When talking about concussions, a topic of increasing concern in the sports world, a commentator may indicate that an athlete has had his or her “lights knocked out,” or that he or she has been left “punch-drunk” by a blow to the head. In many cases, descriptions like these are fairly accurate, but concussion isn’t always such a straightforward condition. In fact, more than 80 percent of concussions don’t involve a loss of consciousness, and people can go for hours or days after an impact to the head before concussion symptoms appear.
Regardless of when symptoms manifest, physicians emphasize that anyone suspected of having a concussion should be assessed immediately by a medical professional. They also warn that a confirmed concussion should always be taken seriously and treated appropriately.
What Causes Concussions?
A concussion is a traumatic brain injury that occurs when the brain gets shaken forcefully enough to collide with the skull, explains Tom Weber, MD, medical director of sports medicine for Sentara RMH. Such a collision typically is caused by a fall or a blow to the head.
“While we know that cellular-level damage occurs with concussion, we’re not currently able to see evidence of a concussion on a CT scan or MRI,” says Dr. Weber. “We diagnose concussion based on a physical examination of the patient and an evaluation of his or her clinical symptoms.”
A large percentage of concussion patients seen at the Sentara RMH Sports Medicine Center are either high school or college athletes. However, even though sports injuries are the main cause of concussions in the United States, the condition also can result from numerous other causes. Raymond Moreland, a physical therapist with Sentara Martha Jefferson Orthopedics, says that patients with concussions treated at their practice are most commonly elderly people who have fallen. Auto accidents are also a frequent cause of concussion.
“Everyone is susceptible to concussion—not just athletes,” points out Dr. Weber.
Signs and Symptoms
Headache is the most commonly reported concussion symptom, followed by “mental fogginess” or delayed mental processing.
“People who have experienced a concussion often say their brain doesn’t feel sharp,” says Dr. Weber. “For example, they may have to think for a minute before they can remember their address.”
Other common symptoms include sensitivity to light and/or loud noises, dizziness, ringing in the ears, difficulty tracking a moving object with the eyes, confusion, memory loss, and nausea.
Concussion severity is determined retrospectively, by looking at how long symptoms persist. For example, a person who gets a concussion but is fine two weeks later, with no symptoms, is usually said to have had a mild concussion.
“However, if four months go by and the person is still struggling with symptoms in school or at work—suffering headaches, for example—we would characterize that as a pretty significant concussion,” Dr. Weber adds.
Most people with concussion tend to get better within about three weeks. A smaller group takes up to six weeks to recover, and an even smaller percentage takes three to six months to get better.
“Studies show that about 80 percent of people improve within three weeks,” says Dr. Weber.
As soon as possible after the injury occurs, doctors and athletic trainers try to get some sense of how serious a possible concussion might be. They may ask patients about any headache symptoms, test their memory by asking them to state their address, or perhaps have them track a pointer or finger with their eyes.
If the patient has a severe headache, or if there’s any change in mental status that doesn’t clear up within several minutes, the person could potentially have a fractured skull or an area of bleeding in the brain. Thankfully, Dr. Weber says, the vast majority of concussions do not involve skull fracture or brain bleeding—but if either condition is suspected, the patient should be sent to the emergency room right away.
Since concussion symptoms don’t always show up immediately after an impact, proceeding with caution is crucial. A familiar scenario is the football player who gets hit on Friday night, feels fine over the weekend, and then goes to school on Monday—and then symptoms start to show up. In such cases, the extra brain stress brought on by study and concentration in school often elicits the symptoms.
That’s why it’s important to “rest the concussion,” according to Moreland. Too much brain activity too soon after a concussion can slow recovery.
“We monitor the patient and urge him or her to avoid activities that may worsen symptoms,” Moreland says. “So we try to make sure the patient isn’t spending too much time at school or work, in front of a television screen, or exercising. We try to manage their symptoms and gradually increase their activities to get them back to their normal routine as soon as possible.”
Rest typically is the primary mode of treatment for concussions. Other treatments depend upon a patient’s specific symptoms—for example, wearing sunglasses for sensitivity to light or wearing ear plugs for sensitivity to sound.
“Sleep is important in helping the brain heal,” says Dr. Weber. “If the patient has difficulty sleeping, we can prescribe medications to help him or her get the proper amount of rest.”
Following a concussion, some people experience vestibular (inner-ear) problems that affect balance, or they may experience problems with vision, including tracking difficulties or issues with peripheral vision. In such situations, Moreland says, physical therapy often can help.
Avoiding Second Impact Syndrome
In the days when doctors knew relatively little about concussion, athletes suffering a head impact often would go right back into a game shortly after the injury. Now, however, physicians warn that under no circumstance should someone suspected of having a concussion be allowed to return to a game, or to any other activity involving a risk of reinjuring the brain, before being cleared of symptoms.
“The biggest risk with reinjury is ‘second impact syndrome,’ or another trauma to the head that can create a very dysfunctional cellular and vascular response,” Dr. Weber warns. “A second impact can also cause a bleed. For instance, a vessel that got injured just a little bit in a first concussion could rupture suddenly as the result of a second impact—and that could be catastrophic or even fatal.”
Repeat concussions—even those occurring years apart—seem to make a person more susceptible to new concussions, which can result in permanent brain damage and take a devastating toll later in life. There is even evidence that repeated concussions may lead to Parkinson’s disease or Alzheimer’s disease.
“I’ve counseled three or four college-age athletes to stop playing contact sports because they had already suffered five or six concussions,” says Dr. Weber. “Each successive concussion had taken longer and longer to heal, and while our knowledge about concussion is limited, we suspect that they had already experienced significant brain damage. Our goal is to prevent negative outcomes down the road.”
The End of Contact Sports?
Even though concussions are serious and should always be assessed and treated as such, calling for an end to contact sports in general is believed to be far too extreme a measure. Considering the vast numbers of people who regularly engage in multiple sports at all levels of competition, the incidence of concussion is relatively small.
“We don’t want people living in a bubble, scared to participate in sports,” says Dr. Weber. “Most sports—even tackle football—are fairly safe, and concussions are relatively uncommon.”
If medical imaging technology advances to the point where doctors can see a concussion on MRI or CT—a development that’s likely still several years away—physicians may be able to better assess and predict the long-term consequences of concussion.
“That kind of technology would help us immensely in guiding the course of recovery,” Dr. Weber says.
Even so, the basis of treatment for concussion—rest for the brain and preventing further injury—likely will be the same in the near future as it is today.
“Sometimes,” adds Dr. Weber, “simple, common-sense medicine makes for a good treatment plan.”