As a general internist, I’m responsible for knowing about a lot of medical conditions. Not only do I treat a wide range of medical problems but I regularly attend conferences that cover topics including hypertension, diabetes, migraines, menopause and more.
As a hockey parent, I have a particular interest in concussion. Kids with small brains skating rapidly on slick ice and crashing into other players or the boards cause me to clench my jaw and pray.
Several years ago, I attended lectures on concussion and was trained as a safety officer for my son’s hockey team. This gave me access to a sideline test (King-Devick), conducted on an iPad, that I dutifully carried to the rink in case a kid had a potential concussion. The testing is objective and takes the decision about returning to play out of the hands of the parent and coaches. Concussion, by its nature and because it involves the brain, is tricky. Sometimes symptoms of concussion are obvious. More often, however, they are subtle, and it takes discipline to avoid explaining away symptoms in the heat of the moment.
Despite my training and expertise, I felt woefully unprepared when it was my kid lying motionless on the ice after a player on the other team struck him in the neck and knocked him down, sending his skull crashing onto the ice. Four days later, having seen a top-notch team of concussion experts, there’s a lot I wish I had remembered at the time of the hit.
Mayo Clinic’s David Dodick, M.D., an internationally recognized neurologist and concussion specialist, walked me through the many different things happening in my son’s brain and body that caused him to experience symptoms:
- The blood-brain barrier, the important wall protecting the brain from chemicals in the rest of the body, is disrupted. This breach allows unintended and unusual crossover between the two compartments.
- Blood flow to the brain is reduced, maybe due to increased water in the brain. At the same time, immune and inflammatory cells in the brain react with an increased inflammatory response.
- Nerve strands (axons) and cells in the brain are injured. The shearing forces literally stretch these tissues that are typically tightly protected in the skull.
- Metabolic needs increase in order for the body to repair and heal the brain.
“These reactions in the brain don’t stop at the time of impact — they’re only just getting started,” says Dr. Dodick. “This is, in part, why symptoms tend to evolve and accumulate in the minutes, hours, days after injury.”
I also wish I had remembered:
- Concussion is a rush. The brain is jarred and responds with inflammation. This happens quickly and causes a slightly different response in each individual. My son was dizzy, unsteady, nauseous, and complaining of headache and neck pain. He was also crying and incredibly emotional. His memory of the minutes between the hit and his coach hovering above him asking questions was gone.
- Other signs and symptoms of concussion include lack of awareness, confusion, vomiting, sensitivity to light and visual changes. They also include a lack of cognitive flexibility and the tendency to get stuck on a thought, behavior or action (perseveration).
- Quick sideline tests exist. My son’s league is committed to protecting its players. Each team has a trained safety officer with access to the sideline King-Devick test for which a baseline is established for each player at the beginning of the season. Being more than 1 second slower than baseline on the sideline test measures means the player cannot return to play. My son was more than 1 minute slower, and he was removed from play.
If you have a child who plays a sport in which concussion is likely, see if the league offers similar sideline testing or has trained volunteers to conduct concussion evaluations immediately after a trauma.
- Concussion does not require head trauma or loss of consciousness. Whipping the head around and making sudden stops are enough. My son’s brain was effectively struck twice: first by the player and then by the collision with the ice. Rotational head and neck movements — being whipped around — are as bad, if not worse, as a direct hit to the head.
- Treating concussion requires patience. The approach involves more “not doing” than doing. Inflamed brains need to rest and heal on their own. You can support that by limiting stimulation — though not cocooning the player in a dark room — and allowing space for rest. My family opted for takeout instead of going to a restaurant, and workouts during off hours at the gym when it was quieter.
Contrary to the old belief that those who sustain concussions should stay awake, experts now appreciate the importance of sleep. Sleep is when the brain cleans out the waste that’s accumulated over the course of the day. With the inflammation and buildup of toxins that follows brain trauma, this is particularly important. Adequate hydration and a healthy diet, especially foods with brain-friendly omega-3 fatty acids such as docosahexaenoic acid (DHA) from fish or supplements, can support the pro My son set aside his cheddar crackers for salmon, edamame and walnuts.
- Symptoms improve before the brain has recovered. My son’s nausea and dizziness were gone the next morning. His headache and neck pain were better after taking ibuprofen. This made us second-guess whether we had overreacted at the time of his injury. Maybe he just had whiplash? We were swiftly redirected by the neurologist, who confirmed the diagnosis of concussion and warned us that symptoms would recur when our son returned to regular activities. We saw this when he tried an elliptical machine — his headache worsened immediately with the up-and-down movement. He tolerated the stationary bike, which allowed exertion with very little head movement, but only as long as he pedaled slowly and kept his heart rate down. This elite athlete found himself working out at an incredibly low intensity.
- Physical therapy can help. Exercise is key — but only if symptoms such as headache, dizziness and fogginess don’t return. Exercises that challenge the vestibular system — involving head movement, eye tracking and balance — can be designed to retrain and gently push the brain in its healing process. As one exercise, our son held a popsicle stick in front of him and tracked it with his eyes while doing rhythmic head and body movements. With time, these movements will get faster and help him reach a point where he can quickly swivel his head while tracking the puck.
- It’s a game. I’m a hockey parent. I’ve made countless accommodations for my sons’ hockey careers. Still, there’s nothing more important than his health and allowing his brain to recover fully. The worst thing that can happen after a concussion is a second injury — during the so-called window of vulnerability. According to Dr. Dodick, this is “the time between when the athlete or patient tells you they’re better (symptoms gone) and when their brain is actually better. Before the brain has healed, a far lesser degree of impact can cause recurrence and even worse symptoms.”
As heartbreaking as it is for him, my son will miss practices and games until he is ready to return. If he returns too early, he runs the risk of bigger consequences and a complete ending of his hockey career at the age of 14. We’ll take the necessary time off.
This is a plea to learn about concussion if you have kids in sports or high-risk activities. You are your child’s best advocate, and your child’s brain needs you.
Denise Millstine, M.D.
Dr. Millstine is a women’s health internist and integrative medicine specialist at Mayo Clinic in Scottsdale, Arizona, where she lives with her husband and twin sons. She serves on the Editorial Board for the Mayo Clinic Health Letter and is the Medical Director for the women’s health blog on Mayo Clinic Press. Find her on Twitter @drdmaz.