Concussion is one of the most common injuries reported by athletes, with an estimated 3.8 million sports related concussions occurring in the United States every year. In high risk sports like football and soccer, an estimated 20 percent of players suffer a concussion, with 40 percent of those players returning to the sport before making a full recovery.
Dr. Jennifer McVige, director of the DENT Concussion Center, attributes low diagnosis and recovery rates to a lack of knowledge and medical training surrounding concussions.
What is a concussion?
“A concussion is a direct or indirect, pathophysiological process that affects the brain, caused by a biomechanical force,” said Dr. McVige.
This distinction means that a person does not have to directly hit their head to be diagnosed with a concussion.
“In addition to hitting your head, a person can actually have a significant whiplash injury, where the head goes backwards and forwards within the skull, causing a concussion,” said Dr. McVige.
Dr. McVige likened concussions caused by whiplash to shaking an egg.
“If you shake an egg, the yolk within collides with the interior shell of the egg. The same idea can be applied to your brain. The brain is in cerebral fluid, and if the head is shaken hard enough your brain will hit the sides of your skull causing a concussion,” said McVige.
Concussions are most commonly marked by the rapid onset of short-lived neurological impairment that resolves spontaneously.
This neurological impairment can manifest in a number of ways. A person may have a hard time retaining information or concentrating, they may be experiencing headaches or dizziness. This altered neurological state occurs because the trauma caused to the brain is temporarily impairing its biologic responses.
Dr. McVige focuses on what she refers to as the 5 modifiable factors of concussion, which she uses to diagnosis concussion:
2. Sleep Disturbance
3. Mood Issues
4. Dizziness and Imbalance
5. Attention and Concentration Impairment.
Dr. McVige also stressed the fact that a person does not need to lose consciousness to be diagnosed with concussion. In fact, less than 10 percent of those diagnosed with concussion lost consciousness. It is important to note however that a loss of consciousness can signal a more challenging recovery.
Imaging plays a large role in the accurate diagnosis of concussion. Medical imaging allows doctors to look inside the brain to ensure everything is functioning correctly, and to rule out serious complications.
“Typically, what we have seen with concussions is that standard CT Scans are not useful in telling us if everything is ok. As doctors, we are only as good as our tools, in this case the quality of our imaging.” said McVige. “Often with a standard CT Scan, even when a brain has suffered a concussion the image will reflect a normal brain. The MRI is much better, especially for seeing small injuries.”
Dr. McVige also noted that a CT scan is commonly used if there is suspicion of a bleed or fracture in the brain. A CT is also common if a person is in imminent danger or falling in and out of consciousness.
What happens to your brain during a concussion?
Any disruption to the brain, caused by either a front, backwards or rotational force, pulls on the brain parenchyma (the functional tissue in the brain). This pulling can interrupt sensory nerves in the cortex causing those nerves to pull and shear, creating an injury which resembles a rip or tear, called a diffuse axonal injury.
This can happen in the cortex (the top of the brain) and the brain stem, which connects the brain and the spinal cord. Most individuals lose consciousness when the injury occurs in the brain stem. When this disruption happens, whether by a direct or indirect force, it causes the neurons in the brain to swell. Neurons are the cells in the brain that are responsible for all the life functions, including communication.
Dr. McVige likens neurons to electric cords, you have two parts, the plug and the cord. The axon acts as the cord and the neuron is the plug. If the axon swells or gets inflamed by an injury, it disrupts communication between neurons. This disruption causes the symptoms that are associated with concussion, like slowed processing and difficulty retaining information.
The force, whether direct or indirect, that causes a concussion can also alter blood flow to the brain. Altered blood flow can cause a number of problems because it restricts the oxygen to the brain. That loss of oxygenation hinders the body’s regulatory processes. For example, if a runner attempts to return to running before they are fully recovered, this could cause them to be easily winded because self-regulation is altered. This impairment has been shown to last 6 – 18 months after a concussion, even though a person may feel fully recovered.
In the brain there at 2 types of “cords” or neurons. These cords can be myelinated and non-myelinated. This is important because myelinated fibers are covered allowing them to go fast. Non-myelinated fibers move much slower, and are much more susceptible to damage. This distinction is especially important in children because children’s brains are not done growing, which means that all of their cords are non-myelinated. Due to the fact children are still developing critical thinking skills and fine motor skills, damage to their non-myelinated fibers could hinder those processes. Studies have shown that children 12 years of age and younger are especially vulnerable to long term damage.
Post-concussion syndrome refers to a condition where concussion symptoms persist beyond a certain period in time after the diagnosis of concussion.Dr. McVige refers back to the 5 modifiable factors of concussion to diagnosis post-concussion syndrome. In post-concussion syndrome any or all of these factors can last months.
Treatment for concussion depends on a number of factors, including what symptoms a person has, if they have any pre-existing conditions including depression, ADHD, even headaches. All of these are incorporated into a treatment plan.
“Treatment for concussion is very individualized,” said Dr. McVige. “Sometimes it just takes time to heal. I cater treatment to what symptoms people present with and what the patients’ concerns are.”
Exercise is a very important component to recovery. Dr. McVige noted that there is often a sweet spot to get back to exercise, starting with light walking and gradually returning to more intense exercise. For contact sports, Dr. McVige’s general rule is that patients should not return to contact sports before they are 7 days symptom free without medication. Dr. McVige also advises a gradual return to play.
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The content of this post is intended for general educational and informational purposes only; it does not constitute medical advice. Readers should always consult with a licensed healthcare professional for diagnosis and treatment.