Concussion is an injury to the brain which occurs when the head is subjected to excessive force, such as when it hits an object, an object collides with the head, or the head is shaken. Patients diagnosed with concussion report a range of neurologic symptoms including dizziness, headache, confusion, loss of consciousness, seizure, or loss of memory (Heller, 2012). It is a significant public health issue because of its increasing incidence, its acute and long term effects, as well as the costs involved. This paper discusses the epidemiology of concussions, its impact on the young population, and possible strategies towards promotion of children’s health.

Each year, nearly half a million of people are seen in the emergency room with concussion, and current estimates show that 75-90% of them are children (Gioia et al., 2009). Further, public health data reveal that 304 of every 100,000 children sustain a concussion, with infants aged 0-4 and preschoolers, mostly boys, involved in the majority of cases (Toledo et al., 2012; Heads UP, 2012). More than 170,000 persons within the 0-19 age range suffer a sports-related concussion each year, discounting the vehicular-accident-related cases, which are common among those aged 15-19 (Toledo et al., 2012). The cases included in the above statistics are nonfatal in nature.

Statistics

Per school year, cases of concussions related to sports among high school students amount on average nearly to 136,000, which is a conservative value since in some sports, particularly in football, about 50% are unreported (Toledo et al., 2012). In a study of 20 sports, high school athletes who suffered concussions were predominantly girls, and it accounts for most of the injuries that female athletes reported (Marar et al., 2012). In the general population, cases of concussions have tripled compared to 15 years ago; and with greater participation of children in sports nowadays compounded with the popularity of extreme sports, the incidence is likely to further increase.

In the acute phase, clinical management includes ruling out other conditions, such as contusion, through imaging and other diagnostic tests. Neurocognitive tests are also performed to help determine severity, and treatment consists mainly of symptom management. Once acute symptoms improve, patients are advised to have bed rest and should be discharged. The recovery period may last hours, days or weeks, while some kids still show symptoms for months after injury. However, studies show that recovery among children takes a significantly longer time compared to adults, which potentially impacts on health care costs (Toledo et al., 2012).  

Over a decade ago, hospital costs involved in concussion-related treatment were noted to approximate $12 billion (Heads Up, 2012). With the sustained involvement of children in sports in recent years and an increase in incidence of concussions since a decade ago, annual national costs may have well exceeded this value. Besides direct costs, additional expenses may be incurred for health care needs at home and follow-up clinic visits. Productivity losses may also result when working parents stay at home longer to care for the injured child. Despite the notion that concussions eventually resolve without any significant consequences, recent studies suggest the possibility of chronic conditions following injury, whose management adds to the costs.

The physiological responses  of concussions

A reduction in blood flow to the brain, as well as edema, occurs during concussion (Toledo et al., 2012). These physiologic responses cause further neural injury, apart from the direct damage resulting from the force applied to the head. Evidence shows that disseminated and recurring edema is more likely to occur in a child’s brain following a concussion compared to that of adults. This tendency contributes to the longer recovery period noted in pediatric patients, which may last for years. Consequently, there is a continuing damage to the brain that is manifested as persistent problems in the various functions controlled by the affected regions of the brain, which are collectively called post-concussion symptoms (Toledo et al., 2012).

Post-concussion symptoms (PCS) can be either symptomatic or subtle and permanent or reversible. Moreover, as a child’s brain is still in a state of rapid development, chronic edema can potentially affect this development in ways that are irreparable. Thus, even if symptoms have ben resolved a long time ago, there may still be lingering cognitive and behavioral problems, such as learning or speech difficulties, which can be aggravated further if a subsequent similar injury is sustained (Toledo et al., 2012). Incidentally, it is noted that children who suffered a previous concussion are more likely to experience another one, although the reason behind is unclear. The course of concussion then extends beyond the acute and recovery phases. Such evidence underscores the urgent need to address the issue.

Types of interventions

The points covered above describe the context in which nursing interventions geared towards diminishing the problem must be developed. Now elevated into a public health issue, nurses can meaningfully complement federal and state efforts of decreasing the incidence of concussions. Nurses working in the community and the school are well placed to initiate awareness building, promote safety, ensure prompt treatment, and aid in the recovery period and beyond. Nurses can also enable collaboration between the different entities involved in the child’s care, namely the family, the school and the physician, to ensure integrated management.

The school, being the child’s other environment besides the home, is an important venue for interventions since it is here where many injuries take place. First and foremost, safety must be ensured within the classrooms, corridors, cafeteria, playgrounds, gymnasium, entryways, exits and other areas frequented by students to prevent falls and similar accidents, especially among very young children who have the highest incidence of cases (Heads Up, 2012). Adequate supervision during break time and outside the classroom must also be provided. Nurses can raise the concern about ensuring a safer school environment to the administration, which has the resources to implement the necessary measures.

Besides guaranteeing safety in the physical environment, awareness-building regarding safety issues is also an important component of any safety intervention (Moser, 2007). Nurses can initiate information dissemination campaigns among students, faculty, staff, and parents in the form of health teachings in classes or meetings, posting information on bulletin boards or giving handouts.  In achieving a common knowledge of the problem among the school’s population, it is easier to obtain their support for and compliance with safety initiatives. Misconceptions about the issue will also be clarified in the process.

A great number of concussion cases in schools are sports related. Hence, nurses must put special focus on athletes as they are at a higher risk for sustaining such type of injury. Contact sports have the highest concussion incidence rate, which is attributed to the inevitability of physical contact, as well as the contact with the floor and equipment. Although sports gear such as mouth guards do not totally prevent a concussion, and their efficacy is not well supported, they can at least decrease its severity by providing a degree of protection (Knapik et al., 2007). Therefore, promoting the use of protective equipment may also help. Additionally, the need to stress the importance of reporting concussion injuries among student athletes cannot be ignored since it facilitates a prompt and adequate reaction, which the school should be prepared to provide.  

Secondly, management of the injured child during recovery and his/her return to school should be consistent with evidence and the standards set by the federal and state health agencies. A central problem concerning student athletes in this period is the return to play. Because of the lack of standard protocols governing the management of concussion, physicians base their recommendations for a return to a play primarily on reported and observed symptoms. The lack of reliability of this method often results in students engaging in sports 1-3 days after the injury. With the observed longer recovery period among children and the possibility of residual effects, an early return to previous activity levels deprives them of the rest they need.

In addressing the absence of standards, the CDC has developed the Heads Up information packet for physicians, which is useful for nurses as well, outlining the definition of the condition, its pathophysiology, the signs and symptoms, the management and primary prevention methods which are based on evidence (Heads Up, 2012). An Acute Concussion Evaluation (ACE) care plan was also developed to provide assessment and management guidelines for the return to home, school, and sports and to ensure appropriate recommendations and referrals if necessary (Gioia & Collins, 2006).

The ACE advocates for a gradual return to normal activities and continued follow-up.  The goal is to provide adequate rest and support until the time when symptoms resolve and neurocognitive tests indicate a normal and stable condition over a given period. These are important criteria that should be met before recommending athletes a return to a play. Collaboration with school personnel regarding the student’s academic requirements should be ensured in order for necessary adjustments to be made. Children may need to have a rest at home, shortened school days or class hours, less home work and more time to accomplish them, and exemptions from tests and exams (Heads Up, 2012).       

Conclusion

In summary, current evidence highlights the realization that concussions, as a public health issue, must be treated more seriously than before, especially in children. The possibility of PCS and cognitive impairments following injury cannot be discounted, which emphasizes the need for evidence-based management in and outside of the acute care setting. Information from literature and health care agencies at various levels are resources that can be used when developing interventions and health teachings. Examples of useful tools include the CDC’s Heads Up information manual and the ACE care plan. Nurses are at the heart of the management process since they facilitate comprehensive care as the injured child moves from one environment to the other.

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