If asked about concussions, most people would first think about sports. Many confine concussions to the world of football, hockey, soccer, lacrosse, so on and so forth. And yes, all of these athletic activities are subject to causing head injuries such as concussions. However, that’s only half of the story.
Fifty percent of concussions are sports-related, which means the other 50% of concussions are not related to sports. Head injuries occur frequently in everyday life outside the constructs of sports. People may trip and fall headfirst onto the pavement or hardwood floor; they may hit their head on a cabinet or be involved in a car or bicycle accident.
What is a concussion?
Considered to be a mild traumatic injury, a concussion is a functional injury to the brain, meaning that the brain is affected only from a functional perspective. MRI’s and CAT scans of a concussed brain appear normal, but a patient’s ability to think clearly might be impaired. Caused by a bump, violent jolt, or blow to the head, a concussion can occur whether the patient did or did not lose consciousness after the initial impact.
Concussions lead to a variety of cognitive symptoms.
- Confusion
- Lack of coordination
- Memory loss
- Inability to multitask
- Mood changes (frustration, nervousness, anxiety)
Other physical symptoms may materialize.
- Headache
- Fatigue
- Nausea
- Vomiting
The onset of symptoms does not always occur right away and can often be delayed 24 to 48 hours after the blow to the head. It is possible for all of the symptoms listed above to be present in a concussion patient at the same time; it is also possible that not every symptom will develop.
How do you diagnose a concussion?
Both the medical and non-medical community are in a much better place today when it comes to concussion recognition. Everyone from teachers and coaches to physicians is significantly more educated on the topic and knows that early recognition is key to a quicker recovery.
That being said, diagnosing a concussion is not always a walk in the park. Several diagnostic tests need to be done to form a baseline of the brain’s condition directly after the concussion. These examinations include
- A full neurologic assessment
- Physical examination
- Special concussion questionnaire testing
- Computerized testing specifically for concussions
This combination of tests is used at the time of diagnosis and then repeated to assess healing. The return to work, school, or athletics is dependent upon the improvement of test results when compared to the baseline.
A visit to the ER is not essential for a concussion, unless there are warning signs. The warning signs include
- Loss of consciousness for 15+ minutes.
- Significant weakness in a limb.
- Seizures.
If no warning signs are present, seeing a primary care doctor, pediatrician, or sports medicine doctor is perfectly safe.
Shift in the age group of the concussion population
Currently, I am seeing more and more adult patients over 30 years old who are having significant concussion issues from non-sports-related injuries. No pun intended, this scenario is a completely different ballgame and will take a little longer and a little more work to get the patient back to 100%.
When looking at concussions in the age group of 30 and older, we have to look at the implications of life. For example, when looking at concussions in students college aged and younger, the return to school and the social isolation of being away from friends are both big deals.
But the school system, in my experience, has been prepared for and caters to the needs of these students very well. The teachers, coaches, and athletic trainers do their best to reintroduce the student to the school gradually without putting too much pressure on the concussed individual. Students are allowed frequent breaks as well as extra time on testing and homework.
Yet, when it comes to the “real world,” the livelihood of adults isn’t put on pause. Missing work for a week or two has the potential for large implications on our finances, ego, and sense of well-being in general. Since concussions in the adult population are often caused by a work injury or car accident, PTSD can be a significant issue where psychologists and psychiatrists need to be included in the rehabilitation process.
How do you treat a concussion?
Rest.
It cannot be overstated: rest is key once diagnosis is made.
Six or seven years ago, we used to tell all patients to avoid phones, television, and electronic stimulation all together, and they should focus on rest and sleep. Now, we understand that this practice is not totally beneficial as it may induce the onset of significant anxiety due to the social isolation a patient feels.
The rule of thumb now is if it’s not bothering you too much, it’s okay to tolerate it. Now, don’t play video games until two in the morning, but 30 minutes of video games is reasonable. Don’t do an aggressive, intense workout, but if your symptoms are minimal and you want to go on a walk or even a light jog, that is acceptable.
Why is rest so important?
We know that in our younger population of 30 and under, rest will help heal a concussion in 90% of the cases. The other 10% of the population will need more help and will need to other forms of therapy such as vestibular therapy, which is an exercise-based program utilized to reduce dizziness and improve balance.
The duration of extra therapy heavily depends upon the baseline of the individual patient. The more intense the injury, the more complicated the situation, the longer the therapy will be.
Window of improvement
There is limited time window for how drastically improvement can be made. This healing window is estimated to be around two years, so the sooner treatment is started for concussion the better. The more time that has lapsed between the onset of the more intense concussion and treatment, the harder it will be for you to return to 100% quickly.
The healing after two years does not stop but will just be very, very slow. We cannot use the same major interventions after the two-year mark that we can use early on in the healing process.
The healing window is something we discovered not through concussion literature but actually through traumatic brain injury literature. We know that neurologically people can improve for up to two years.
If we want to rehabilitate a patient using various therapies, there’s an amount of effort that the patients gives and an amount of reward that patient receives. As we move further and further away from the onset date of the injury, the effort given from the patient will remain high, but the return received will be minimal.
So, when we hit that two-year benchmark, usually being in a structured environment such as physical therapy isn’t really going to have any major yield anymore. Again, it is not the end of total improvement, but the two-year window is the time frame we have to make the most impact with structured therapies.
Frequently asked questions
If I suspect my child has a concussion, do I follow the same protocols of looking for warning signs before going to the emergency room?
Children can be a slightly trickier situation. Children are not always the best communicators when it comes to their symptoms. For instance, when we as the parent or adult say to a child, “Does your head hurt?,” a child that is eight years or younger will almost always say yes.
The age group of eight and under really wants to please the parent or adult figure. They want to answer yes to any adult. So, if there are no warning signs such as no big gash on their heads, no loss of consciousness, no big bruise or hematoma, it’s perfectly reasonable to have that child on what we call a neuro-check for the first 24 hours.
- Check on them every two hours when they’re asleep.
- Wake them up, have a short conversation.
- Let them go back to sleep.
The neuro-check is just a necessary effort to rule out a subdural hematoma, a type of brain bleed where a pool of blood forms between the brain and the brain’s outermost covering. But if you as a parent are by any means concerned about your child, a visit to the pediatrician or emergency room is always a safe bet.
Can a concussion from 20 years ago be the basis for migraines today?
We do not know for a fact that concussions cause migraines. Migraines typically have a genetic predisposition. However, it is also possible that someone who already experiences migraine headaches ends up with a concussion, and then post-concussion their migraines are more intense.
So, yes, it is possible, but with the research we currently have we cannot say for certain that there is a direct cause and effect between concussions and migraines.
Would someone be sensitive to light or noise after a concussion?
Yes.
Sensitivity to light and noise is what we use as a pathognomonic, meaning it is red flag that signals a possible concussion. We often have to write notes to teachers to allow their students to wear sunglasses in class until this symptom is resolved.
How does having multiple concussions in succession change the treatment options if the first concussion hasn’t healed?
Multiple concussions can be more complicated in regard to treatment. It all depends on the level of impairment the individual patient is dealing with.
Someone who has significant dizziness, lightheadedness, or poor vision, we can refer to a vestibular therapist. For a patient who is dealing with predominantly emotional psychological issues, we can address those symptoms with psychotherapy and psychologists. For someone who has more physical issues such as neck pain or migraines, we can try medications or even Botox injections.
If a patient for example has healed as much as possible after three concussions, and comes into the office with a fourth, the approach is a little different. I want to fix the symptoms as much as I can so that I can figure out which symptoms might be reoccurring issue that will last for a longer time.
The picture is muddied from one concussion on top of another, but there’s almost always something that we can do to help these patients.
Which sport is best to play that has the least opportunity for concussions?
Parents frequently ask this question in regard to their children. It is important to remember that 50% of concussions are non-sports related.
I am often asked if I would let my kids play football, and the answer is yes. If my child is committed to playing any sport, and he or she loves the game, I am 100% in support of letting them play. I do not believe the risk of concussions is enough for me to hold my kids out of any sport.
However, if a child is on his or her fourth concussion from a specific sport, that is a very different conversation. At that point, yes, we have to look at risk stratification.
If you really need an answer, it’s basically either track, cross-country, or swimming, but I have also seen and treated concussions in track and swimming athletes.