Concussion

What is a Concussion? with Dr. James Ebben

A concussion, or mild traumatic brain injury, occurs when we have a direct force on our head or body creating trauma to the brain inside the skull. Straight on, rotation, or indirect forces to the head or body can all cause a concussion. Stretching or damage to brain tissue can cause functional deficits for brain function. This can lead to symptoms of headache, dizziness, confusion, nausea/vomiting, amnesia, limited tolerance to physical exertion, and limited tolerance to cognitive exertion. Concussion symptoms usually resolve in 1-3 weeks but can persist longer. Initial treatment focuses on rest and reduction of symptomatic activities or stimuli. Return-to-learn and return-to-sport considerations are important through recovery to ensure smooth and optimal recovery.

Anatomy
Brain tissue is very well protected and resilient inside our skull. The under surface of the skull is very irregular and when the body sustains contact that causes the brain to move inside the skull, it can cause trauma to the brain that can lead to concussion symptoms. Immediately after injury the brain requires increased blood flow and energy to heal. This is a main reason our body has a limited tolerance to physical and cognitive exertion - it creates competition for our blood and energy. After the injury has recovered the brain usually resumes normal function independently. In cases where it continues to struggle, physical therapy can be utilized to help progress recovery through post-concussion syndrome symptoms.

Causes
Direct trauma to the body or head are the cause of concussion. High speed, contact sports can lead to higher levels of concussion injuries. Females are at an increased risk for concussions again with contact sports or sports with a projectile involved such as soccer, basketball, and volleyball. The brain can be injured through the direct trauma or the "shaking of the brain" that occurs inside the skull from dramatic forces to the body, for example, a car accident that doesn't have a direct contact to the head can still yield a concussion.

Symptoms
Common symptoms after concussion include headache, dizziness, confusion, amnesia, limited tolerance to light, limited tolerance to noise, fatigue, irritability, altered sleep patterns, decreased tolerance to physical exertion, decreased tolerance to cognitive exertion, and nausea/vomiting. Symptoms, their intensity, and their duration can be variable depending on the patient. If the patient has history of multiple concussions, they may be at risk for more severe symptoms and symptoms of longer duration. This is even more likely if the patient sustains a second concussion and they haven't recovered from the first one yet. 

Diagnosis
Diagnosis of concussion is often made through clinical exam based off of symptom presentation. Different testing protocols such as Impact or Scat testing can facilitate diagnosis of concussion but need to be paired with a clinical exam. Imaging studies such as CT scan or MRI may be performed, but are often normal and usually done to rule out more serious injuries such as "bleeding on the brain," otherwise known as a subdural or epidural hematoma. Testing protocols can also be done to ensure recovery from concussion. This battery of tests often includes cognitive challenges and return to play physical testing to ensure safety to return to sport.

Treatment
The primary treatment for concussion is rest and reduction of noxious stimuli or activities. These activities can be both mental and physical. This allows for optimal healing and recovery of brain function. At times your physician may prescribe medications to help manage symptoms. Should symptoms progress beyond the normal 2-3 weeks you may be referred to physical therapy. Physical therapy interventions would utilize balance training, vision/vestibular treatment, manual therapy for cervical spine-based symptoms, and an active rehab progression to facility normalization of brain function.

Recovery
Most concussion symptoms, when treated appropriately from time of injury, resolve in 1 3 weeks. Sometimes symptoms may persist longer. Excessive activity, whether cognitive or physical, that occurs before brain healing is complete can cause a longer recovery. Previous history of concussion can also lead to more variable recovery time frames.

Prevention
Concussion prevention centers around education. Primary injury prevention can focus on proper hitting form for contact/tackling sports. Education with coaching staff/parents on concussion identification/diagnosis to ensure the patient is removed from harmful situations/further traumatic exposures. Preventing a second concussion can be based around patient education and ensuring full recovery of initial concussion and taking through full return to sport/activity testing.