ANNOUNCER: Welcome to the American Speech-Language-Hearing Association’s podcast series, highlighting issues in the field of human communication.
JOE CERQUONE: Youth sports are often fun and rewarding. However, for the kids who play them, they can also lead to a concussion. This ASHA podcast will look at what a concussion is, the extent of the injury in the world of Youth Sports, how it can be prevented, and care approaches for when it is suspected or has actually happened.
My guest is Melissa Duff, Ph.D. Dr. Duff is Assistant Professor in the Department of Communication Sciences and Disorders and the Department of Neurology at the University of Iowa. A speech-language pathologist and member of the American Speech-Language-Hearing Association, or ASHA. Dr. Duff is the author of “Management of Sports-Related Concussions in Children and Adolescents”, an article that appeared in the July 14, 2009 of thhe “ASHA Leader”. Dr. Duff, welcome.
DR. DUFF: Thanks for having me.
JOE CERQUONE: I guess to begin with, I’ll simply ask, what is a concussion? And, what are the leading symptoms?
DR. DUFF: A concussion is any type of brain injury and this can be caused by a blow to the head and it interferes with the way the brain works. A concussion can affect a number of things, including one’s balance and coordination and the ability to think, remember, or make good judgments.
One common misconception about concussion is that it has to involve a loss of consciousness, and that’s simply not the case. You can have a concussion whether or not you lose consciousness.
The symptoms can be categorized in several different areas. There can be physical symptoms, such as headaches, nausea or dizziness. There are symptoms associated with how we think, including slowed thinking, problems concentrating or solving problems.
There are also changes in how people act or feel. So individuals who have had a concussion frequently report feeling frustrated, irritable and even depressed.
JOE CERQUONE: So to go back to the misconception that you raised, does that mean that a lot of concussions to undiagnosed?
DR. DUFF: Many do – particularly because people think that there has to be this loss of consciousness or someone is knocked out. That is a common misconception and, in those cases, I do think there are lots of kids who go – or who are not identified.
JOE CERQUONE: Well, speaking of a few sports in particular, how extensive are concussions?
DR. DUFF: Well we don’t have really good numbers for the rates of concussion in really young children. But what we do know is that there are several pieces of information that would suggest this is a growing public health concern. So we do know that sports and recreational activities are the third leading cause of traumatic brain injury in the United States for children and adolescent and we know that every year in the U.S. there are more than 300,000 sports-related injuries – brain injuries. Most of these can be classified as concussion. Finally, we know that nearly sixty percent of high school students participate in organized sports every year and that number is growing annually for the number of young children that are participating. So we do know this is something that we need to be paying closer attention to.
JOE CERQUONE: Is it implied in your answer that organized sports for children younger than adolescence are not being tracked for things like concussions?
DR. DUFF: They are not systematically at this point, but this is an area of great interest and research that is going on right now. So I think we will have better numbers for that soon.
JOE CERQUONE: Okay. Well, with regard to the sports where concussions are showing up, in which of them are concussions the most common.
DR. DUFF: We see the highest rates of concussion in contact sports such as football and ice hockey, followed by sports like soccer, wrestling and basketball. But it’s important to remember that a concussion can also occur in individualized sports like gymnastics or diving.
JOE CERQUONE: And what do we know about who gets the concussion in terms of – I would assume that it would be more boys than girls simply because the numbers of participants in sports are greater among boys. How does that break down gender wise?
DR. DUFF: It’s surprising. More girls are playing in sports than ever before and we’re seeing their numbers on the rise as well. But just like the general demographics for traumatic brain injury, we do see more boys who have concussion than girls.
JOE CERQUONE: Okay, so we have a situation where a certain sport is being played, someone gets injured – they suffer a blow to the head. Is there a typical way such situations are being handled in the immediate aftermath of the injury?
DR. DUFF: Well, there is no status quo or agreed-upon approach for this right now. But what is frequently used are published guidelines for making decisions about when an athlete can return to play. I think these are pretty widespread in their use among coaches in this country and they make recommendations for when a student athlete can go back to play and these recommendations are based on the severity of the concussion and then whether or not this is a first, second, or third concussion for that season. These guidelines have been really helpful in promoting a common terminology for coaches and players, but currently there are over 22 versions of these and so there is a lot of variability among them and this leads to no agreed-upon best course of action.
JOE CERQUONE: Twenty-two versions. How did that come to be?
DR. DUFF: Everyone has a different opinion about what variables are the most important. And they are pretty nuanced differences. But there are that many versions out there right now.
JOE CERQUONE: So does that then – I guess that speaks to the fact that there is some lack of consensus as what to do in this situation?
DR. DUFF: That’s right.
JOE CERQUONE: Well I know that there has been – in reading your article – that there is a movement afoot to take a more individualized approach to caring for someone who is thought to have suffered a concussion in terms of how they go about returning to play. Could you talk about that a bit?
DR. DUFF: Sure. This interest in individualized return to play comes from the recognition that there is all of this variability in these published guidelines. Also despite that variability, each guideline adopts what is called a one-size-fits-all approach and it ignores individual factors such as the age of the concussed individual, their gender and any unique circumstances of that particular injury.
So what’s being proposed is to individualize this decision-making process by completing neuropsychological testing for each student athlete at the beginning of the season before there is an injury and then again, if there is an injury that occurs during that season. So this testing, most of which is computerized, assesses domains like the student’s reactions times, memory and then allows for comparison between the individual’s pre-injury and after the concussion. So we are making decisions based on the individual recovery and abilities of that person and not just a guideline that would just say if they’d been knocked unconscious and this is a second injury, then they should miss two games, for example.
JOE CERQUONE: Okay.
DR. DUFF: So then when an athlete’s performance is back to their pre-injury baseline, then and only then, would that person – that student athlete be allowed to return to play. But let me add one important point and that is that while this movement is considered very important and exciting, this method, these tools are new. They are still being validated and I’m sure that they are going to be tweaked over the years if not replaced by even more sensitive measures.
JOE CERQUONE: I see. How common is full recovery from a concussion?
DR. DUFF: I’m really glad you asked me that because some of what you read about concussion and the affects seem quite dire – and they can be. But this often leaves parents terrified about whether or not their child should get to play any sports at all so it’s important for folks to know that almost all children who sustain a concussion will make a full and complete recovery.
JOE CERQUONE: But I take it that that recovery can take – depending on the individual – can take a unique course. It’s very difficult to generalize about how it would happen
DR. DUFF: Absolutely. The response to a concussion is very individualized and there aren’t specific patterns in terms of the duration of concussions, symptoms, and even which symptoms would persist the longest.
JOE CERQUONE: Right. Well I’m aware of the fact – and I’m sure that you are even more so – that there has been interest in this subject. Probably more interest than ever, since the beginning when sports first started to be played. But I’m wondering what have been the chief strides to date in terms of understanding what a concussion is and how to treat it. What would you say has been the chief stride that has been taken during that time?
DR. DUFF: I think the most exciting stride or advancement has come from animal models of concussion. So we are learning more about very physiological changes in the brain after concussion. Changes like the blood in the brain and changes in the brains production of certain chemicals and so from these models, we’ve learned that these changes that occur in the brain take time to resolve. Hours and days for the brain to go back to its normal functioning. These findings have been translated into treatment approaches which is another stride. So because we have a better understanding that it takes time for the brain to recover, we are increasingly more sensitive to making sure that athletes are symptom free, both at rest and during various light or more rigorous activity before they go back into the game.
JOE CERQUONE: Dr. Duff, for those parents who are listening to this podcast who have children, young people playing sports, what is the best piece of advice you have for them in terms of the treatment of their children should they suffer a concussion and the best way to manage that treatment?
DR. DUFF: I think the best thing that parents can do is just to get more information about concussion and the symptoms of a concussion so that they can keep an eye on their children and recognize this. And then to be an advocate for their child. And some ways that parents can advocate is to insist that their child – if their child has a concussion – that they cannot return to play in that game. They should first see a doctor.
Parents should also communicate with the school when their child has suffered a concussion. It’s important to remember that not all concussions happen during school hours or on school grounds. So many times the teacher and the school administrators don’t know that this is something the child has experienced. So once the teachers know this, they can also assess how or if the concussion is affecting the child’s classroom performance, if they’re tired or having difficulty concentrating in class. We are also learning that increased activity, even mental activity, can interact with and interfere with the brain’s recovery after a concussion.
JOE CERQUONE: I suppose too, it would make sense for them before their child actually begins to participate in sports, to inquire as to what the approach is of the school or the sports organization with respect to treating concussions. Would you say that’s reasonable?
DR. DUFF: Yes, I do think that’s reasonable and even if the school doesn’t have an approach, if parents start asking that question, I think it will encourage the coaches and the school to attend to it more and to increase their own awareness.
JOE CERQUONE: Right. Right. Well, I’d like to talk a bit now about the role of speech-language pathologists. What is it? What is that role that they play in caring for children or youth who have suffered a concussion?
DR. DUFF: Well right now, speech-language pathologists do not have a specified role in working with this population. And this is one of the reasons that I wrote the article for “The ASHA Leader.” I’ve spoken with some of the developers of some of these computerized baseline assessment tools and I was really surprised to learn that these instruments were being routinely used in high school and there is an eye toward using them in elementary and middle schools. These developers didn’t know what SLPs do – didn’t know we were in the schools and also didn’t think of us as a resource in the schools for children with brain injuries. So in many settings, the recommendation for who works with these kids and who assesses them is that the school nurse or an athletic trainer will be the ones who administer this baseline testing.
So I wrote the “The ASHA Leader” article to suggest that SLPs are really well-suited to take a role in working with children with concussion because of our training in assessment and understanding the skills and abilities necessary to be successful in academic and social settings and because many SLPs have specific training in cognition and traumatic brain injury. But it is also important for us to think about this role, if we are going to have one, and I think there is certainly room and reason to argue that we could and should have this role. But we would need support from school administrators to give the SLPs in the schools, who are already very stretched caring for large caseloads, more time and support to provide the best services to these kids.
JOE CERQUONE: Along those lines, what is a step or two that you would suggest for your SLP colleagues as to how they could make themselves better known?
DR. DUFF: I think the first thing is just to educate other school personnel and school administrators and school psychologists, if the school has one, that this is something that we do. This is in our scope of practice and when there are kids who have cognitive impairments or brain injuries that affect communication and social functioning or learning, they should think of speech-language pathologists as a key member in a team working for those kids.
JOE CERQUONE: In those cases where a speech-language pathologist is involved in the care of someone who has suffered a concussion, what tips do you have for parents as to the most effective way to work with that speech-language pathologist?
DR. DUFF: I think the most important thing in facilitating this relationship is to keep the lines of communication open. Speech-language pathologists can do a better job treating that child who has a concussion if they have a more complete picture of how the child is doing in all areas of their life. That is, at home or on the weekends, what activities are more difficult for that child after the concussion? Or in what situations does the child become particularly fatigued or irritable? Having that kind of information, along with the observations that the SLP will have of the child at school, will allow for a more complete treatment approach.
JOE CERQUONE: That’s very good. I’m wondering to if you could add to that, take it beyond working with a speech-language pathologist, to just a couple of general tips for parents whose children are playing sports. What are a couple of helpful tips and where can they go for resources?
DR. DUFF: Sure. I think first is talk to your child about the risks of concussion and what those symptoms are. Talk to your kids that if they do get hurt, stress to them the importance of telling the coach and the other team members that this has happened and how they feel. Do they feel dizzy or they don’t remember the last play and that they should sit out for the rest of the game until they can see a doctor. One of the best resources, I think, for parents and the public in general comes from the Centers for Disease Control and Prevention. They have a program called the “Heads Up” program. For free, you can request fact sheets and videos and posters and other educational materials that talk about concussion and concussion prevention and what those symptoms are. So I think that’s a great resource for parents.
Second I would say that if your child wants to participate in sports, to keep a healthy perspective about what those risks are and encourage your kids to be active and to participate in sports.
JOE CERQUONE: Well Dr. Duff, you’ve given us some great information. Thank you for joining us today.
DR. DUFF: Thank you for having me.
JOE CERQUONE: Dr. Duff’s related article in The ASHA Leader can be found at http://www.asha.org/Publications/Leader. Also, other podcasts like this one are available at podcast.asha.org [now blog.asha.org/category/podcast/]. And finally, listeners can find a speech-language pathologist or audiologist in their area by visiting www.asha.org/findpro/.