Blanca

Head Game

Concussions can leave a lasting impact on young athletes’ lives, but Rady Children’s is helping kids get back in the game.

By Chase Scheinbaum

Toward the end of the soccer game’s first half, Blanca Salas made her move. High Tech High School’s varsity team was leading Hoover High 1–0. Trying to protect that lead, the 15-year-old charged toward her rivals as they drove the ball closer to the goal. But players soon jumbled around and a melee ensued. An opponent bumped Blanca’s teammate, who in turn inadvertently shoved her to the ground. She hit face first.

Blanca briefly lost consciousness, but the match continued around her. “There was so much going on; no one could see me,” says the Barrio Logan resident. “The refs never realized I was on the ground.” About a minute later she picked herself up and got back in the game, but something was off. The ball came to her, and she remembers her teammates yelling to kick the ball away from their goal. “I didn’t know what I was doing. Finally I realized I was playing soccer and kicked it out,” she says.

Her head quickly began hurting so much she had to sit on the bench. She explained what happened to a trainer, who gave her a bag of ice—though it felt like the ice and the sunshine were worsening the pain. Eventually it went away. She stayed for the end of the game and went home feeling fine.

However, at school the next morning Blanca began to feel dizzy, lightheaded and sensitive to noise. About a month before, a friend had suffered a concussion, so she figured she had, too. Blanca’s mom, Diana, picked her up and took her to the Sam S. and Rose Stein Emergency Care Center at Rady Children’s Hospital-San Diego, where her suspicion was confirmed.

A Common Injury—but Difficult to Diagnose

Blanca became one of the more than 500,000 American children who visit an emergency department for traumatic brain injuries each year, according to figures cited by the Weill Cornell Concussion and Brain Injury Clinic. A concussion is actually a form of traumatic brain injury, and three out of five of those kids suffered a concussion while playing sports. Perhaps surprisingly, girls’ soccer has the highest rate of concussions per capita among all youth sports (three times as many as boys’ soccer). Football is a distant second, according to a recent study by Northwestern University’s Feinberg School of Medicine. A separate study found that nine high school sports accounted for 2.2 million concussions between 2005 and 2015.

Blows to the head are the numberone incident that sends adolescents to the ED, and the leading cause of disability and death in American children, particularly in the age groups of 0–4 and 15–19, notes the Centers for Disease Control and Prevention.

These studies come on the heels of increased scrutiny on concussions suffered by professional football players. But as evidenced by Blanca and the half million other kids who end up in the ER each year, it’s not only the pros who are at risk. Kids are actually more likely than adults to suffer traumatic brain injuries, because their bodies aren’t fully grown. “When you’re little, your neck is weaker,” says Pritha Dalal, MD, a physician at Rady Children’s specializing in physical medicine and rehabilitation. That allows the brain to more easily impact the inside of the skull or undergo a twisting motion, both of which lead to concussions.

Unlike cuts or broken bones, concussions can be extremely hard to diagnose, and just 10 percent of them cause loss of consciousness. Concussions can even result from a blow to the body followed by an impact to the head.

The vast majority of concussions are not life threatening, but even mild ones can cause prolonged problems. Beyond physical pain like headaches, symptoms can include cognitive, sleep, mood and balance issues. Up to 30 percent of concussed high school athletes can experience symptoms for more than six weeks, according to the Concussion Legacy Foundation. Symptoms also can take days, weeks or months to appear, so it’s tricky to know when kids are ready to return to school, sports and other daily activities.

“Concussions can vary, anywhere from no symptoms whatsoever, to short-term memory or behavioral changes, headaches, nausea, vomiting or vertigo,” says Michael Levy, MD, PhD, head of pediatric neurosurgery at Rady Children’s and former sideline head injury consultant for the NFL.

After a first concussion, kids are up to six times as likely to suffer subsequent and more severe concussions, so returning to play at the right speed is imperative. And too little mental rest—or possibly too much screen time— can drastically prolong the recovery period. “Concussions always resolve over time,” says Dr. Levy, “but you need to protect the athlete in the interim so they don’t reinjure themselves while in a vulnerable state.”

Getting Patients to a Specialist Faster Makes a Big Difference

Rady Children’s has overhauled its concussion treatment process, from diagnosis to the moment the patient is allowed back on the field. Experts treat all forms of pediatric traumatic brain injury, and one team specializes in concussions suffered by youth athletes. Rady Children’s concussion clinic is part of the Division of Orthopedics & Scoliosis, which is ranked seventh in the country by U.S. News & World Report.

The staff of the Hospital’s 360 Sports Medicine program are trained to make advanced diagnoses and rehabilitate patients to reduce pain, strengthen key muscles and get back into a jersey. Since impaired balance is a common symptom that can linger for months, they’ve also created one of just a handful of pediatric balance and vestibular programs in the world.

Many patients who suffer a concussion first go to a school nurse or their primary care physician rather than an emergency room. That’s why Rady Children’s involvement extends to schools. They’ve pioneered a medical information system to keep primary care doctors updated on the latest guidelines and recommendations—which is particularly important considering that Rady Children’s network spans such a large region. “We have fi gured out a better way to make it easy for pediatricians to understand the best ways to treat them,” Dr. Dalal says.

Some of those guidelines pertain to when a doctor should send their patient to a specialist. If a specialist is not needed, it’s better not to waste anyone’s time. Conversely, when a patient needs to see a neurologist, they should do so right away. For that reason, Rady Children’s has created an expedited track for referring patients to specialists, often in just a few days.

“We put pathways in place to have a patient seen quickly, so they can be diagnosed and start treatment quickly, and begin getting back to their normal activities,” Dr. Dalal says.

Recovery Means Resting Both Body and Mind

Doctors told Blanca to stay off the soccer fi eld for a while. “I was kind of freaking out because I felt like I couldn’t do anything,” she says. Though she didn’t have to take any days off school, returning to her studies wasn’t a simple process. Following a concussion, patients must return to schoolwork carefully and avoid screens. Limiting computer time was difficult for the High Tech High student, who does most of her work that way, but her teachers were able to switch some assignments to paper so she wouldn’t fall behind.

Initially, Blanca’s return to schoolwork ate into her sleep time. Adequate shut-eye is crucial to recovery as well, so her doctors urged her to get extensions on assignments and maintain seven to 10 hours a night. “Getting kids back to school safely and in a way that’s accommodating and not stressful is very important. It’s a key aspect of what we focus on,” Dr. Dalal says.

Blanca was experiencing headaches, and her balance was out of whack. “I’d think I was standing still and everybody would be like, ‘You’re shaking,’” she says. During a concussion, the inner ear’s mechanism for maintaining the body’s orientational awareness can be thrown off, causing dizziness and imbalance. The neuroscientists at 360 Sports Medicine’s balance and vestibular lab can test patients for precise diagnoses, which physical therapists can then use to create treatment programs. Blanca’s team prescribed neck-strengthening and other exercises. After six months of “wobbling,” as she calls it, she finally regained her equilibrium.

In the past, doctors believed getting ample physical rest was the most critical measure for healing concussions. “The brain is the only organ that truly needs sleep, so adequate rest is imperative,” says Andrew Skalsky, MD, director of Rehabilitative Medicine at Rady Children’s. “But kids need to resume normal social and physical activities that aren’t at risk for repeated concussion in order to avoid mental health conditions, such as depression or anxiety, that may follow from being socially withdrawn. The newest recommendations are to rest for a short period, then start doing more as you feel better, as long as symptoms aren’t becoming worse.”

The consensus has likewise evolved about resting the mind. “They used to believe you didn’t need cognitive rest, but it turns out that’s not the case,” Dr. Levy says. “So we work with schools to make sure kids are integrated back properly.”

Blanca’s return to soccer began with a few weeks of daily 20-minute walks. Eventually she ramped those up to jogs, which at first she could do for only five minutes without headaches. After a while, she was allowed to do warmups and some ball drills at soccer practice. (Blanca plays club soccer, so her competitive year stretches through the summer.)

She eventually got the okay to play a bit more aggressively, but at one point she bumped into a teammate and her headaches worsened, so she had to dial back the intensity. “It was really hard for me to realize I couldn’t give it 100 percent. I wanted to go for it and be around my teammates, but I had to go really slowly.” Blanca’s doctors think she may fi nally be ready to play soccer full steam when school starts up again this fall.

Originally published in the Fall 2018 edition of Healthy Kids Magazine.