Concussion and the Brain

Happy October 1st! Fall is upon us and schools here in the Pacific Northwest has been up and running for about a month.  With the return of school comes the start of the local fall sports teams.  This year I've noticed several patients in the clinic coming in with a recent concussion.  For my caseload, they've all been girls and most of these have occurred with playing soccer.  This is of course not a rule - in the past I have worked with males who have experienced concussions and they've come from all sorts of mechanisms of injuries.  What comes to mind are falling off a bike, getting hit in the head playing softball, inner tubing, and trampoline parks.  Though football players statistically tend to have more concussions, I don't think I've treated any of those.

I personally have experienced two concussions myself!  My first one was in high school when a friend of mine and I were walking away from each other and she threw a basketball and it bounced off the back of my head.  I initially thought I was fine and later woke up on the bathroom floor.  I had a headache for a few days and saw a doctor for it but was ultimately fine.  My second concussion was getting hit in the face with a softball that broke my nose and I had a loss of consciousness for about 3 seconds.  Apparently that's what the glove is for... catching the ball.  I didn't see a doctor that time, which was not the smartest on my part.  With that one I also had headaches for a few days, dizziness, some nausea, and a lot of sensitivity to light.  My sleep was disrupted and I had trouble looking at my computer screen at work.  My glasses broke during the injury so I was wearing my prescription sunglasses at work which helped some.  I'm so fortunate that both of mine were years apart and that I recovered so quickly, and it helps me to relate to these patients since I've gone through it a little bit.  Plus this gives me a great opportunity to share the photos of my black eyes from when I had my last one!  Notice the softball stitches visibly imprinted into my face.

Concussions are a really interesting diagnosis because each person presents very differently.  I've previously written about the WNBA Concussion Protocol here following one of the Seattle Storm players experiencing a concussion this past season, but since I've been treating more of these patients in the clinic, I've been reviewing my previous Medbridge courses on concussion and refreshing my knowledge to better treat this patient population.  Here are some interesting things about concussions you should know.

1) Concussions are brain injuries.  Concussions get a reputation for being less significant than they are because people have used terms like "getting their bell rung" to describe what happened on the playing field when the injury occurred.  This is a problem because concussions are brain injuries.  Many of the kids who come in for concussion treatment have a variety of symptoms - headaches, dizziness, trouble with school from a variety of causes, difficulty sleeping... and they almost brush these off as normal because of a concussion.  But these are all symptoms of the brain going through a healing process!  You wouldn't act the same way if you had a fractured skull or a stroke - both also serious head injuries.  Let's start acknowledging how serious a concussion is so that kids who experience them take their recovery a little more seriously!

2) Concussions are not anatomical problems- they are physiological.  I'll simplify that.  Anatomy defined: the structure of something.  So with a concussion - we're not looking at the structure of the brain.  With an anatomical (structural) problem, when a doctor is trying to diagnose what is wrong, imaging is generally done.  Typically, a person who has experienced a concussion will not have anything wrong on XRAYS, CT Scan, or MRI.  These imaging studies are used to look at anatomy - again - like the skull fracture - to see if any structures have been damaged.  Imaging is helpful to rule out these other anatomical problems, but they don't tell us much about the concussion or the person experiencing it.  So - if the structure of the body isn't the problem - what is?  The function of these structures are what is affected in a concussion.  Physiology is how things work... so how the anatomical structure operates.  Example - your lungs are a structure which can be injured.  They also function to breathe.  Anatomy: lungs.  Physiology: breathing.  Concussion structure involved is the brain - but there is no anatomical problem.  The physiology of the brain is what has been injured.

This concept is important because it can impact expectations of recovery.  It's pretty easy for people to understand the idea of an anatomical injury and how that recovers.  A broken bone takes approximately 8 weeks to heal and can be seen on an XRAY broken and then healed later on.  Concussion recovery is much more complicated and you can't see a starting point or a finish line.  So what's actually happening?  Well.. that's what I'm working hard on learning to better understand. 

The brain is composed of about 100 billion neurons.  Neurons are the types of cells that make up nerves.  Neurons look a bit like this:

https://biology.stackexchange.com/questions/25967/nerves-neurons-axons-and-dendrites-by-example

These nerves interact with each other to send electrical signals throughout the brain and the body so you can do whatever task you want to do in life - and even the tasks you don't choose to do but that the body does for your survival, like breathe.  When a concussion occurs, these nerve structures can be stretched or twisted just enough that the way that the electrical signals are passed along is impacted and all different types of messages can be influenced.

If you fall on the ground and scrape your knee on the ground, your skin may experience an abrasion and bleed a little bit.  The skin cells near the surface will, over the next several days, heal.  Fortunately, with the type of injury that occurs to neurons (nerve cells) during a concussion, they can also generally heal.  Most concussions will heal spontaneously very quickly, but some take much longer to recover.  These patients with slower recovery concussions are the ones I generally work with in the clinic.  People whose neurons may have recovered from the initial concussion processes, but who are still experiencing symptoms.

3. Treatment varies for each person with a concussion. This is because every person who experiences a concussion will present differently.  Even better... a single person experiencing concussion symptoms can vary hour by hour or day by day with their own symptoms, particularly in the first few days after a concussion.  So I track symptoms (using a graded symptom checklist like this one) over time with these patients to see if they're trending towards improvement and I can't compare one person's recovery to any other.  Every time I have taken a course learning about symptoms with concussion, it has been important to recognize that the goal is not to be a 0 on all of these items.  Teenagers get headaches occasionally.  They also get emotional sometimes.  But the goal is to reduce the overall symptom total and get them to stay at a relatively consistent level that does not fluctuate in response to physical or mental stressors.

I will say that there are some common themes with treating these patients.  Just like I don't treat every patient who experiences an ankle sprain the same way - the components of treatment for those patients is usually similar.  With a person who has experienced a concussion, there is often a headache and neck pain which tends to come from the upper cervical spine more than the lower cervical spine.  Some have vision and vestibular symptoms that require completely different treatments.  Symptoms for concussion have been grouped together into four categories of concussions: 1) vestibular symptoms, 2) visual symptoms, 3) cognitive symptoms, and 4) migrainous/headache symptoms.  These can overlap, but the treatments tend to fall into the categories that match the symptoms.  If the person is experiencing headache symptoms alone, the treatment likely shouldn't target vestibular or vision problems.  This is important because a person experiencing vestibular symptoms likely won't recover from those without specific vestibular treatments and those should be addressed prior to the other considerations.

4. It is the law that you must be cleared by a medical provider to return to sport activities following a concussion.  Laws vary by state and Washington State was the first one to pass such a law in 2009.  However, if you are a coach, and you have an athlete who experiences a concussion, there are many states which require 1) That the athlete stop playing immediately and cannot return for a minimum of 24 hours and 2) that the athlete must be cleared by a healthcare provider to play.  Some states allow physical therapists to be the person who clears these athletes for return to activities - but at Seattle Children's Hospital, we leave that decision up to the diagnosing physician.  So any of these kids who I'm working with to get back to sports - they're not playing in a sport competition until the doctor says so.  And it's not just word of mouth.  Schools are supposed to require that the clearance comes in writing!  Here's why these rules are important.

First - let's say you hit your head in a game and show some mild signs of a concussion but then a few minutes later you think you're feeling ok and try to play again.  Concussion symptoms are not immediate to show up, but reaction time and coordination can be impacted by a concussion.  So now, you've just experienced a concussion and are re-entering your game at considerably higher risk for another injury.  This is dangerous.  No sporting event - championship or scrimmage - is ever important enough to risk a brain injury.  Second - there is actually a name for someone who experiences a concussion, and then experiences a second one before the first one has resolved.  It is called Second Impact Syndrome.  It has a name because it increases the risk of mortality by 50% and it increases morbidity by 100%.  That means that if you experience two concussions in close succession, you increase your risk of death by 50% and 100% of these people have significant delay in recovery.  Doesn't it just make more sense to recover fully from the first one to reduce the risk of these much more severe outcomes?

I'm really enjoying learning about this patient population because it is fairly complicated in comparison to some of the other things you treat, and once these patients start to feel better, their quality of life is significantly impacted for the better.  Concussions can affect tolerance to sitting through classes in school with reading or looking at the whiteboard, they can influence tolerance to lights and noises and participation in sports - which is huge for some of these kids.  They can make you dizzy which makes all activity terrible.  These are serious and I hope that writing this helps people better appreciate the need for them to be treated appropriately. 

Happy Fall Sports Season, everyone!  Let's try to play smart and safe!