Concussions, A Traumatic Brain Injury That Cannot Be Ignored

By: John Roberts

I see many patients every year who have suffered concussions. Usually these are athletic injuries, but it is frequently seen in others as well. Concussions have always been a part of sports, particularly those involving high-energy impacts including wrestling, football, soccer, lacrosse, basketball, and baseball/softball. Intensive research, along with lawsuits, including the one the NFL Players Association brought against the NFL, are causing research to move rapidly to help get a firmer grasp on how to prevent and manage concussions.

A concussion is a trauma-induced alteration in mental status that usually does not involve a loss of consciousness and does not have to be a result of a blow to the head. In fact, only ten percent of concussions are associated with a loss of consciousness.

Concussions are caused by soft brain tissue moving violently inside the bony skull. This can result in varying degrees of microscopic injuries to brain tissue, the majority vast majority of which do not show up on radiologic imaging studies like CT or MRI scans.

Concussions alter the ability of brain cells to use energy to communicate. The brain’s demand for energy exceeds what can be delivered, resulting in the many concussion signs (observable by others) and symptoms (what the athlete perceives). The injured brain is at increased risk of additional injury, occasionally catastrophic, until this mismatch of energy supply and demand is resolved.

Concussion signs may include appearing dazed, stunned, or confused. Observers may note the person is moving clumsily, saying nonsensical things, or exhibiting mood changes such as aggression or sadness. It may cause amnesia, either retrograde (forgetting what happened before the injury) or anterograde (forgetting events after the incident – a more concerning symptom).

Most concussed individuals report a headache. Other common symptoms may include nausea, dizziness, balance problems, blurred or double vision, light or noise sensitivity, “brain fog,” concentration/memory problems, fatigue, anxiety, depression, and changes in sleep patterns.

Athletes who sustain a concussion need to be removed immediately from the contest or practice until they are evaluated by a certified athletic trainer, coach, or physician who has received training in concussion management. This is especially critical in younger athletes who appear to be more susceptible to potential severe neurologic injury if they are allowed to return to competition before recovering fully.

Though a patient’s signs and symptoms may appear to resolve, often the brain has not recovered completely. There are subtle neurologic changes that often can’t be picked up by doing a medical history or physical examination.

Computerized neurocognitive testing such as ImPACT, has enhanced our ability to manage concussions more effectively. These tests are more objective and, most importantly, can assist us in getting athletes back on the field more

safely. Typically, athletes take a baseline examination at the start of the season and repeat the test at varying times following a concussion. Athletes are usually kept out of competition until their physical exam is normal and their test returns to their baseline.

All NFL and NHL teams and virtually all colleges utilize neurocognitive assessment software of some type. Thankfully, this type of testing has filtered down to the high school level in most areas. While not infallible, most doctors consider these tests to be a standard aid in the management of concussions. However, it is important to note that these tests are but one tool in determining a person’s readiness to return to normal activity. Concussion is a clinical diagnosis that requires an assessment by a clinician with experience in concussion management.

We are constantly searching for tools to aid us in diagnosing and managing concussions. Some of my patients have asked me about the “concussion blood test.” These questions have originated from headlines such as this one from the New York Times: “Concussions Can Be Detected With New Blood Test Approved by FDA.” Unfortunately, this is inaccurate.

The test was developed to detect two proteins released into the bloodstream that indicate there is bleeding in the brain, not to aid in the diagnosis of concussion. The test will be used primarily in emergency rooms to determine if a patient needs a CT scan to detect bleeding in the brain.

There are steps that can be taken to help reduce the risk of concussion. It is critical to teach players to wear properly fitted safety gear and instruct them on proper technique, especially tackling in football. Prevention of falls is important in non-athletes, particularly the elderly.

Everyone should understand the potential serious nature of even a “minor” concussion. Athletes in particular need to be taught to report their own or their teammates’ symptoms or signs immediately.

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– Dr. John Roberts is a retired member of the Franciscan Physician Network specializing in Family Medicine.