Concussions are a familiar injury to Jeff and Amanda Staples of Haymarket, Va. Their ninth-grade son and seventh-grade daughter play ice hockey. Both have experienced concussions, but their daughter's case last fall was treated much differently than their son's several years ago.
When Jacob, 12 years old at the time, was diagnosed and treated in the emergency room in the summer of 2013 after being hit in the forehead with a slap shot, he was instructed to sleep and rest with no television, texting or reading until his headaches and dizziness were gone. Exercise was also prohibited until he had gone a full week without symptoms.
Jacob's concussion was diagnosed -- as it is in many emergency rooms, doctors say -- based on his reporting of symptoms and on simple balance tests.
Sydney, who was also 12 last fall when she hit the boards and fell hard onto the ice, was evaluated more extensively at a family medicine practice that offers concussion care. Her balance was assessed in multiple positions -- standing on two legs and one leg, on the ground and on a foam board, and with her eyes open and closed. Her eye movements and ability to track a moving object were also examined, as was how much her symptoms worsened with each task.
She was prescribed exercises targeting deficits in her vestibular system, which provides balance and spatial orientation, and her vision system, which coordinates eye movement and focus. Activities that stimulate the brain -- including physical activity, reading and screen time -- were significantly scaled back but not cut out completely. Sydney could take a slow, quiet walk, for instance, and spend a few minutes texting occasionally, as long as her headache and dizziness did not rise.
With evaluations every week and what experts call an "active" approach to treatment -- one that involves prescribed therapies rather than just rest -- "we were able to
quantify Sydney's improvement," said Amanda Staples. "I felt much more confident with her recovery, and it was much more 'bearable' for Sydney."
Concussions are mild traumatic brain injuries that can damage cells, cause chemical imbalances and disrupt the brain's normal functioning in various ways.
For years, cognitive and physical rest has been the cornerstone of treatment for young athletes and others who experience concussions in sports and from falls and other accidents. Patients have been told to darken their rooms, turn off their screens, limit their movement and cut out activities that require attention or concentration. Such steps have been driven not by strong evidence but by experts' concerns about worsening the damage or re-injuring the brain.
Rest is still the critical primary prescription, especially in the first few days after injury. But increasingly, physicians at concussion clinics, concerned about young people who don't recover quickly, have been managing patients differently, intervening earlier to pinpoint problems and prescribe targeted therapies.
The new approach is not yet backed by strong evidence. Small observational studies have shown positive effects of single therapies -- such as exercise, or vestibular therapies -- in patients who have had symptoms for a long time. Research looking at multiple therapies, and therapies started early on, is underway.
"We're taking active, individualized approaches, rather than just having them rest and waiting for the brain to right itself on its own," said Brooke Pengel, medical director of youth sports medicine at Denver's Rocky Mountain Hospital for Children, which is known for its guidelines on helping students gradually resume their schoolwork.
It's like physical therapy for the brain. "We don't treat every stroke patient the same way," said Jeffrey Bazarian, a physician with the sports concussion program at the University of Rochester Medical Center in New York. "We figure out: Do they have a language problem? Do they have eye trouble? Trouble with their gait?"
Based on data from the Centers for Disease Control and Prevention, the Brain Injury Association of America estimates that at least 2.5 million U.S. children and adults each year sustain a traumatic brain injury, the majority of which are concussions, said Susan Conners, the association's president and chief executive officer. This "does not include people who don't seek medical care, so the actual number is probably much, much higher," she said.
Most young athletes see their symptoms go away within two to three weeks. About 10 to 20 percent, however, are affected for weeks, months or longer, according to a 2014 Institute of Medicine report.
There is growing appreciation for the ways concussions can affect the vestibular system, a network involving sensory organs in the inner ear and connections to various areas of the brain, the eyes and muscles throughout the body. Doctors have traditionally homed in on the vestibulo-spinal system, which helps control posture and maintain balance. It was Jacob's vestibulo-spinal system that was evaluated in the emergency room.
Some concussions affect the vestibular-ocular system, which allows us to maintain stable vision while moving our heads - to read street signs while walking, for instance. Injury to this system causes dizziness, nausea and other symptoms.
Still other concussion-induced impairments involve the vision system. With a healthy vision system, we track moving objects effortlessly. We can move our eyes quickly among visual targets that are still, and we can keep objects in focus as they move toward us. Injuries to this part of the brain can cause blurred vision, headaches, difficulty reading and difficulty navigating crowded hallways and other busy environments.
In Sydney's case, simple tests found that her concussion had affected all of these systems. Her treatment included balance exercises, along with activities requiring her to focus on moving objects, and "gaze stabilization" exercises aimed at improving her vision while she moved her head.
Over time, as she did the exercises at home and in weekly visits, she saw steady improvements in her main symptoms of headache and dizziness.
"Sometimes you have to tax the brain a little bit, give it stimulus to encourage the physiology to adapt," said Garry Ho, who directs the Fairfax Family Practice Comprehensive Concussion Center, where Sydney was treated.
"It's the concept of neuroplasticity," Ho said. "We're using the brain's inherent ability to adapt and recover from what the concussion has caused or thrown off."
The principle of adaptability also applies to low-level physical exercise. Carefully monitored exercise may help promote recovery, experts say, while prolonged and complete rest can lead to depression, fatigue and deconditioning that lowers tolerance for physical activity.
"The thinking 'used to be' that if you stress the brain 'with physical exertion,' you'd worsen the metabolic hyperactivity caused by a concussion, causing prolonged symptoms and maybe even permanent damage to the brain. But there really is no evidence for that," said John Leddy, medical director of the University at Buffalo Concussion Management Clinic.
"There is some evidence that if you introduce too much activity too soon, you will indeed prolong recovery," he explained. "But after several days of complete rest, we want to try getting back into activity using symptoms as the guide."
Leddy has shown through several small published studies that such exercise therapy helped patients who had persistent symptoms after more than six weeks, and he is now testing exercise therapy begun in the first week after injury.
Leddy said he believes that concussions can affect the flow of blood to the brain and disrupt the autonomic nervous system, which controls such functions as heart rate and blood pressure. Controlled exercise that causes symptoms to increase only minimally and temporarily can help correct these disturbances, he said.
Teasing apart the causes of headaches -- and targeting therapy accordingly -- is another part of the new approach. Some concussion-induced headaches reflect vision-system impairment and will respond to vision therapy. Others are migrainelike or cervicogenic (relating to neck injury) and may be treated with medication or physical therapy, respectively.
Thus far, the new approaches have been driven largely by experts sharing their protocols and outcomes with one another. Michael "Micky" Collins, who directs the Sports Medicine Concussion Program at the University of Pittsburgh Medical Center, hopes to establish a consortium to conduct the controlled research that would provide evidence to support individualized active treatment.
Among the questions he and others want to address: When should treatments be initiated - right after injury, for instance, or as symptoms begin improving? At what dose or what pace? How much can active treatments shorten recovery time? And can these approaches guarantee a more complete recovery?