The Mighty ‘C’ Word

11 Mar

I am hoping to bring the information about a concussion to a level that everyone can understand.  Recently I have been on a media blitz and am finding out that people know about a concussion but not what a concussion is.  The hope is that this original article will help with understanding.  You may link and use parts of this article as needed, however you may not reprint it without expressed written consent from The Concussion Blog and Dustin Fink, MS, ATC.  I hope you enjoy and looking for some feedback as well, ALL feedback!!!

What is a Concussion?

Simply put a concussion is an injury to the brain.  There are much more complex pathophysiological (I know huge word, sorry bout that) mechanisms happening to the brain.  What is not so complex is that your brain, my brain, our brains do not repair themselves, nor do we have the technology to repair them.  Every individual is given ONE brain, and really it amounts to a mound of jello suspended in fluid, pretty fragile, eh?

As the brain is violently and abruptly shifted inside its case (skull) it creates a cascade of events down to the cellular level.  Instead of boring you with medical terminology just think of your brain as a snow globe.  When all is good the flakes in the globe are at rest and the water is clear.  Now shake the snow globe.  The flakes are flying everywhere without rhyme or reason; this is a concussion (at its basic level).

During the excitement of the flakes the brain does not function correctly sending the body signals that are impairing function such as; headache, blurred vision, balance disturbance.  The brain wants to function normally however with all the chemicals, hormones and such “flying” around – out of order – the normal responses to signals the brain is used to sending is no longer happening.  We as clinicians have been able to, through research, identify areas of the brain impacted by the sudden insult to the brain due to the types of signs and symptoms presented.

In order for the brain to return to normal functioning every single flake in that snow globe must come to rest, and be at a complete restful state.  Returning to activity – ALL ACTIVITY includes physical and COGNITIVE stresses – too soon makes it MUCH easier to excite the flakes once again, and even make the symptoms and reaction much worse (think Sidney Crosby).  Getting a second insult to the brain before all the chaos has subsided WILL translate into a longer recovery period, and in adolescents this can lead to Second Impact Syndrome, a killer.  Even if there is one little tiny flake floating around in your snow globe, your brain is NOT READY for any more trauma, PERIOD.

What to look for

With a concussive episode the brain sending improper signals results in SIGNS and SYMPTOMS; signs being what is observable, symptoms being what is reported or not-seen.  Classic symptoms include; headache, blurred vision, being in a ‘fog’, restlessness, anxious, nervous, nauseous, but are not limited to that.  Anything that is being reported by the injured that is NOT NORMAL would be considered a symptom.  Classic signs include; balance disturbance, loss of consciousness, vomiting, ‘gazed’ eyes, memory problems, slurred speech, again not limited to that.  For example a student that had a concussion did not show classic signs, however he was a “class clown” of sorts prior to the injury, and after the injury he became reserved and introverted, a SIGN something was wrong with his brain.

The message here is that if anyone takes a blow resulting in an insult to the brain, abnormal reactions and information from said individual should lead to further examination and possible referral.

Myths

-          You have to be hit in the head to get a concussion

o   All that is needed is a jarring incident that “rattles” the brain in the fluid where it rests.  Sudden whiplash motion or twisting of the head can and will elicit a concussion episode if the force is great enough.

-          You have to be knocked out to get a concussion

o   Loss of consciousness is simply one of many signs, less overt issues such as concentration issues and memory lapses are more troublesome regarding such an injury.

-          I only have a “mild” concussion

o   Can you be “mildly” pregnant?  Either your brain received a force/trauma great enough to elicit a negative response, or it didn’t.  Moreover, treatment of ALL concussions, regardless of signs and symptoms should be treated the SAME.

-          If my headache is gone I am fine

o   The pounding upstairs may be gone, but what about the sensitivity to light one may be having after the headache.  Perhaps controlling the headache with medicine is masking the actual issue and other things like not being able to sleep should be paid attention to.

-          All concussions resolve in a week to ten days

o   Obviously we have seen examples of this not being true, yes about 90% of concussions seem to resolve in about a ten to 14 day window, the other 10% can linger for longer, even a lifetime.

What we think we know

Concussion research is just now beginning to develop promising leads, we have been lagging in definite answers and however this is not because of a lack of trying.  The human brain is extremely complex with so many variables that wading into this frontier is a daunting task.  What is known is that the brain cannot heal itself, and unlike bones/muscles, no surgeon has the technology or knowledge to repair it.

Time for another analogy, this time let’s use a driving route from point A to point B, the fastest one, on that route is a bridge (3 lanes wide).  When the bridge and roads are good travel is easy and nearly automatic for one to take (think of your drive to work), including knowing what signals do what, when and how all other traffic generally flow.  This is how the information traveling in your brain conducts business, in a basic way, an electrical superhighway of sorts.

Now the route has sustained damage (concussion), the bridge has lost its far left lane due to an accident, obviously the cars can still make that route, it just has been compromised and slower.  Instead of a road crew coming out to repair the bridge, it will never be fixed (because the brain does not heal itself), the crew only ‘shores’ up to prevent greater damage.  In order for you to make the travel on that route with the same arrival time you may now have to leave a bit earlier, but you can function normally as it has not impacted other parts of your life, more of an inconvenience.

Now if there were another accident while the crew was trying to shore up the bridge there would be greater damage than the initial accident, due to the weakened structure and chaos surrounding the adjustments.  This would be akin to sustaining another concussion before the first one healed.

Now that bridge has lost all three lanes, you will no longer be able to pass that route, but there are other options out there.  Instead of going over the bridge you now must travel considerably further and have to back track a bit to get to point B.  This requires more energy and time for you to accomplish the same goal, one that previously was on “autopilot”.  Even though the bridge will not be fixed you can make it to where you need to go, and even though the brain cannot repair itself it will find different pathways to get the message to where it needs to be.  But it will be slower and even drastically impaired until that route becomes second nature.

No one know how long the brain needs to “reset” its autopilot function when dealing with tasks such as memory and cognition, what we do know is that all the broken bridges leave deposits on the brain.  These are tau proteins and are indicative of Chronic Traumatic Encephalopathy (CTE), and with enough deposits the executive functioning of the brain becomes diminished and trouble ensues.

Thoughts

I do not feel that concussions have been increasing at an alarming rate, per say.  Rather the technology, education and awareness about concussions have led us to finding more incidences of.  What should not be debated is that the professional athlete is MUCH MUCH  bigger/faster/stronger than in the past.  If Sir Newton has taught us one thing it is that the greater the acceleration (faster) and mass (bigger/stronger) the larger the force delivered.  Thresholds (amount of force necessary) for concussive episodes remain the same, while the forces impacted go up, it seems extremely logical.

In terms of equipment, nothing we currently have in sports will prevent a concussion, the best we can do is limit the forces getting to the brain (helmets), this still does not take into consideration the rotational and whiplash type forces that translate the insult to the brain.  In motor sports there is something called the HAANS device that does just this, but rather impractical for all other sports.

We need to change our thought process when it comes to these brain injuries.  No longer should it be acceptable that someone with a concussion is not afforded a recovery period with some rehabilitation.  When an athlete breaks a bone or tears a ligament are they rushed right out?  Heck when an athlete sustains an ACL injury we as general observers inherently know that it will be a 6-8 month process or longer.  Why then we cannot hold the same reservations about a player sustaining a concussion?  Determining the exact time is an issue unto itself, everyone reacts differently, but expectations that a player will be sidelined for a month or longer should be entered into the conversation.

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2 Responses to “The Mighty ‘C’ Word”

  1. Jennifer Wuyscik March 6, 2014 at 13:36 #

    Dustin, what are your thoughts about the possible increased risk of depression that can come with completely shutting down a student-athlete? No school, tv, computer, texting, social media, etc… (We almost always stay completely away from video games). Do you think that it may be okay to allow the student-athlete to participate in activities that do not cause an increase or worsening of their symptoms? With every concussion being different and every student-athlete’s recovery from their concussion being different, clinically, we have found that allowing some activities can actually help the student-athlete to recover faster.

    • Dustin Fink March 8, 2014 at 10:00 #

      A valid thought but also overblown in my opinion and observation… We are asking for 2 maybe 3 days of strict adherence to this, then return, gradually, to normal… Now if the kid is “sheltered” for longer than a week, yes this can be a concern…

      Do we worry about the “depression” of an athlete that has surgery or fracture and is groggy from meds and is isolated for 2-3 days from school?

      And finally, although we ask for “complete” rest what are the chances that anyone does that? Who has the patience to stare at a wall for hours? Not many. It is ideal for complete rest but the expectation is that they use technology somewhere… And when they say their symptoms are still there 3-4 days later and I ask them what they have been doing and they have been using computer, video games, technology, etc then I can say “told you so”

      In conclusion, the depression from shutting down is real but overblown in most cases… It is no different than the flu in terms of isolation…

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