Megan Serko slipped and hit her head while jumping off a school bus about seven months ago. She iced her head for a moment before rejoining her classmates, and because she had a history of headaches, ignored what were likely the symptoms of a concussion.
Just four days later, the 12-year-old was on the soccer field when a fumbled tackle landed her and another player on the ground. On the way down, Serko took an elbow to the head.
Her vision blurred and she felt dizzy, but she quickly got up and finished up the last 10 minutes of the game. “I didn’t think anything of it [then],” she said.
Serko only would complain of a headache once she got in her mother’s car after the game. It would only get worse — she would get the spins that night in bed, and after a fitful night, woke up to more severe headaches, vomiting and dizziness. Diagnosed with a concussion, she would leave school for a few days.
A month later, with her symptoms showing no signs of abating — and now followed by Dr. John Kuluz, the director of traumatic brain injury at Miami Children’s Hospital — she was pulled out of school completely, instead following a reduced curriculum at home. It would take her five months of resting and physical therapy with the MCH’s concussion clinic before she would be symptom-free and cleared to play.
Megan’s story is in many ways a worst-case scenario — most concussions take days, not months, to heal — but also stands as a parable for all the risks younger kids face when it comes to concussions.
With important gains having been made to protect athletes at the high school level and up, some of those treating and researching concussions — the most common type of brain injury — want more attention paid to younger kids.
“The first thing is that concussions are not being recognized and treated as much as with high school kids and young adults. There are some really great programs for high school athletes. … But at the middle school level and below, there hasn’t been that much emphasis,” Kuluz said.
Kuluz says that in his experience, very young kids often bounce back quickly while those hitting puberty take longer to heal. But so far, very little research has been done on the incidence, diagnosis or treatment of concussions in pre-teens and children.
One study released this January in the journal JAMA Pediatrics found that middle school female soccer players were more likely to sustain concussions than their older counterparts. And more than half of those concussed reported continuing to play with symptoms — breaking concussion management’s cardinal rule: If you’re still symptomatic, avoid all physical and mental exertion.
It’s also unknown how reliable baseline tests, which measure an athlete’s cognitive abilities pre-and post-injury to help determine healing, are when it comes to younger kids. The ImPACT test — the best-known and most widely used — is advertised to anyone 10 and up, but some experts object to using with anyone below 14. Even more won’t use it for children under 12.
“There’s a lot of controversy in that area, and very little data to guide us. Which test should we be using? What ages does each test cover? How often should a baseline test be repeated during this time of rapid growth?” asked Kuluz, who added he’s hoping to start gathering that sort of data through his work at MCH, where baseline tests are being offered.
His concussion clinic often prescribes light physical therapy to exercise balance and vision and track patient recovery. It also often recommends painkillers like ibuprofen for headaches and melatonin for insomnia. But Kuluz admits that most-concussion treatments — including his own — are untested.
“Right now, all we know is to rest these kids. There’s no data to support any of the medications that we use to try and ameliorate their symptoms, which can be very, very disabling. That’s what we’d like to look at with our research efforts.”
A state law passed in 2012 requires that any student-athlete suspected of sustaining a concussion be immediately removed from play and receive medical clearance to return. The problem — especially for younger athletes like Serko — is the law’s implementation.
Athletes at the high school level and up are more likely to play organized sports than younger athletes, according to Dr. Gillian Hotz, director of the UHealth Sports Medicine Program at the University of Miami. That makes it much easier to target concussion education and establish protocols for prevention, management, and proper return-to-play practices, she said.
The Miami-Dade and Broward county school boards have made the crucial decision to hire athletic trainers for all public high schools, Hotz added, which means that there’s someone trained in and accountable for concussion management at every school. It’s also those trainers that have made possible the implementation of baseline testing for all public high school contact sport athletes in Broward and Miami-Dade counties.
But middle schools usually don’t have athletic trainers, who are certified health care professionals, and typically neither do the myriad of private clubs and leagues in which younger kids play.
Teams from both MCH and Joe DiMaggio Children’s Hospital U18 Sports Medicine Center in Broward hope to fill the concussion knowledge gap in those leagues and clubs, and have started doing outreach in their communities to educate those coaches and parents.
U18 director Tony Milian says the outreach effort sometimes has to push back against a “suck-it-up mentality” in coaches, but that more often than not it’s mostly a case of dispelling misconceptions. A lot of coaches, he says, still believe that if an athlete don’t lose consciousness, they don’t have a concussion.