Though the media has bombarded us with articles, news reports and even a film on concussions, the confounding thing is that so little of the information geared to the general public has served to really educate and inform. There is so much more to this story than football and chronic traumatic encephalopathy (CTE). For instance, how do you know if you’ve suffered a concussion? If you have, what should you expect? Where should you go to receive optimal care, and what should that entail? How scared should you be? Buckle up, take a deep breath and relax… there is a wealth of information to share.
The mild traumatic brain injury (MTBI) that is a concussion happens to countless ordinary people every day. You or someone you love may even have been one of them. The injury might have resulted from a simple fall or a tumble taken in sports like skiing or cycling. Trauma sustained in a car accident or in a war zone blast might be to blame, or maybe you sustained a contact injury in a heated game of just about any team sport. Regardless of the mechanism of injury, the course of care should follow a very specific process. A thorough assessment is step one, in order to identify any cognitive, visual or vestibular and balance dysfunctions (all of which will be explained later) as well as a myriad of possible symptoms that must be addressed. This should be followed by highly personalized treatment focused on restoring symptom free and full function.
Concussion care is a fairly new specialty because for so long little was understood about the injury itself as well as the appropriate course of treatment. There remains much to learn. The medical management of concussions is a specialty that requires post-graduate education regardless of the professional discipline involved (neuropsychology, vestibular/physical therapy (PT), neuro-optometry, occupational/visual therapy and sports medicine (physicians, orthopedic PTs & athletic trainers). Experience counts for a lot and, as with professionals in any field, not all are created equal. Educated consumers have to know what to look for in order to best advocate for themselves and their loved ones.
The important thing to emphasize, however, is that with accurate diagnosis and appropriate treatment, the overwhelming majority of people with MTBI recover fully, even those with post concussion syndrome; More on that to follow.
The CDC (Center for Disease Control) literature1 reports “that an estimated 75%-90% of the 1.4 million traumatic brain injury (TBI)-related deaths, hospitalizations, and emergency department visits that occur each year are concussions or other forms of MTBI. 2,3 In addition, approximately 1.6 – 3.8 million sports and recreation-related TBIs occur in the United States each year”, 4 and many “of these are MTBIs that are not treated in a hospital or emergency department.” There are many other places to go for care.
The numbers reveal an economic factor at play as well – even outside of the NFL. A study done in the US in 2000 found that direct as well as indirect costs – such as lost productivity from MTBI – totaled an estimated 12 billion dollars 5
A little background information on concussions:
It is important to recognize that not every head blow causes a concussion. This was the first thing Dr. Steven Erickson, emphasized when we spoke. Dr. Erickson, who, in addition to being a co-founder and the Medical Director of the Banner Concussion Center in Phoenix, AZ, is a consultant for MLB umpires.
Any head trauma that results in the onset of temporary neurologic symptoms (be it from a direct or indirect blow) is considered to be a concussion. The injury is due to the brain moving quickly within the skull and may or may not entail a loss of consciousness; Typically, a collection of cognitive, physical, emotional and/or sleep-related symptoms results.
This includes some of the 22 common symptoms specifically listed and rated on a 0-6 scale on a form that each Banner client completes both prior to and following every treatment (See the list in Figure 1 below), as well as neck pain and ringing in the ears (tinnitus). It also includes any less typical symptoms a patient might report, such as “seeing the color green”.
Figure 1: Banner Concussion Center’s In-Office Symptom Score Sheet
Clients rate each symptom on a 0-6 scale prior to and following every treatment session.
- Headache 12. Sensitivity to noise
- Nausea 13. Irritability
- Vomiting 14. Sadness
- Balance Problems 15. Nervousness
- Dizziness 16. Feeling more emotional
- Fatigue 17. Numbness or tingling
- Trouble falling asleep 18. Feeling slowed down
- Sleeping more than usual 19. Feeling mentally foggy
- Sleeping less than usual 20. Difficulty concentrating
- Drowsiness 21. Difficulty remembering
- Sensitivity to light 22. Visual problems
Patients are also questioned regarding these additional common symptoms:
- Neck Pain
- Ringing in your ears
The most common symptoms after concussion include: visual disturbances, sensitivity to light or noise, headaches, nausea or vomiting, difficulties concentrating or remembering, balance problems, emotional changes and alterations in sleep pattern.
While more severe traumatic brain injuries cause structural damage, the clinical signs and symptoms of altered brain function after MTBI can be attributed more to dysfunction of brain metabolism. This entails “a complex cascade of ionic, metabolic and physiologic events.” 6
Making the Diagnosis:
A thorough initial evaluation is of paramount importance to determine whether the injured person has something even more serious. Concussion is a diagnosis of exclusion – emergent conditions such as skull fracture or an acute subdural hematoma (a bleed between the covering of brain – the dura – and the brain itself) must first be ruled out.
Dr. Erickson stressed that the best place to start is at the Emergency Room, where greater awareness and improved training has resulted in movement away from automatic CT scans for mild head trauma.
Tests such as Magnetic Resonance Imaging (MRI) or Computerized Tomography (CT) are not able to diagnose the disturbance of brain function typical after concussion because there are generally no associated abnormalities on structural neuroimaging. Mild concussive trauma is unlikely to cause tearing of the tissues in the brain and so no bleeding results. It is the collection of blood that would otherwise be evident on imaging.
Dr. John DenBoer, Clinical Neuropsychologist/Sports Psychologist at Banner, whose outside private practice affiliation is with Mental Edge Neuropsychology in Scottsdale, emphasized that with “almost any other injury or illness, you do a scan or run a blood test and you can define it… whereas the testing after concussion focuses on function.” He commented that though “diffusion tensor imaging (DTI) 7 shows how the white matter tracks in the brain are disrupted by concussion, this is not widely used due to cost and availability. They have it in only ten clinics around the country and currently use it largely for legal cases or research studies.”
Diagnosis can sometimes prove tricky because symptoms can mimic those of other diagnoses (such as headache syndromes, PTSD…) and may have a delayed onset. However, once concussion is diagnosed, it is best to seek care within the first week.
When examining a patient after head trauma, gaining an understanding of the nature of the force sustained can be helpful; was it a direct blow to the head or a body (indirect) blow? A body blow may cause a whiplash injury where the head moves forward then backward rapidly. If the impact was a direct one, where was the hit absorbed? Different symptom patterns may emerge depending on the specific mechanism of injury.1
In addition, the severity of symptoms may relate to the degree of impact. Those who have sustained multiple concussions may exhibit more involved symptoms than expected, a reflection of their vulnerability and/or a psychological overlay whereby increased anxiety about the consequences of sustaining another blow can amplify symptoms.
Patients should be screened for amnesia, which may result after sustaining concussion. This sometimes affects recall of events prior to the injury (retrograde amnesia), or may affect memory of event that followed (anterograde amnesia). In addition, the examining physician generally relies on bystanders to determine whether the individual suffered seizures (an atypical occurrence). Family members can also contribute valuable information regarding signs of mild brain trauma that they may have observed since the injury was sustained.
The immediate post injury period:
If concussion is suspected, it is important to avoid physical activity and mental exertion (stimulation such as watching television, using a computer or reading), get plenty of rest, stay well hydrated and avoid caffeine or alcohol (information on brain foods that boost cognitive function can be found here). This initial protective phase after injury is key. A medical provider should be consulted and, in the event of severe symptoms, going to the ER immediately is crucial.
The Recovery Process:
An uncomplicated course of recovery is generally seven to 14 days for adults and 14 to 21 days (for children and adolescents). This is interesting because – though younger people have increased plasticity of the nervous system8 – the immature brain takes longer to recover from trauma. 9,10,11
If you’ve had one concussion are you more likely to sustain another?
Dr. Erickson, noted that his “guess is that at least 10% of those with full symptomatic recovery and complete cognitive recovery may still have vestibular dysfunction that predisposes to other injury.” This actually represents an incomplete recovery. In other words, even if you think you are better, you may not be. Inadequate care may leave you with residual vestibular or visual dysfunction, creating an otherwise avoidable susceptibility to additional head trauma.
Dr. Erickson’s experience has also shown that there is what he refers to as “a concussion threshold that is lowered even after a complete visual, cognitive and vestibular recovery and when an individual is symptom free. Individuals are more likely to have a subsequent concussion for a period of several weeks to months even with less impact involved. There is no definitive formula.
At the most extreme end of the spectrum is what is referred to as Second Impact Syndrome. Dr. Erickson noted that this condition is preventable. “An emphasis must be placed on kids reporting injury, and then getting them off the field immediately thereafter. Many play through, and every year a few kids die of this syndrome. Another big head blow very shortly after an untreated concussion can result in a loss of control of the auto-regulation of blood flow. This results in swelling and death. Second Impact Syndrome has been seen only in kids. There have been no reports in the literature of this occurring in adults.
This can’t be researched for obvious reasons – it would entail intentionally delivering a second blow and monitoring the outcome.”
Post Concussion Syndrome:
According to Dr. Erickson, approximately 70% of concussions follow an uncomplicated course. Recovery that occurs outside the normative recovery curve (longer than what is expected) is referred to as post concussion syndrome. Here, the literature is confusing, with some publications saying that symptoms persisting for three or more months constitute post concussion syndrome 12, while others note that it begins after four weeks (Banner), and still others only after a year.13
I believe the discrepancy in these definitions is due in part to the fact that clients at the Banner Center receive care that identifies and addresses any and all deficits across the various systems. Because of this, the typical patient has an uncomplicated course of recovery within the expected time period.
A prolonged recovery is generally due to persistent vestibular, visual or cognitive deficits, usually with some emotional or psychological stress or anxiety. The psychological component – which is a biological response that may also include depression – is “completely understandable for those with delayed recovery and persistent debilitating symptoms, such as headaches.”
Sherry Massingale, MPT, Senior Clinical Manager at the Banner Concussion Center, noted that with post concussion syndrome, “the overarching concern – and the fear of further trauma or setbacks that often accompanies delayed recovery – can serve to worsen or perpetuate physical symptoms or symptoms of depression. It may also result in self-limiting behavior due a fear of returning to the activity that resulted in injury or any activity that subsequently exacerbates symptoms”
Though post concussion syndrome is more likely after each successive concussion, 10 there is no definitive generic pattern. The higher incidence is more likely due to alterations neurochemically or psychologically, especially if the sufferer/athlete has had prior longer-term recoveries. Persistent symptoms are also more common after mild brain injury to those with a history of anxiety/depression, or those who have previously exhibited neurologic hypersensitivity. This population typically has a heightened somatic response to psychological stress – whereby pain is more readily elicited or amplified. Dr. DenBoer stressed that this type of pain – though very real and not at all imagined – can be effectively modulated or resolved via strategies such as mindfulness or other behavioral modification techniques.
The biologic responses that occur with these techniques provide strong scientific evidence of their benefits in the prevention and treatment of chronic pain as well as in effectively boosting mood.14
Part 2 of this article will focus on Assessment, and Part 3 on Football and CTE. Articles referenced and footnoted will appear at the conclusion.