Concussion

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Doctor examining child with suspected concussion by showing her 3 fingers

A concussion is a type of traumatic brain injury that temporarily disrupts normal brain function. It is most usually the result of a blow to the head. However, events that cause violent shaking of the head and/or upper body can also cause concussions.

The disruption of brain function is usually temporary but, while the concussion is ongoing, the patient may experience a wide range of symptoms. These can include headaches, difficulty concentrating or remembering things, dizziness as well as  impaired co-ordination and balance.

It is important to realize that, while concussion can cause a loss of consciousness, this is reported to occur in less than 10% of cases.

The widespread presence of traumatic brain injuries in sports where concussion was not previously recognized as a factor (e.g. heading the ball in soccer) is a contemporary subject of great interest in sports medicine. Several proposals are under consideration for rule changes or changes in protective headwear that may reduce the risk of a head injury. In sports medicine, these injuries are frequently referred to as T.B.I. (Traumatic Brain Injuries).

One sport in which concussion is particularly common is rugby. It has been shown to happen in that sport at the professional level as frequently as once every 6 games, amongst all the players involved.

The good news is that most victims manage to achieve a full recovery following a concussion. However, if a concussion does not receive proper treatment, there is a risk that the patient may suffer additional T.B.I.s in the future. Repeated concussions can lead to a serious long term decline in brain function known as chronic traumatic encephalopathy (CTE). This is commonly,referred to as dementia pugilistica.

CTE has for some time been recognized as having a high prevalence among boxers and participants in other combat sports. However, recent studies have reported that it is also a much more widespread problem than medical professionals have previously realized.

Causes & Risk Factors

Causes

Generally speaking, concussion can be a result either of a direct blow to the head or of violent shaking of other parts of the body that results in rapid movement of the head, as is the case in whiplash type injuries.

The most common causes of traumatic brain injuries are falls, blows to the head or violent shaking of the head or upper body. A blow to the head will cause the brain to collide violently with the inside of the skull. Shaking the head or upper body, or falling awkwardly, can also result in  sharp acceleration or deceleration of the brain relative to the skull. The result of either event will again be violent collision of the brain with the inside of the skull.

The brain is surrounded by cerebrospinal fluid inside the skull. The fluid cushions the brain and prevents it colliding with the inner skull as a result of normal head movement.

However, this fluid cannot protect the brain from violent collisions with the inner skull as a result of sharp external shocks. Examples are shocks from a powerful blow, a fall or violent shaking. These collisions with the inner skull cause damage to the brain cells that can then cause a concussion.

In case of severe shocks, the damage to the brain can include bleeding in or around it. This can obviously have serious and possibly fatal results.

Risk Factors

The three main causes of concussion are road traffic accidents, accidental trips or falls and participation in sports or recreational activities.

Many sports can cause concussions, but contact sports (hockey, soccer and football, for example) can also cause this injury. Athletes in these sports frequently collide violently with other players and fall awkwardly as a result. These sports-related concussions can be the result either of the contact with the other player or of the fall. Snowboarding is another sport that presents the risk of concussions due to falling.

Traumatic brain injuries can also occur in sports such as cricket or baseball. They can occur if a player receives a blow to the head from the ball. This can be especially true if the ball is travelling at a high velocity. However, these incidents are relatively rare, partially because of the widespread modern use of helmets by many baseball players and cricketers.

Sports such as boxing or kickboxing, in which participants receive frequent blows to the head as part of the sport, (These blows can cause a T.B.I. injury.) can lead to the occurrence of a TBI.

Motor vehicle accidents can be another frequent cause of concussions. They can occur especially when the vehicle comes to a sudden stop on colliding with another vehicle. Pedestrians or cyclists who are hit by a vehicle are also at a greater risk of experiencing this type of injury.

Motor racing (either using cars or motorcycles) also increases the risk of concussion injuries. This is due to the potential for high speed collisions or accidents in general.

Concussions are also an ever present danger to soldiers, and especially to those in combat zones. The powerful vibrations from the high forces released during explosions frequently cause traumatic brain injuries.

Other factors that can increase the risk of experiencing a concussion include:

  • Physical abuse at the hands of a spouse or (if the patient is a child) an adult; or
  • Having experienced a previous concussion. Athletes with a  history of two or more concussions within the previous year are at increased risk of further brain injury and of having a slower recovery compared with people who have not suffered any concussion. These individuals should seek medical attention from practitioners experienced in the management of concussion before resuming participation in their particular sport.

Symptoms

The signs and symptoms of concussion can include one or more of the following:

  • Headaches;
  • Seizures;
  • Amnesia, especially about the cause of the concussion. This may sometimes manifest itself as repeating the same question over and over;
  • Confusion about what has happened or is happening;
  • Problems with balance or co-ordination;
  • Ringing in the ears;
  • Nausea
  • Fatigue or sleepiness;
  • Blurred vision;
  • Vomiting;
  • Dizziness, or the feeling of “seeing stars”;
  • Temporary unconsciousness;
  • Slurring of speech;
  • Delays in understanding and answering questions;
  • Dilated eye pupils or pupils that are unequal in size.

Some symptoms of concussion can appear several hours or days after the injury. These may include:

  • Personality changes, such as increased irritability;
  • A sudden sensitivity to noise or light;
  • Difficulty getting a full night’s sleep (insomnia);
  • Loss of taste or smell;
  • Depression & other psychological problems.

Young children are accident prone and are therefore especially liable to experience concussions due to falling or other accidents. They experience the same symptoms as adults with concussion. However, the challenge here is that they may not be able to fully explain what they are feeling. As a result, it is important to pay particular attention to external signs and symptoms that may be indicative of a concussion. A small child may be a bit grumpy and sleepier than normal. It is common and normal for them to want to sleep for a while after a bang to the head. However, if they are still drowsy after they have slept for an hour or longer, this should be interpreted as a sign of possible concussion. Caretakers should seek medical help in these cases.

What To Do If You Think You Have A Concussion

If you believe that you (or someone in your care) may have suffered a T.B.I., see a doctor without delay. Although these may not be immediately life threatening, they are very serious injuries. The patient should therefore not contemplate a return to regular activities until a doctor has confirmed that he or she has recovered fully.

If your doctor confirms that you have a concussion, you should refrain immediately from sporting or other athletically demanding activities. If you do participate in sports again too soon after the injury, the risk of repeat concussions may be very high.

Diagnosis & Treatment

Diagnosis

If the injury occurs during sporting activity, a physician can do a preliminary check for possible concussion signs. He or she can do so by looking at the patient’s eye pupils. This type of examination can be done using a penlight equipped with a pupil gauge.

As part of the diagnosis, a doctor may perform a thorough neurological assessment. This  usually includes a formal quantitative assessment of the patient’s consciousness level using the Glasgow Coma Scale (GCS). The GCS gives a score ranging between 3 and 15 and reflects the severity of the brain injury sustained. The lower the score the more serious is the injury.

Further, the assessment includes an evaluation of the patient’s vision, hearing and physical strength. In addition, the physician may test the ability to feel and smell, the reflexes and the degree of physical co-ordination.

Cognitive testing will also be an important part of the examination. Concentration and memory will be important mental functions for evaluation.

If the patient is displaying physical signs of a T.B.I. (e.g. headaches, seizures or vomiting), the doctor may carry out one or more brain imaging scans. These will help in determining the extent of the brain injury and, in particular, whether bleeding inside the skull is a factor. The imaging may be done via a CT scan or an  MRI.

CT (computerized tomography) scans use X ray technology. MRI (magnetic resonance imaging) scans use magnets and radio waves to produce highly detailed brain images.

If the patient is a young child, the doctor’s preference will likely be for MRI imaging in order to reduce exposure to radiation. However, if the doctor suspects a skull fracture, he or she may opt for a CT scan anyway.

After the above parts of the examination, the doctor may decide to have the patient remain in hospital overnight for further observation. Alternatively,the doctor may allow the patient to return home under the supervision of a caregiver.

In patients who have had a traumatic brain injury, it is important to be aware of ‘red-flag’ signs that could suggest that something more serious like a bleed in the brain could have occurred. If someone who has had a concussion develops any of the following red flag signs, immediate medical help should be sought:

  • Drowsiness or being unable to wake up;
  • A headache that is getting worse despite using painkillers;
  • Confusion or slurred speech;
  • Collapse or a seizure (shaking or twitching);
  • Vomiting

In children, it may be difficult to spot the above signs. For this reason, it is important to look out for other signs such as incessant crying, unwillingness to feed, lack of interest in their surroundings and irritability.

Treatment

Treatment of a concussion injury may involve some or all of the following:

  • Refraining from activities requiring unusual amounts of thinking or concentration. Such activities would include watching TV, reading, using a computer and even texting or playing video games or other games like chess. However, doctors do not generally recommend complete rest (e.g. lying in a darkened room as one would do for a migraine headache).
  • The patient should continue this “rest” period for at least 48 hours.
  • In addition to refraining from taxing mental activity, the doctor will normally advise the patient to avoid athletic activity
  • Once the patient is ready to resume normal physical and mental activity, he or she should do so gradually. The idea should be to increase these activities at a rate that does not cause the concussion symptoms to return or worsen.
  • Even while gradually restoring his or her normal activities, the patient should be careful to completely avoid any activities that could lead to a fall or blow to the head;
  • The patient may also be required to undergo special rehabilitative programs for restoration of functions like vision, balance or cognition;
  • If headaches persist during the recovery period, the patient may be permitted to take pain relieving medication. However, he or she should check with the doctor for advice on which of these is safe. Some of these medications may increase the risk of intra-cranial bleeding.

How To Reduce the Risk Of A Concussion

To reduce the risk of suffering a T.B.I., both athletes and non athletes alike can consider the following actions:

  • Wearing protective headgear. For sports like hockey, football and baseball, this would be a helmet. Helmets can also increase safety in sports such as cycling and even motor racing (both cars and motorcycles). These are sports in which crashes can sometimes present major T.B.I. risks;
  • Athletes in combat sports should certainly consider using the standard protective headgear designed for these sports.
  • Athletes in contact sports like football and soccer can undergo training to increase leg strength in order to more easily maintain balance while running. As we have mentioned above, falling while playing these sports is behind many of the sports related concussions that doctors encounter;
  • Follow common sense measures like buckling car seat belts before switching on the engine. This can help to reduce the risk of concussion if there is an accident.
  • If you live in a region with heavy winters, ensure that you salt the driveways and walkways around your home before snowfalls. This will reduce the risk of slipping on them during entry to or egress  from your home.

There have been claims that wearing a mouthguard can reduce the risk of concussion. However, the evidence supporting this claim is very limited.

As a result, athletes should not (at least at present) rely on such claims as part of a strategy to control concussion risk.

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