What is a Concussion?


What-is-a-Concussion-Blog---ProActive-Physical-Therapy

Fall is in the air. As you, family members or friends engage in fall season sports, we are reminded of the consequences of participating in contact sports. It is well known that a concussion can occur in any sports-related activity and especially those that involve contact and collision. According to a July 2016 FAIR Health study, September and October are the months with the highest incidence of concussions for children and young adults under 22 years of age.(1) Of course, the first sport that people relate concussions to is American football. In the following paragraphs, I hope you will appreciate that not only are sports responsible for concussions, but other direct or indirect trauma to the brain can be equally as serious.

Let’s first review what a concussion is. According to the Centers for Disease Control and Prevention (CDC), Concussion is the mild form of a traumatic brain injury (TBI). (2)  The International Symposium on Concussion in Sport and Zurich Guidelines defines Concussion “as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.”(3)  In short, it is a direct or indirect blow to the head, face, neck or other part of the body causing forces to be transmitted to the brain.  An example of a direct blow would be a head injury sustained from a fall. An Indirect blow example would be a whiplash injury sustained in a motor vehicle accident.

Concussions have reached a level of notoriety through the prevalence of head injuries in the NFL as well as mass media’s attention to traumatic brain injury/concussions. One doesn’t have to search too far to find sobering statistics surrounding head injuries. Dr Edmonds reported in a December 2015 op ed article on Concussions,  that approximately 1.7 million traumatic brain injuries occur in the US each year and the lifetime costs for TBI ranges from $85,000 to $3 million.(4)  A 2013 CDC study found that US emergency departments treat an estimated 135,000 sports and recreation related head trauma patients annually.(5)  The same study reported that greater than 50% of adolescent athletes will sustain a concussion by the time they graduate from high school.(5)  Because of statistics like this, it is essential that parents, coaches, players, and health care providers be diligent in recognizing and treating the signs and symptoms associated with traumatic brain injuries.

With football season well underway across the United States, I often will ask friends or family if their son or daughter is participating in football.  In most cases their response is “no”, football is too dangerous. So, is American football the number one contact sport responsible for TBI’s/concussions?  According to a 2017 American Academy of Orthopedic Surgeons study on concussions at the high school level, football ranked fourth behind women’s soccer, women’s basketball and women’s volleyball.  Men’s hockey, soccer, basketball, and volleyball finished out the list behind men’s football.(6)  More compelling are the findings in a 2013 CDC report that found 54% of all TBI/concussion emergency room visits, hospitalizations and/or death among 0-14 years of age was not secondary to contact/collision sports, but to falls.  Just as alarming, the same report found that 79% of TBI related (including concussion) emergency room visits, hospitalizations and/or deaths in adults 65 and older were due to falls.(5)

So you may be asking yourself if the majority of traumatic brain injuries, including concussions, are related to falls or indirect trauma such as whiplash, then why all the attention to contact sports?  In a study published by Dr Lovell in the Clinics of Sports Medicine in January 2009, the increasing concern of children 12-17 years old who sustained a concussion had their symptoms resolve in less than 15 minutes, yet they required 7 days for cognition to return to baseline.(7)  Dr Field and colleagues found that high school athletes (females greater than males) have a more prolonged neuro-cognitive impairment than college or professional athletes.(8)  Because coaches, teammates, and/or parents may not recognize a cognitive change in an athlete within this short 15 minute window, 41% returned to play too early and possibly placed them at risk for further traumatic brain injury. (9)

How do you recognize if someone has sustained a TBI? As a parent, coach, teammate or health care provider, look for changes in three primary areas; cognition, physical function and behavior. Traumatic Brain Injury symptoms in order of prevalence are: headache, nausea, dizziness, blurred vision, sensitivity to light or noise, feeling groggy, problems with concentration, changes in sleep patterns, feeling tired, unsteadiness, and/or loss of consciousness.(10)  According to Makdissi the most common symptom is headache (88%) followed by confusion, visual disturbances, amnesia, dizziness, and nausea.(10)   The above signs and symptoms may occur immediately or evolve over hours to days. If a concussion is suspected in anyone, especially an individual 65 or older, seek immediate medical attention. An athlete who is suspected of a concussion, remove the athlete from the field of play, assess the athlete, DO NOT return to play or practice the same day until evaluated by a health care provider and inform the athlete’s parents/ guardians. If in doubt, sit it out!

How long does it take to recover from a concussion? Dr Lovell and colleagues found that 80% will recover in 21 days. Please appreciate that recovery time is variable due to individuality and risk factors.(7)  The top 3 risk factors for a prolong recovery in individuals who sustained a concussion are dizziness, mental decline, and headache at the time of injury.(10)  Other risk factors include a history of amnesia, female gender, migraines, geriatrics, and pediatrics.(10)  As mentioned above, traumatic brain injuries can evolve over time. This is why anyone who has sustained or is suspected of a TBI should be evaluated by a health care provider. There are a plethora of published concussion guidelines and best practices in the literature.  It is beyond the scope of this Blog to review them all. However, please appreciate that in the US, the trusted authority on head trauma including concussion, is the American Academy of Neurology (a neurologist). Physical therapists and athletic trainers, who are trained in the management of TBI’s (including concussions), are commonly found on the sidelines, locker rooms and rehab clinics.

In a perfect world, every individual should have a baseline neuromusculoskeletal assessment by their primary care provider. This is even more important for older individuals, infants/children and high school age athletes. For high school athletes, baseline testing, time of injury assessment, removal from play/practice, post-injury assessment by a qualified healthcare provider, and graduated step approach back to play are considered best practice in a Concussion Management Program. Physicians, physical therapists and athletic trainers are health care providers who can perform baseline testing, time of injury assessment and removal of an athlete from play or practice. Post-injury assessments should be conducted by a physician or his/her designee, such as an orthopedic or sports physical therapist, within 48 to 72 hours. Emergency room staff are not the ones to approve whether an athlete can return to play. In many cases a physician, physical therapist or athletic trainer may not be positioned on the sideline or courtside to perform a time of injury assessment. This is why coaches and parents/guardians need to be aware of the signs and symptoms of a concussion.

For further information on the identification and prevention of concussions, I invite you to read the many programs on the Centers for Disease Control and Prevention website Also, family members should be aware of the common side effects of medication their loved ones are taking. For instance, an elderly parent taking a blood thinner is at greater risk for bleeding than those who are not taking blood thinners. Remember, head injury signs may present immediately or take hours to days to evolve. If you, a family member and/or friend have a history of falls, you should be evaluated by a physical therapist. If you’re interested in learning more about how ProActive Physical Therapy can help with fall prevention, contact us today. And remember, if you are concerned that a family member or friend has sustained a head injury, reach out to your primary care or emergency room department.

 

References:

  1. Gelburd, R. (2016). Youth Concussions: A Matter of National Concern. The Daily National. Retrieved from https://fairhealth.org/newsroom/mediacoverage
  2. Centers for Disease Control and Prevention. What Is a Concussion? Retrieved from https://www.cdc.gov/headsup/basics/concussion
  3. McCorory, P., et al., (2013). Consensus Statement on Concussion in Sport-the 4th International Conference on Concussion in Sport held in Zurich, November 2012. British Journal of Sports Medicine 2013, 47(5). DOI: http://dx.doi.org/10.1136bjsports-2013-092313
  4. Edmonds, C. (2015). The Steep Cost of Brain Injury Recovery. Retrieved from: https://www.nextavenue.org/the-steep-cost-of-brain-injury-recovery/
  5. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/traumaticbraininjury/get_the_facts.html
  6. American Academy of Orthopedic Surgeons. (2017). Female Soccer Players Suffer the Most Concussions in High School Sports. Newsroom.aaos.org. March 14, 2017. Retrieved from: http://aaos-annualmeeting-presskit.org/2017/research-news/concussions_hsu/
  7. Lovell, M. The Management of Sports Related Concussion: Current Status and Future Trends. Clin. Sports Med.2009;28(1): 95-111.
  8. Field, M., et al. Does Age Play a Role in Recovery from Sports-Related Concussion? A Comparison of High School and Collegiate Athletes. Journal of Pediatrics. 2003;142(5): 546-553.
  9. Nessler, T. (2009) Center for Injury Research and Policy. Retrieved from: https://www.360neurohealth.com
  10. Makdissi M., et al. Natural History of Concussion in Sport: Markers of Severity and Implications for Management. Am J Sports Med. 2010;38(3): 464-471.

Scott Gaustad

PT, MPT, CSCS | South Tucson