaff children used helmets prior to passage and an increase after passage of the ordinance. This past summer, Arizona passed a law raising the age requirement for booster seats. Now children younger than 8 years old need to be in a booster seat. Previously it was younger than 5 years old. Safety in crashes was a determining factor in passing this law. BUILDING STAMINA When he started physical therapy, David had trouble standing in place for 30 seconds. Now, among other things, he bounces a ball while naming different fruits. David enjoys the challenge of physical therapy. "PT is the most helpful," he said. "Take it slow and take care of it the right way." Pierce is gradually working to build stamina in three of his body systems: vestibular (inner ear), vision and proprioception (the feedback systems in muscles and joints that tell you where you are). All of these aid in balance. Pierce might have a concussion patient reach and point to a letter on two different letter charts while standing on foam or a wobbly, balance disk. She might have the patient walk on a line while turning the head. She might give three commands: do 15 jumping jacks, 27 crunches and meet me at the Brock string, to test memory and at the same time push physical endurance. The Brock string has three beads on it and aids in vision therapy. TAKING ONLINE CLASSES Zarske specializes in brain behavior relationships. He first completes a thorough examination of the concussion patient: memory, visual, spatial, motor coordination, academic. "The tests are so sensitive," Zarske said. He also talks with a parent to get an idea of how the patient behaved before the concussion. "We then discuss results in a meeting to explain what to expect," Zarske said.
He said most should expect a gradual return to normal activities. He generally recommends patients return to practicing activities they normally do.David still has challenges ahead but is improving every day. He can now walk the line and spin in a circle. But he still can get headaches. He loves to lift weights and work out. But he still can get dizzy. His eyes are improving in tracking. But he still can't read for any length of time. As a result he hasn't returned to school but is taking online classes. "It's more involved than you think it's going to be. It's physical, vision, balance," Susan said. "It's hard having to be some place in an appointment, rather than being a kid." Cecile LeBlanc can be reached at 556-2261 or firstname.lastname@example.org. (c)2012 The Arizona Daily Sun (Flagstaff, Ariz.) Visit The Arizona Daily Sun (Flagstaff, Ariz.) at www.azdailysun.com Distributed by MCT Information Services