Concussions and head injuries have been made out to be the “smoking” of this generation in regards to future disability and death. The news media have portrayed it as the boogie man disease that once it is sustained, there is no recovering. The movie, Concussion, spotlighted the current mass hysteria. But in all seriousness, what is concussion? How does it affect? What are the dangers? How do we recover? And ultimately, how do we prevent them?
What is a Concussion?
According to the Concussion Statement of 2016, a sport-related concussion is often defined as representing the immediate and transient symptoms of traumatic brain injury (TBI). Now, any time” traumatic brain injury” is used, it raises a lot of concerns. Traumatic brain injury can, indeed, be terrifying. It is a life-changing injury that can vary on how severely it affects the person, but here are some things to consider. A lot of times in the media, mild TBI is used interchangeably with concussion, yet that is not supported in the research. A TBI has a definitive appearance on advanced imaging, such as MRI and CT, and is predictive of future outcomes. But for a concussion, a clear definition of what it is and the future effects are challenging to know because it ultimately is not understood. Every four years, new research is assembled and presented at the consortium on concussion. This creates a new consensus and changes our views, and ultimately we become better at managing concussion with less long-term effects. An excellent example of change concerns sleep. Initially, we didn’t allow concussed people to sleep; this recommendation has now done a 180-degree turn, and sleep is now encouraged. We’ll discuss why that is later on (Jump to treatment if you can’t wait).
Additionally, these changes to treatment and management will affect long-term outcomes. The athletes in the media being studied now had horrible management and continued to play after injury. This mismanagement led to the compounding of the trauma. This is not seen in current-day athletics. In the Minnesota High school leagues, if there is a suspected concussion-like injury, the athlete is removed for the day. This relatively recent change means the previous long-term studies are much less relevant in regards to current populations. What does this mean for your child? It means that things are always changing, and we are getting better at preventing long term severe effects of concussion with appropriate management.
So, go play!
Now let’s dive into how a concussion is sustained. Concussion traditionally occurs when the head strikes a solid object with force, or when the head “snaps” in a direction without actual head contact. Some of the worst injuries are a result of head movement and no head contact.
Symptoms of a concussion can develop over a time of 72 hours; in this window of time, monitoring the injured is most important. It is equally vital to remove someone from an activity to help protect them preventatively. A concussion can cause short term discomfort and need modifications to live, but if a second impact occurs before the first heals, this is where the danger lies. When a second impact occurs, there can be rapid swelling of the brain. This can cause seizures, coma, and even death. Multiple hits in close succession are where the real danger lies.
As of right now, a concussion is a diagnosis of elimination, meaning all tests have to be negative while symptoms remain. There is no “gold” standard for a concussion, so let’s look at the symptoms and compare them to a whiplash of the neck since the energy that causes both are so similar.
The symptoms of a concussion and whiplash are very similar, and one cannot exist without the other. This makes it essential to treat both.
CTE – The protein we don’t understand
The biggest concern due to the media with multiple concussions is CTE or Chronic Traumatic Encephalopathy. CTE is a buildup of protein in the brain called tau; it can only be found after death via autopsy. The buildup of the protein causes Alzheimer's like symptoms - depression, and suicidal thoughts. The movie concussion brought this to public awareness, but there are significant holes in the research that need to be addressed. The research of CTE has only been done on high profile athletes and has not included the general public. This means that CTE may be present in other non-contact sport athletic populations and has not been found yet. Even the American College of neurology has stated that correlation doesn’t equal causation. Meaning we don’t fully understand what causes CTE and if other potential factors cause the formation.
This means that not allowing children to participate in sports because of fear of injury is wrong. The benefits of activity in these perceived “high risk” sports vastly outweigh the potential concussion risks. Main Stream media has led some people to believe that without activities like football, concussions would all but disappear. However, per participant at the Colorado Training, the US Olympic committee has the most documented concussions during synchronized swimming camps.
Treatment of Concussion
Here is what you need to know when it comes to seeking help. Ultimately most concussions will resolve on their own in 10 days and have no long-term effects. There are times that care can decrease healing time.
In the first 24 hours is when a concussed individual should be monitored. Here is what to watch out for:
Symptoms get significantly worse
Multiple rounds of vomiting
Slurring of Speech
A Headache that keeps getting worse or is described as the worst headache of their life
A concussed person can feel “hungover” - Headache, nauseous, light and sound sensitive, dizzy. But if a concussed individual suddenly starts acting “drunk”- Slurring of the speech, vomiting multiple times, losing conciseness -this is a medical emergency, and they need to go to the emergency room. This is no longer a concussion — this a most likely internal bleeding of the brain.
During the first 24 hours that the concussed individual is being watched, here is the recommendation:
Someone with a concussion needs to sleep and rest their brain. This was a significant change from the early 2000s when people were kept awake. Initially, it was thought that if a person slept, they would slip into a coma. Granted at that time, more instances of second impact syndrome occurred because people were not pulled from play. We now know that sleep is required to heal the brain. In addition, here is a list of recommendations to do or avoid when recovering:
Rest in a dark room quiet room
o Cell Phones
o Video games
Avoid Activities that are mentally taxing
Modify school and activates based off symptoms *
Modify physical activity **
* this will require a note from a medical professional *
** return to play should be monitored by a trained health care professional **
At the bare minimum, the first 24 hours should be sleep/rest. After that, a steady progression can start to fully return to all activities of daily living, including - work, school, and sport activities.
According to the consensus statement, to recover the fastest, it is crucial to have a graded return to activity. This should be monitored by a trained health care provider – MD, DPT, DC, ATC.
An essential component of concussion management starts before the season begins with baseline testing. Depending on the age of the athlete, baseline testing is recommended every six months to two years. The younger someone is, the more often the testing should occur due to changes with growth. A baseline test is only used if a concussion type of injury occurs. This helps determine a return to normal baseline function and help eliminate confounding factors.
There are three types of baseline tested used the King-Devick, SCAT 5, and ImPact tests.
All tests have their advantages and limitations. It is up to the provider to know which is best for the situation. But it is crucial to take the time to get a preseason baseline before injury no matter what sport you will be participating in.
According to Collins et al. (2014), strengthening of the deep neck flexors reduces concussion by providing increased head control. Increased neck control has been proven to result in decreased dragonesses of concussion.
AANS Head injury