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What is a concussion?
By: Kelsey Logan, MD, FAAP |
- What is a concussion?
- The definition of concussion
is ‘a complex pathophysiological process affecting the brain, induced by
traumatic biomechanical forces’.
This makes a lot more sense when several concepts are understood:
1) A concussion is sustained from a force to the head, either by direct
blow or from force delivered via the body or neck (such as a whiplash
injury). 2) The symptoms reflect a functional, not anatomic,
problem. The neurons (brain
cells) don’t work well immediately after a concussion, so the brain
functions poorly. The
anatomy of the brain is not usually disturbed, such as with bleeding
inside the brain. 3) Because
this is a functional problem, traditional imaging studies (xray, CT, MRI)
do not help diagnose concussions and should not be routinely done for
this injury. Physicians do
imaging studies after concussion to assess for other problems in the
brain.
- How are concussions usually sustained?
- Concussions can occur in any
sport, even in sports with helmets.
Usually, a direct blow to the head causes the injury. In football, ice hockey, and
soccer, being hit in the head or helmet has been shown to be the most
common way athletes are injured (Delaney, Clinical Journal of Sports
Medicine, 2006). In children
and adolescents, concussions have been shown to occur more often in
organized sports than in other recreational activities (Brown and Lam,
British Journal of Sports Medicine, 2006). However, they do occur through falls and collisions in
everyday activity, from backyard play to household accidents. - In adults, concussions can
occur in sports, work, in motor vehicle activities, and in all other
aspects of daily life.
- What happens internally when a concussion is
sustained? - When the brain sustains a
force, the neurons stop working the way they usually do to transmit
signals to each other. In
the cell membrane, channels that normally open and close to pass
electrolytes in and out of the neuron remain in an open position for an
extended period of time (hours, days, or weeks). Because of this, there is
abnormal electrolyte balance in the brain which cannot be cured by
electrolyte supplements or other medications. The brain needs several days to weeks to correct this. - In addition, the brain needs
much more energy than normal at this time, to heal the brain (as well as
continuing other usual brain functions, such as breathing and
eating). Unfortunately, the
brain has less energy available to it immediately after a concussion. This creates an ‘energy crisis’
where the brain needs more energy than it has. Symptoms occur because of this problem.
- Symptoms of a concussion?
- An injured person may feel
‘foggy’, ‘stunned’, or ‘dazed’.
- Headache is also a very
common symptom, as is feeling slow or fatigued (one athlete told me his
brain felt like he was on dial-up internet instead of cable). Other common symptoms: - Having emotional changes
(irritability, crying) or personality changes - Slow to answer questions or
follow directions - Easily distracted, poor
concentration - Poor coordination or balance
- Vacant stare/glassy eyed
- Loss of consciousness can
occur, but it is not necessary.
Most often, a person does not get ‘knocked out’, but the person
may still have a concussion.
- Amnesia (memory loss, either
from before or after the injury) can occur but often does not. Like loss of consciousness,
amnesia does not have to occur to have a concussion.
- How is a concussion treated?
- A medical evaluation by a
person with concussion expertise should be done after any
concussion. In some cases of
head injury and concussion, it is necessary for transport to an emergency
department for evaluation. - After the injury has been
determined to be non-life-threatening, the focus of concussion treatment
should be on symptom relief and returning the brain to normal. No medications can completely do
this. This is accomplished
by resting the brain, both from physical activity (even simple activities
like climbing stairs) and from cognitive (mental) stress. For students, this may
include missing some school time to allow the brain to heal.
- What is the recovery time for most concussions?
- There is good evidence that
college age athletes recover in 7-10 days, and high school athletes
usually recover in about 2 weeks.
However, there is little evidence on recovery for younger
athletes. What I see most
often in my middle school and junior high athletes is 3 weeks or so for
recovery and 4 weeks for elementary aged athletes. - At this time, we operate on
this concept for recovery: a concussed person should be symptom free at
rest and with exertion (cognitive and physical) AND have normal brain
function on objective testing (usually done by computer and not invasive)
before clearance for return to sports is given.
- What is the long term damage for repeated concussions
and when should an athlete stop playing his/her sport? - We learn more and more about
the potential for long term damage all the time. Concussion is being greatly
studied now, so we should continue to get closer to answering this
question. However, the long
term consequences are unclear.
We do not know why some athletes take a long time to recover (or
never recover) and some heal quickly. There is potential for long term memory and
concentration problems with even one concussion, and that risk goes up as
a person sustains more head injuries. - An athlete should consider
‘retiring’ from contact sports if: - Concussion symptoms never
resolve (you never get back to normal). - Concussions happen with less
and less impact. For
example, some athletes who have had multiple injuries start getting
typical concussion symptoms with small forces, like with just getting
jostled on the field instead of actually hit in the head.
- What sports are the most high risk for female
athletes? - Women’s soccer and lacrosse
have been shown to have higher concussion rates than other sports
(Covassin, Journal of Athletic Training, 2003 – collegiate study). Female athletes may be at higher
risk for concussions because of lack of protective equipment and lower
neck strength compared to men.
- Guidelines to follow when answering the question,
“Can I go back in the game Coach?” - Three things tell us when it
is safe and appropriate to go back to play. Until these things are accomplished, the athlete
should not be in contact activities. - No symptoms at rest.
- No symptoms with exertion,
either cognitive or physical. - Normal brain function on
objective testing.
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