March 22, 2023 — Layla Blitzer, a 17-year-old high school junior in New York City, was playing field hockey for her school last October and was hit hard by the ball, right above her eye.
She sustained a serious concussion. She’s also had neck issues and headaches for the last 4 months. “They’re so severe I still need physical therapy for them,” she said.
At first, the staff at the opposing high school where she was playing didn’t realize she had a concussion. “Even the referee said, ‘You’re not throwing up, so you’re fine,’” Allison Blitzer, Layla’s mother, said.
It was soon clear that Layla wasn’t “fine.” She consulted with a school-referred neurologist who diagnosed the concussion.
Similar Symptoms, Different Severity
David Wang, MD, head team doctor at Quinnipiac University in Hamden, CT, said concussion symptoms — such as headaches, dizziness, visual disturbances, light and sound sensitivity, mood and cognitive problems, fatigue, and nausea — are similar between adolescents and adults.
“But the symptom scores and severity are higher in adolescents, compared to younger kids and adults,” he said.
Moreover, the recovery time is longer.
“The effects of an adult concussion, especially in men, may be around 7 days, but 3 to 4 weeks isn’t unusual in teenagers, and it can be even longer in female teens,” Wang, who is the director of Comprehensive Sports Medicine in Connecticut, said.
The severity of symptoms, and how long they last, in teens “has to do with their stage of life because adolescents are going through puberty and in a rapid evolution phase, biologically, and are not neurologically mature,” he said. “The changes going on in their bodies may make them more vulnerable to the impact of a concussion, compared to younger children and adults.”
Similar to patterns found in adult women compared to men, girls tend to have more severe symptoms and a longer recovery, compared to boys — something Allison Blitzer was surprised to learn. Her older son has had sustained two concussions playing sports in high school, but after a couple of weeks, “he was fine and back at it.” Layla’s symptoms were more severe and long-lasting.
One of several possible reasons for the sex differences in concussion is that females generally have less neck strength, Wang said. Weaker neck muscles allow for more head acceleration following a blow, which results in greater forces to the brain.
Working With a Teen’s Recovery Time
Layla attempted to go to school 3 days after the concussion, but “it didn’t go well,” she said. The bright classroom lights disturbed her eyes. And most of the instruction was digital, on a computer or a projector, and too much screen time causes eye strain and headaches following a concussion.
“I couldn’t look up and I couldn’t do any of the work my class was doing,” Layla said. The noise stimulation in the lobbies, cafeteria, and elsewhere was overwhelming, too, so after 2 weeks, she stopped going to school.
Because Layla has several siblings, her home wasn’t consistently quiet either, so she isolated in her room.
“I fell behind in work,” Layla said, despite help from a concussion specialist who arranged with the school so Layla could have a reduction in workload, breaks, and extra time to complete assignments and exams.
Even after a few months, Layla was unable to keep up with her schoolwork. The school was “super supportive,” she said, but still didn’t understand how extensive her recovery time would be.
“It seemed like I was expected to be fully better much quicker. And although I’ve been improving, it’s almost 5 months since the injury and we’re in the middle of midterms, but I can’t take them because I’m still behind on my work,” Layla said.
In addition to headaches and memory issues, Layla experienced prolonged fatigue, which was worsened because of insomnia. The neurologist gave her medication for sleep, which helped the fatigue, but the headaches continued.
Finally, Layla consulted another specialist who was able to localize exactly where the headaches were coming from. He prescribed highly targeted physical therapy, which Layla attends twice a week.
“PT has been the most helpful for me and I’m finally beginning to catch up on my work, even though I’m still behind,” she says.
A recent analysis of eight studies (including almost 200 participants) looked at the effectiveness of physical therpay for post-concussion symptoms (such as headaches) in adolescents.
The researchers found evidence that physical therapy is effective in treating adolescents and young adults following a concussion, and that it may lead to a quicker recovery compared to complete physical and cognitive rest, which are traditionally prescribed.
Return to sports cannot be rushed, Wang said, not only because the person is still recovering and might not be “on top of their game” but because a second injury can be more harmful during recovery time.
“We call this “overlapping concussion syndrome,” he said. “The concussion is partially resolved, and the adolescent is functional enough to return to some playing, but then they get hit again. This complicates the situation and prolongs the recovery even more.”
‘Academic Quicksand’
Adolescence is a “challenging time,” Wang said. Teens are learning about themselves in the world, in school, and in their social group. An interruption in this process can disrupt the flow and make this process even more challenging.
“What we’ve seen with 2 years of teens who have missed school due to COVID is that they’re often not well adapted and not yet ready for the college environment,” Wang said. “These are critical maturation years. Similarly, when a teenager misses school or social activities due to a concussion, it increases the stress.”
Wang likens this to “academic quicksand,” and said, “it feels like the more the teenager struggles, the deeper they sink because the struggle itself can be so stressful.”
Layla can attest to this.
“The stress of being behind, especially in a highly competitive academic environment, has definitely caused me a lot of anxiety,” she said. “I see everyone in my grade moving up and I’m still catching up on old math units, doing one old unit that the class had finished a long time ago, as well as the one everyone is working on now.”
Her mother said it’s hard for Layla to watch her friends go out on weekends and knowing that wherever they hang out is likely to be too loud and too bright for her while she’s still recovering.
“This is an invisible injury and it’s hard to quantify or show someone else how much a person is suffering, so it’s very isolating,” she said.
Advocacy Efforts
Layla is an intern at PINK Concussions, a nonprofit organization focused on concussions in women, where she advocates for other teenagers who have sustained concussions.
When she was playing field hockey, “we weren’t wearing goggles or helmets because the hockey league felt there wasn’t enough evidence to support wearing protective gear for girls,” Layla said.
Now she’s working with her school’s athletic director and with the director of other private schools to change her league’s rules so that protective gear will be required in field hockey games.
“I think my concussion could have been prevented if I’d been better protected,” she said.
She’s also advocating for a more realistic back-to-school protocol.
“Some teachers might worry that students with concussions might delay returning to school,” Katherine Snedaker, a licensed clinical social worker and founder of PINK Concussions, said. “But our research found that students want to be back in school so badly, they were minimizing their symptoms to get back to school/sport before they were ready. Students were not using their concussion as an excuse to stay out longer.”
Layla said teachers “should be educated to expect that kids who have had a concussion may not be up to speed in work for some time. Some teachers may not be aware that recovery in girls and boys can be different. And they should know how to help a student successfully handle schoolwork again.”