By Susan Levine
Washington Post Staff Writer
Tuesday, October 10, 2006
After a nasty collision on the field, a face-first dive and a fierce somersault, soccer player Kerry Aldrich went home three weeks ago with a post-scrimmage concussion. Had it happened several years ago, her coach might have told her to rest through the weekend and report for practice Monday.
Today, however, the Vienna 10th-grader remains on the sideline. A doctor still has not cleared her return to the game.
Research is rewriting the rules for the treatment of juvenile concussions and for the hundreds of thousands of young athletes who get "dinged" annually in the United States. What was once considered "a relatively benign condition," as a recent commentary in the journal Pediatrics noted, is being recognized as a critical medical issue with distressing, potentially permanent consequences.
Growing evidence indicates that youth is not a plus with concussions. When jolted violently from a hard hit or fall, a juvenile brain may be more vulnerable to harm and slower to heal. It also seems in greater jeopardy of subsequent damage. Yet many pediatricians and frontline practitioners are only beginning to adjust what they tell patients.
"It can be a very serious injury," said Gerard Gioia, director of the sports concussion clinic at Children's Hospital, one of the few programs on the East Coast that focuses on such cases. "And with what we know about the developing brain, it can be an even more serious injury."
The risks explain why 15-year-old Kerry is on inactive status while her school and touring teams play major fall games.
"It's very, very important that you give yourself a break," Gioia emphasized when Kerry returned to the Rockville clinic last week. He went over the latest blue-and-red test results showing how well she was retaining and reacting to information. All the bars had moved the right direction, back toward normal, just not far enough yet.
"That's the good news," he told her. "The stinky news is that we've still got some handcuffs on you."
Concussions in children have long been underestimated, misdiagnosed and poorly managed, Gioia and other specialists say. They do not cause bleeding or swelling in the brain, so they do not show up on X-rays or usual diagnostic scans. Until recently, there have been few ways to measure the effects, from headaches, dizziness and double vision to sluggishness, confusion and poor concentration.
Doctors have had to depend largely on their patients to describe the severity and duration of symptoms. In a sports-driven culture that celebrates the competitor who pushes through pain, some coaches, parents and young athletes have minimized or overlooked warning signs. Most likely, few understood that those could lead to lasting learning problems or personality changes.
The burgeoning ranks of children in competitive sports -- and heightened awareness of the danger -- have helped propel the focus on concussions. With some of these athletes experiencing difficulties long after their ostensible recovery, recommendations about managing such mild brain injury became suspect.
"We've learned more about this injury in the past five years than in the past 50 years," said neuropsychologist Michael Collins of the University of Pittsburgh Medical Center. The center has been the leading researcher of sports concussions in the country, designing computerized testing dubbed ImPACT that takes the guesswork out of assessments. Its list of hazardous endeavors: not just football, soccer and basketball, but ice and field hockey, skating, wrestling and cheerleading.
"Kids take longer to recover," Collins said, often weeks longer than college or professional players. Moreover, those who experience immediate amnesia have more persistent symptoms than the small minority who briefly lose consciousness.
The research shows that exertion, whether physical or mental, can exacerbate and prolong symptoms as an adolescent's brain heals. As it resets its vital electrochemical system, significant rest sometimes is what a doctor should order. Class work could be minimized, tests delayed.
The findings are garnering increased attention and support. Last year, the federal Centers for Disease Control and Prevention released a special Heads Up kit that calls the youth problem serious and "often overlooked." Its slogan -- "It's better to miss one game than the whole season" -- was aimed at coaches and trainers. A version tailored to doctors is expected soon.
The CDC also is funding a study, involving Children's and the Pittsburgh medical center, to devise a screening tool to better detect concussions in youngsters and guide pediatricians and emergency room doctors. Hundreds of patients in the Washington area may participate.
And through a federal grant, the Pittsburgh-developed software that assesses an athlete's cognitive function after diagnosis will be adapted for children as young as 5. Sports programs nationwide have relied on ImPACT for several years. St. Albans School in the District uses it to record base-line data on its football players and other teams for comparison after injuries. A parent whose son suffered a concussion underwrote its purchase.
"It gives us really objective data as a jumping-off point for making judgments about whether an athlete is fit to return to competition," St. Albans athletic trainer Jay Driscoll said. "When they say, 'I'm fine, I'm fine, I'm fine,' we can say to them, 'Then pass the test.' "
The program aided Gioia in evaluating Samantha Tomarchio of Ellicott City this summer. The nationally ranked skater took a bad spill with her ice dancing partner at their training rink in June. Even now, the 16-year-old does not remember exactly what happened.
She wishes she could forget much of the next three months. On the ride home, her head throbbed so brutally that the sound of the car's turn signal almost made her cry. The world swirled wildly for days, long past when an ER physician suggested that she could return to the ice. Her alarmed mother took her to a neurologist, who told Tomarchio to give up her driver's education class and many other activities for a while. Well into July, Tomarchio would go blank for seconds at a time.
"It was a stressful summer," Tomarchio said after a workout two weeks ago, skates exchanged for wedge sandals that earlier would have sent her teetering. At night, even her dreams had spun. She very gradually returned to practice and lifts, for a time wearing a hockey helmet for protection.
"I just want to move on," she said.
At least 300,000 sports concussions occur every year in children; there is no estimate of local numbers. The Children's Hospital clinic sees an escalating number of patients, currently more than 500 a year. Gioia is concerned that too many injured youngsters are not adequately treated.
"There's such a gap between what we know and what we do about it," he said.
On the same morning the neuropsychologist nixed Kerry Aldrich's return to soccer -- she still felt a mental fogginess, she conceded after testing, although "it's getting much easier to pay attention" in class -- John Hamilton got Gioia's okay to play in his high school team's afternoon football game. The District 14-year-old had fallen hard during a mid-September practice but continued without complaint. Only hours later, after he arrived home and couldn't tell his mother where he had been, did anyone know he was hurt.
"I thought he was being smart with me," Constance Hamilton recalled. In reality, he didn't remember being on the field.
John improved fairly rapidly, though not fast enough for his team's first game. As he started to suit up again, the coaches and athletic trainer checked in regularly with his mother. "They're probably watching all the players closer now," she said.