Sports-related Concussion in Children: The Role of the Speech-Language Pathologist

This article was originally published in the July 2020 issue of the ISHA Voice; it was republished in the November 2024 issue of the ISHA Voice. 

By Miriam Carroll-Alfano, member of the Medical Practice Issues Committee

Introduction

Summer brings us outside for recreational and sporting activities, especially children.  Although the coronavirus pandemic put many of these activities on hiatus, soon we will be returning to them.  With many of these activities comes risks for injuries, including concussions.  It is important for speech-language pathologists to play a role with this population, including prevention, assessment, and treatment. 

Concussion Facts

The Centers for Disease Control and Prevention reported that in 2014, almost 2.9 million traumatic brain injuries occurred in the United States, leading to emergency department visits, hospitalizations, and deaths (CDC, 2019).  The majority of these are classified as mild injuries. The term mild traumatic brain injury tends to be used as the medical term, whereas concussion is the term used most often in sports medicine and the public. 

There are a variety of causes of concussions including falls, motor vehicle accidents, being struck by or striking an object, and recreational and sporting activities.  The rate of emergency department visits for sports and recreation-related injuries with a diagnosis of concussion or TBI more than doubled among children age 19 or younger in recent years (CDC, 2016; Coronodo et al., 2015; Zhang et al., 2016). Concussion in sports has received increased attention over the last 10 years, from professional sports to youth sports

The consensus statement on concussion in sport from the 5th International Conference on Concussion in Sport (McCrory et al., 2017) defined concussion as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.  Concussion results in rapid onset of short-lived impairment of neurologic function, with acute clinical symptoms emerging as a functional disturbance of the brain, rather than a structural injury; therefore, no abnormality is seen on standard structural neuroimaging studies (McCrory et al., 2017).  It is difficult to pinpoint the exact number of concussions annually due to the various locations of treatment and sometimes lack of treatment.  The Traumatic Brain Injury Program Reauthorization Act of 2018 was signed into law in December 2018 and this bill directed the CDC to implement a National Concussion Surveillance System (CDC, 2019).

Concussion Laws

Concussion in children and adolescent athletes is of concern due to the high prevalence of concussions among this population, coupled with increasing recognition of the potential serious long-term health sequelae of concussions and TBIs (Institute of Medicine (IOM) and National Research Council (NRC), 2013).  Athletes can be at increased risk for concussion and potentially serious long-term consequences; therefore, this population has been targeted with prevention activities and education. Concussion legislation has been passed in all 50 states, with some including specific requirements for education and prevention activities, return to play (RTP), and return to learn (RTL) protocols for youth sports (The Network for Public Health Law, 2019).  Illinois passed its first law in 2011.  The latest law, IL Public Act 099-0245 Youth Sports Concussion Safety Act, was passed in 2015 and went into effect in 2016.  This law expanded requirements for all youth sports, including education for athletes, parents, coaches, and school athletic personnel, removal from play policies, and return to play and learning policies.  An increase in the number of athletes reporting receiving concussion education following implementation of laws has been demonstrated (Carroll-Alfano, 2017 and Chrisman et al., 2014); however, research investigating whether this translates into better knowledge or a change in athlete behaviors found mixed results (Arakkal et al., 2020, Bramley 2012, Feiss et al., 2020, Kroshus et al., 2014, Kroshus et al., 2015, Miyashita, 2013, Rivara et al., 2014).  Compliance with concussion laws can be challenging for schools and sports organizations since funding and implementation procedures are often not provided (Sullivan, 2020). 

Concussion Signs and Symptoms

Concussion signs and symptoms can be classified into several categories including physical, cognitive, and behavioral.  Examples of physical signs and symptoms include headache, dizziness, and nausea.  Commonly reported cognitive signs and symptoms include memory loss, disorientation, and decreased attention.  Behavioral signs and symptoms are much less likely to be recognized and include depression, changes in mood, and increased anxiety (Carroll-Alfano, 2017).  Physical, cognitive, and behavioral signs and symptoms can have detrimental affects on return to normal activities for children who have sustained a concussion.  For example, headaches and fatigue can be a barrier to returning to school (Blume, 2015 & Hicks, Larkins, & Purdy, 2011).  Impairments in memory and attention can lead to difficulty learning new information and concentrating in class, and depression can lead to decreased social interactions and loss of interest in activities (Halstead, 2013).

Continuum of Concussion Care

Most children who sustain concussions recover within 7-14 days (McCrory et al., 2017).  Approximately 10-30% of persons with concussions experience the prolonged recovery times of Post Concussive Syndrome (Makdissi et al., 2013; McCrory et al., 2017). The recovery process for concussion occurs across the continuum of care, from the sideline through the medical and academic settings. Experts identify the key R’s of concussion management as: Recognize, Remove, Re-evaluate, Rest, Rehabilitation, Refer, Recover, Return to sport, Reconsider, Residual effects, and Risk reduction (McCrory, 2017).  Collaboration between professionals is important and may include athletic trainers, neuropsychologists, occupational and physical therapists, educators, and speech-language pathologists (Brown & Knollman-Porter, 2020).

The Role of the Speech-Language Pathologist in Concussion

The speech-language pathologist has a role in working with children and adolescents who experience concussion in both medical and school settings.   These roles include prevention,

assessment, and treatment for children from early childhood through adolescence (Brown et al., 2019, Lundine, Ciccia, & Brown, 2019, Sohlberg & Ledbetter, 2016).  For prevention, speech-language pathologists can provide education to students, families, caregivers, professionals, and others including concussion education including the signs and symptoms of concussion and their affects on students.  Illinois speech-language pathologists can also be a member of Concussion Oversight Teams at local schools or other athletic programs. Speech-language pathologists should complete assessments for possible deficits in language, speech, and cognition, particularly functional deficits the student may encounter in everyday activities when concussion signs and symptoms have not resolved.  Finally, speech-language pathologists can provide treatment when language, speech, and cognitive deficits have been identified, including direct treatment, training of compensatory strategies, and education with the student, family, and other professionals.  Speech-language pathologists play an important role in managing language and cognitive difficulties that can have an impact on educational, vocational, and social situations for children with concussion (Brown & Knollman-Porter, 2020)

Conclusions

Speech-language pathologists have an important role in prevention, assessment, and treatment of concussion in children.  Get educated about concussion by learning about the concussion policies of your school, district, and community organizations.  You can find additional information at these websites and in the references provided here.

Resources

• Centers for Disease Control and Prevention Heads Up: Concussion  

https://www.cdc.gov/headsup/

https://www.cdc.gov/traumaticbraininjury/providers.html

• Concussion Legacy Foundation http://concussionfoundation.org/community-programs
• Illinois High School Association http://www.ihsa.org/Resources/SportsMedicine/ConcussionManagement/Concussion Resources.aspx

References 

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Blume, H., (2015). Headaches after concussions in pediatric: a review. Current Pain and Headache Reports. 19; 42-53.

Bramley H, Patrick K, Lehman E, Silvis M. (2012). High school soccer players with concussion education are more likely to notify their coach of a suspected concussion. Clinical Pediatrics; 51(4):332–336.

Brown, J. & Knollman-Porter, K. (2020).  Continuum of care following sports-related concussion, American Journal of Speech-Language Pathology, https://doi.org/10.1044/2020_AJSLP-19-00131

Brown, J., O’Brien, K., Knollman-Porter, K., & Wallace, T. (2019). The speech-language pathologist’s role in mTBI for middle and high school-age children: Viewpoints on guidelines from the CDC. American Journal of Speech-Language Pathology, 28(3), 1363–1370.

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Centers for Disease Control and Prevention (2019). TBI data and statistics, https://www.cdc.gov/traumaticbraininjury/data/index.html

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Chrisman SP, Schiff MA, Chung SK, Herring SA, Rivara FP. (2014). Implementation of concussion legislation and extent of concussion education for athletes, parents, and coaches in Washington state. American Journal of Sports Medicine 42(5):1190–1196.

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Sohlberg, M. & Ledbetter, A. (2016). Management of persistent cognitive symptoms after sport-related concussion, American Journal of Speech-Language Pathology, 25:138-149.

State of Illinois. (2011). Illinois public act 097-0204, Protecting our student athletes act,

     Retrieved from: http://www.ilga.gov/legislation/publicacts/97/PDF/097-0204.pdf 

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     Retrieved from: http://www.ilga.gov/legislation/publicacts/fulltext.asp?Name=099-0245.

Sullivan, L., Harvey, H., Smith, G., Yang, J. (2020). Putting policy into practice: School-level compliance with and implementation of state concussion laws, 26(2):S84-S92.

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Miriam Carroll-Alfano is an Associate Professor at Midwestern University in Downers Grove and Certified Brain Injury Specialist. She has been a speech-language pathologist for over 23 years working with patients with a variety of disorders including aphasia, motor speech disorders, cognitive communication disorders, head and neck cancer, and dysphagia. She has served on the ISHA Membership Committee and currently serves on the Medical Practice Issues Committee.