What is Concussion?
A concussion is a temporary disruption in the brain’s function caused by trauma. It falls under the category of injuries known as traumatic brain injuries. The severity of these types of injuries can vary greatly—from mild, short-term symptoms to prolonged altered states of consciousness. Concussions are typically characterized by symptoms that resolve on their own, which is why they’re often referred to as mild traumatic brain injuries (mTBI). However, it’s important to remember that a concussion is just one type of mTBI. The good news is that the prognosis is usually positive, with most patients fully recovering from their symptoms.
What Causes Concussion?
A concussion is typically caused by either a direct hit to the head or an indirect injury elsewhere in the body. When people think of concussions, they often consider a strong, direct blow to the head as the main cause. However, indirect forces, like those from a sudden speeding up or slowing down, can also cause injuries to the brain, which can result in a concussion.
Risk Factors and Frequency for Concussion
Every year in the United States, about 1.7 million traumatic brain injuries are reported, often leading to emergency department visits. However, the Centers for Disease Control suggests that the actual number might be higher, ranging from 1.4 to 3.8 million, if we account for those who seek outpatient care or may not seek care at all.
Common ways people get concussions include motor vehicle accidents, being hit by something, assaults, and playing recreational sports. While concussions brought on by sports are a small portion of total concussions, they are a major focus of current research. Football generally has the highest numbers of sports-related concussions among high school and college students.
- Soccer is the sport associated with the highest percentage of concussions in female athletes.
- Females participating in the same sports as males are about twice as likely to get concussions.
Signs and Symptoms of Concussion
When evaluating someone who might have a concussion, a few critical pieces of information are required. This includes understanding how the injury occurred, what symptoms are present, when those symptoms started, and how severe they are. The symptoms of a concussion can vary a lot, but usually involve four main areas:
- Affective/emotional function: This includes symptoms like irritability and mood changes.
- Cognitive function: Symptoms can include confusion, memory loss, feeling “foggy,” and difficulty focusing.
- Physical symptoms: People with concussions often experience headaches, dizziness, balance problems, and changes in vision.
- Sleep: Concussions can impact sleep, leading to increased sleepiness, sleeping more or less than usual, or having trouble falling asleep.
The Sports Concussion Assessment Tool 6 (SCAT6) is a comprehensive checklist of possible concussion symptoms. It’s also important to understand that most people with a concussion (over 90%) don’t lose consciousness, but if they do, it’s a sign of a serious head injury. Sometimes, symptoms don’t show up right away after an injury, but can still develop within a few days.
It’s also crucial to know if the patient has had a concussion before. The number, severity, and duration of previous concussion symptoms can impact how long it takes to recover from a new one. Any pre-existing mood disorders, learning disorders, sleep problems, or migraines may also affect how the concussion is managed.
A thorough physical examination should also be conducted, which should include:
- A detailed examination of the head and neck for any structural injuries.
- A comprehensive neurologic exam to assess strength, feeling, reflexes, eye movement, and balance.
- An evaluation of cognitive function, including orientation and higher-level cognitive processing.
- An assessment of the patient’s emotional state, ideally in comparison to their typical state with input from a family member or friend when possible.
In addition, a trained neuropsychologist can help assess the many areas that concussions can impact.
Testing for Concussion
Diagnosing a concussion is typically done through studying the patient’s history and conducting physical exams. There’s no single symptom that can definitively point towards a concussion, and it requires an evaluation of several factors. This assessment is often done in situations like sports injury incidents, where tools like the Sports Concussion Assessment Tool 6 (SCAT6) are employed to examine athletes who might have experienced a head injury. For children between the ages of 5 and 12, the Child SCAT-6 is used. For these assessments, it’s best if they’re done in a quiet place with few distractions.
It’s important to monitor patients after their initial examination for any new symptoms or signs of neurological decline. Severity can vary, and in some cases, such symptoms can get worse over time. Signs that might suggest a more severe head injury – such as severe headaches, seizures or loss of consciousness – call for urgent medical attention.
Medical imaging tools are often used to rule out other conditions that could be causing the symptoms. A CT scan, for instance, is a common choice in hospital settings for getting a quick understanding of the severity and assessing whether there are any emergencies that need to be addressed. There are guidelines like the Pediatric Emergency Care Applied Research Network (PECARN) head injury guidelines or the Canadian Head CT Rule, that help decide whether head imaging is necessary. But despite these tests, most patients with concussions do not necessarily need a head scan. Moreover, having a normal head CT scan does not automatically mean the patient has not had a concussion.
If symptoms persist, an MRI might be recommended to get more information. Functional MRIs and PET scans are usually used for research rather than clinical analysis.
Work is in progress to develop testing for serum biomarkers of concussion. These could play a significant role in future evaluation. If symptoms persist for over a week, an MRI might be recommended, as it can provide more details. Two serum biomarkers – ubiquitin C-terminal hydrolase and glial fibrillary acidic protein – might have potential. These usually show elevation early after a head injury.
Treatment Options for Concussion
After diagnosing a concussion, doctors usually recommend that the patient be observed at home by someone who’s aware of the warning signs of severe head injury. The patient may need to be kept in the hospital for continued observation if there are alarm signs or symptoms of a more serious head injury. A concussion diagnosis also includes advising the patient to stay away from situations that might cause another blow to the head. For example, an athlete diagnosed with a concussion should be immediately removed from the game or practice.
The main part of concussion treatment involves supportive care. This typically starts with limiting physical and mental activities, followed by a slow return to normal activity levels. Total rest is no longer recommended for a long period. On the contrary, it’s reasonable to rest for the first 24 to 48 hours after the injury, and then slowly start resuming activities. But, there’s no set rule regarding the exact duration for this initial rest period. If symptoms return or worsen during this activity resumption process, the patient should scale back activities until the symptoms improve. Each activity increase should usually take a day, but the best timing for returning to normal activities is still unclear. An athlete with a concussion must not return to play until a doctor gives them the go-ahead.
Researchers are looking into therapies and interventions specifically targeting certain aspects of concussion, which may prove helpful. However, this research is still at an early stage. Some of these treatments include vision training for patients experiencing eye movement problems or cognitive-behavioral therapy for mood changes.
Over-the-counter medicines can be used to manage headaches, but their effectiveness is uncertain. Medications that affect a patient’s cognitive function, sleep pattern, or mood are not recommended because they might hide concussion symptoms. Also, headache-preventive medications are not recommended unless the patient was already taking them before the injury.
What else can Concussion be?
Just after a head injury, doctors need to consider serious issues when making a diagnosis. These might include damage to the neck’s spinal cord, internal bleeding in the brain, or a broken skull. Once time has passed from the initial injury, finding the cause of ongoing concussion symptoms can become more challenging. This is because these symptoms can also be caused by several other long-term health conditions, including:
- Headaches or migraines
- Mental health situations such as anxiety, depression or stress disorders related to traumatic events
- Attention deficit hyperactivity disorder which affects focus and behavior
- Issues with sleep
The doctor’s challenge is to determine if a patient’s symptoms are resulting from a concussion, from existing health issues or from a completely different cause.
What to expect with Concussion
The outlook for a patient with a concussion is generally good, and symptoms often get better within one to two weeks after the injury. Prior studies suggested a typical recovery period of about ten days for a concussion. However, recent guidelines from the 5th International Conference on Concussion in Sports say that most athletes with sports-related concussions usually recover within a month.
Experts in 2013 also highlighted the need to acknowledge that recovery times can vary significantly between individuals. How severe symptoms are within the first few days after the injury is the most reliable indicator of how well someone might recover.
At this moment, there’s no surefire way to predict how long it will take to recover from a concussion. Therefore, the expected recovery time should be tailored based on each patient’s unique situation and needs.
Possible Complications When Diagnosed with Concussion
The common and prolonged after-effect of a concussion is called post-concussion syndrome (PCS). This condition involves continuous symptoms that can persist weeks to months following the initial head injury. The average duration of these symptoms, according to a study, is around seven months. The change from a concussion to post-concussion syndrome remains a little obscure. Any of the concussion symptoms could be seen in PCS, but it generally involves multiple physical, emotional, and cognitive symptoms. The intensity of the first injury doesn’t necessarily predict the chance of developing PCS. However, a history of previous concussions raises the likelihood of activating this syndrome.
A scary but rare complication of a concussion is known as second-impact syndrome. Second-impact Syndrome (SIS) occurs when a second injury to the head occurs before the first concussion has fully healed. This triggers severe brain swelling quickly. SIS might lead to dangerous complications including brain shifting and even death, though much of the confirmed data about this condition is based on individual reports.
Long-term effects of a concussion remain an open topic for research. The most alarming condition that could potentially arise is chronic traumatic encephalopathy (CTE). CTE is a disease characterized by constant decay of brain cells due to repeated head injuries and unhealthy protein build-up. CTE can lead to problems with memory, behavioral changes, and irregularities in speaking or walking. At the moment, the precise rates of occurrence of CTE are not known, and it is only diagnosable definitively by examining the brain. No direct link between concussions and CTE has been established by current research.
Preventing Concussion
People who have suffered a concussion usually bounce back quite quickly and completely. It’s important to know during the recovery phase that a variety of symptoms might occur. Some symptoms may show up right away, while others could take hours or even days to appear following the injury. These symptoms might not be apparent until they return to their typical routines.
If they don’t feel back to normal within a week, it’s advisable to consult with a healthcare professional who has experience with brain injuries. Also, before resuming sports or any recreational activities, it’s crucial to get a go-ahead from a doctor. Getting another concussion before the brain has fully healed can be very risky and potentially lead to long-term issues.
The importance of safety measures in preventing concussions should be stressed as part of educating people about concussions. This includes children buckling up in safety seats, wearing helmets while biking, motorcycle riding, skating, etc. For older people, taking additional steps to prevent falls at home is also recommended.
