Dr. Nicole Reams (NorthShore)
This is a complicated question. If each concussion is treated appropriately, we expect full recovery. There is an unknown threshold where more successive concussions increase the risk of long-term consequences such as cognitive difficulties, making it difficult or impossible for the brain to fully recover. We, as a field, don't know where exactly that threshold lies.

Dr. Nicole Reams (NorthShore)
No. Research has not supported the use of concussion headbands for soccer. They have not been shown to reduce concussion incidence and, in fact, may increase the risk if players that use them feel more invincible.

Dr. Nicole Reams (NorthShore)
Formal neuropsychological testing can be helpful in teasing out diagnoses of ADD/ADHD, as well as learning disorders. It is difficult for me to comment on the contribution from concussions without knowing more of her head injury history. As a general rule, concussion cannot cause ADHD or learning disability on its own. It has been described that concussion may lower the threshold for genetic contributions for disease such as migraine or depression/anxiety. It may be possible that history of concussion made these problems come on earlier or be more significant than they may have been otherwise. Without more information about your daughter, it is difficult to know.

Dr. Nicole Reams (NorthShore)
I would advise that your child be seen by a healthcare provider within 24-48 hours. This can be helpful for diagnosis and initial management to help ensure that their recovery isn't delayed or complicated. Most concussions do not require evaluation in an ER, but if there are concerns for prolonged loss of consciousness >1 minute, or deteriorating neurological status, such as worsening alertness, or new signs such as trouble speaking, weakness or numbness, the patient should be seen immediately in an ER to rule out a bleed in the brain.

Dr. Nicole Reams (NorthShore)
Great point. Symptoms of concussion can be vague and nonspecific, which is challenging for diagnosis in some cases. At this time, there are not clinically used tools that can corroborate symptoms with changes in the brain to ensure correct diagnosis (ie. there is no blood test or scan that is used currently to confirm diagnosis of concussion). There are many types of testing being researched currently and we hope to have this type of tool in the coming years. Right now, concussion is a clinical diagnosis made based on the nature of the impact, the presence of symptoms, the nature of the symptoms and timing and evolution of the symptoms. It can be supported by some exams such as computerized neurocognitive testing, testing of eye movements, or balance testing, but these additional tools cannot be relied upon for diagnosis.

Dr. Nicole Reams (NorthShore)
Yes. The ImPACT test is a computerized neurocognitive test that measures reaction time, verbal and visual memory. This test can be helpful in determining recovery from concussion to ensure a safe return to play. It is especially helpful when the athlete has a baseline test (a test performed prior to any injury) to compare it to. This test has limitations, however, and cannot be used to diagnose concussion on its own and is used as one part of the clinical assessment. For example, patients who had not slept well the night before, have pain or are distracted possibly due to a busy testing environment, can all show abnormalities on this testing that have nothing to do with continued injury or not. It can be helpful in some cases, but again, needs to be part of a more comprehensive assessment.

Dr. Nicole Reams (NorthShore)
Ask general mental status questions: Where are you, who are we playing, what play did we just run, etc to get a sense of if they are confused or if they have slow mental processing. I ask them to describe the hit and any symptoms that happened afterwards (headaches, nausea, sensitivity to lights and sounds, dizziness). I hold up a finger and ask them to follow it to ensure they don't have double vision or nystagmus (jumping of the eyes), and ask them to stand on one foot to see how their balance is doing. If they report any symptoms that could be consistent with concussion or show any abnormalities during the quick exam, sit them out. They should not return to sports that day if there is any concern for concussion. It's okay if you're wrong and sat them without needing to. Their safety is the most important thing. They should then be seen by a healthcare provider for further diagnosis and instructions.

Dr. Nicole Reams (NorthShore)
Yes. I perform these in my clinic for appropriate patients. They can be successful in patients with prolonged headaches outside of the expected time window for recovery of concussion, and in particular, in patients who had cervical strain as part of their injury and headaches are likely stemming from continued cervical dysfunction. Their story typically is posterior or frontal aching or pressure headaches, present upon wakening in the morning, worse with head movements or sustained postures, may worsen as the day goes on. I don't perform these in the acute recovery phase, or for continued headaches that are likely from another source (ie. migraine). There are scientific publications to back their efficacy for cervically-related headaches.

Dr. Nicole Reams (NorthShore)
Recent scientific data as well as expert opinion is supporting earlier return to physical activity. Data has shown that prescribing complete rest or prolonged rest can worsen symptoms and cause the symptoms to last longer. We are now encouraging light physical activity towards the end of acute recovery, even while symptoms are still present and instruct that it be "symptom-limited". This means that the exercise should not continue if it provokes exacerbation of symptoms. We still advise that return to exercise follow a progressive graded approach (starting with something easy and stationary like bike, followed the next day but jogging or running, followed the next day by agility or weight-lifting, then on to non-contact practice, then contact practice, then full release for those in contact sports), even if its a home exercise program, to ensure that the concussion has resolved. If symptoms exacerbate during these stages, you should stop and attempt that stage again the next day.

Dr. Nicole Reams (NorthShore)
Treatment recommendations change depending on where in the recovery pathway the individual is. If they are in the acute time frame (typically within 2--3 weeks out from injury), I advise them that it's okay to take over-the-counter pain medications as needed, but to try to limit their use if possible. If I'm concerned about cervical strain as part of their injury, I will give them some simple home neck stretches to start with. If they are subacute (3-6 week out from injury), I typically recommend scheduled anti-inflammatories such as Aleve twice daily, every day for 5 days, which can reduce headache. Consider PT for the neck at this time also. If the patient has more chronic headaches, we consider more long-term medications for headache prevention, which may include nortriptyline or gabapentin depending on the headache type.

Dr. Nicole Reams (NorthShore)
I am not aware of any direct hereditary or genetic factor that would cause prolonged concussion recovery in family members. That being said, it has been well-described that personal or family history of migraine, ADD or depression/anxiety can prolong recovery. If these diagnoses are present in your family, they may affect your children and their ability to recover from concussion in a similar manner. There may also be non-physiologic factors such as their social environment. Neurofeedback can be helpful for recovery in some people. The scientific data beyond it is somewhat lacking, but anecdotally, I've had success with it in some of my patients.

Dr. Nicole Reams (NorthShore)
If the injury is within the last 24 hours AND you are concerned about deteriorating status: They are becoming more lethargic, more confused or have new vomiting, then take them to the ER. The real reason to take someone to the ER is to rule out the possibility of a bleed in the head. If the injury is >24 hours old OR they do not have deteriorating signs, they should be seen by their pediatrician or a concussion specialist. Though if there are ever concerns about deteriorating status as mentioned above, an ER visit should be considered.

Dr. Nicole Reams (NorthShore)
This is a difficult question, because we just don't have the science to answer your question. At this time, CTE is a pathological diagnosis (one that is made under the microscopis of a brain at autopsy). We do not have much information about the clinical symptoms that may or may not be related to the changes they see under the microscope, nor do we know much about the typical clinical course or symptoms to expect in patients with progressive neurological degeneration related to repetitive head trauma. We expect that the clinical course could cause progressive cognitive changes and personality, mood or behavioral changes.

Dr. Nicole Reams (NorthShore)
I advise starting light physical exertion such as walking and stationary bike towards the end of their acute recovery (i.e. they can still have mild symptoms at this time). This should be symptom-limited and not aimed at exacerbating symptoms. Following symptom stabilization or resolution, you can start through progressive return to play stages as follow: 1. Stationary bike 2. Running or Jogging 3. Agility or weight-lifting 4. Non-contact practice 5. Contact practice 6. Full release for competition Progression through these stages requires that the previous stage did not cause return of symptoms. The player should not return to contact play unless they are at their pre-injury baseline and until they have been seen by a physician for clearance. They should also be back to full school if they are a student athlete prior to return to sport.

Dr. Nicole Reams (NorthShore)
Most patients with concussion will see total resolution of their symptoms in 2-3 weeks. If symptoms last longer, we look for reasons for this, such as not the right amount of rest, genetic factors that could prolong recovery, additional injuries such as neck strain or psychological factors that could promote injury.