Concussions are defined as a mild traumatic brain injury (mTBI), “mild” because they are not usually life-threatening even though their effects can be serious. They are caused by the head being struck by or against something (a “bump, blow, or jolt to the head”) that can potentially alter the way the brain works and leaving the individual to possibly feel dazed, disoriented or confused.  Concussions can also be caused by a fall or hit to the body that causes the brain to move quickly inside the skull. They are always trauma induced, and may or may not involve the loss of consciousness (whether it be seconds, minutes or longer). They can however, result in loss of memory (amnesia) for events that took place immediately before or that occur immediately after the trauma. Lastly, they can result in local neurological deficits that may or may not be transient (coming/going) and due to this they are not always frequently understood or diagnosed leading to subsequent problems that are not always attributed to the concussion.

Who can get a concussion?

Concussions are not prejudice - they can happen to anyone regardless of age, sex, skin color, religion or race and occur more regularly than people may realize. Over the years in my practice, I have treated a wide age range of patients and concussion is one condition that I have to say that I have seen at least once in each age group. With that being said, there are select groups that are more at risk to acquiring a brain injury due to age, development, or activities.

Some individuals are more at risk than others

According to the Centers for Disease Control (CDC), the most likely age groups to sustain an mTBI include younger children ages 0-5 years, older adolescents aged 15-19 years, young adults aged 20-24 years, and adults aged 65 years and older. These are due to childhood abuse or falls, sports/recreational activities, motor vehicle accidents, and falls respectively. The greatest number of sports and recreational related concussions were from bicycling, football, playground activities, basketball, soccer, horseback riding, and all-terrain vehicle (ATV) riding. It is estimated by the CDC that 1.6 million to 3.8 million people experience this type of sports related concussion every year in the United States. Other common causes for concussion are alcohol intoxication, domestic violence/abuse, and military injuries/combat-related blast injuries. Concussions can occur at any age as mentioned, and can result in physical, cognitive, and behavioral symptoms causing both short- and long-term problems. With this being said, it is important to note that every concussion is considered a serious injury needing immediate attention by a healthcare provider. 

So, what does a concussion look like? 

Even “mild” head injuries or concussions can be followed by lesser degrees of temporary confusion/disorientation, incoordination and staggering, headache, fatigue and or tiredness initially. There may not be a full loss of consciousness but perhaps just a brief period of being “stunned” with the individual otherwise appearing outwardly “normal”. This has been seen in sports, for example if a baseball bat (even with the player wearing a helmet) or soccer ball hit the player in the head leaving them to appear to be “out of it” for a second and then they proceed to “shake it off”. Other examples would include falls down stairs or slips on ice or a wet floor where the head hits hard on the steps, wall at the end of the stairs, or floor, and the person sits up feeling stunned for a moment but then gets up and continues on. Other daily and common incidents occur from objects falling off of a shelf and knocking someone in the head, or an individual standing up underneath a low ceiling, counter, television or hard object and striking their head. Following these incidents, it is not uncommon to experience the feeling of blacking out for a time being or “seeing stars”. Again the person may initially look hurt, realize there is nothing “bleeding or broken” and then return to what they were doing “mustering through” any temporary pain, discomfort, or symptoms.

I have hit my head but not hard enough to break the skin or fracture my skull. Could I have still had a concussion?

The amount of force to the head and whether or not the skull itself is damaged by the blow, does not indicate the severity of the brain injury. The skull, although rigid, is still flexible enough to yield an impact that injures the brain significantly without causing fracture. There has been research that shows even in immediately fatal head injuries, autopsy reveals an intact skull in 20-30% of the cases. Furthermore, regardless of the type of hit to the head and whether the skull breaks open or not (open vs closed head injury) or the direction of the blow (rotational as in a punch to the side of the face, or flexion/extension as in whiplash from stopping short or impacting another car in a motor vehicle accident) the trauma itself is enough to cause sudden acceleration or deceleration of the brain inside the skull and can cause damage to blood and nerve vessels. This can lead to metabolic alterations or direct damage to physical structures like brain cells, cause adverse chemical changes in the brain, as well as impaired neurological functioning.  Moral of the story- don’t let the fact that there is no open head wound lead you to determine that the brain is fine. 

What symptoms do people feel when they have a concussion?

Where the type of injury occurs in/on the head, and depending on what part of the brain is injured, determines what types of symptoms an individual will experience. All traumas to the head have the potential to cause nerve fibers to be stretched or torn, blood vessels to be damaged causing bleeding, and areas of the brain to swell. Typical concussion symptoms that occur thereafter can be divided into three categories: physical/somatic, cognitive, and behavioral-emotional. The physical/somatic category includes the possibility of the individual experiencing light sensitivity, noise sensitivity, headache, fatigue, impaired hearing, blurred/double vision, nausea, dizziness, numbness, loss of balance, poor sleep, or neurological abnormalities. The cognitive symptoms that may appear include inattentiveness, diminished concentration, poor memory, impaired judgement, slowed processing speed, or trouble with planning, making decisions, and other executive type functions. Lastly, behavioral-emotional symptoms noticed may be depression, anxiety, agitation, irritability, aggression, or impulsivity. From blast type injuries, military men and women have even experienced epilepsy or aneurysms from the shock wave of force as well as tinnitus (ringing in the ears) and intense migraines. For most people, these symptoms will resolve within a period of 2-4 weeks. For the 10-15% of patients experiencing “Post-Concussion” symptoms, or symptoms that have lasted anywhere from 4 weeks to 4 years or longer, symptoms may present as brain fog, chronic headaches, dizziness that is not true vertigo, head pain, with an intensification of the symptoms during mental and physical effort, as well as poor posture that appears as “stooping” or “straining”. 

I think I have had a concussion, what should I do?

Effective management of concussions requires a team approach and open communication between the patient, their doctors, and rehab team (Physical therapists, occupational therapists, and speech therapists to name a few). These professionals should thoroughly assess and recommend a treatment plan.  Acute concussion and post-concussion are usually handled very differently. In acute (new) concussion your primary care provider should do a though exam, rule out the need for imaging (such as a CT scan), and provide the patient instructions for what to monitor for in a worsening case, as well as the steps and process of how to slowly re-introduce yourself back into school, sports or the workforce. They will manage your condition with other providers such as physical therapists, speech therapists, occupational therapists, and optometrists as warranted. Typically, doctors will inform patients to take a period of physical and mental rest, but not rest too long, avoid screen time such as computers, television, video games, reduce reading, give up sports activity temporarily (ie. reducing all physical and mental exertion), avoid bright lights and loud sounds, and they may even recommend medications to help with symptoms. Once symptoms have abated, therapists such as speech, occupational and physical therapists can help patients regain abilities lost if needed. For patients who have had chronic, long-term or “persistent post-concussive” symptoms lasting longer than 4 weeks, a different approach is taken. In my office, I perform a comprehensive neurological evaluation and the patient is checked for abnormal eye movements, abnormal strength and sensation, abnormalities with the senses, memory, ability to recall, ability to follow instructions for certain tasks and perform the task correctly, and evaluation of balance, gait and movement as well as spinal and orthopedic testing. And of course, a history of the injury is recorded. I also do a dynamic posturography exam using the FDA cleared CAPS machine. Should the patient’s symptoms and exam results warrant a CT scan or other imaging, that would be ordered. Since my specialty is in treating patients with “post-concussion” by the time a patient comes to see me in my office, they have already seen their primary care provider, the emergency room or neurologist, have worked with other rehab specialists, and are coming in for management of persistent symptoms. 

So what can be done about treatment for concussions? What is a rehab protocol? 

Depending on who you see this can vary and as mentioned above, acute care and rehab differs from chronic or post-concussion rehab and care. What we do in my practice is to first perform the in depth and thorough assessment mentioned above. We then offer a personalized 6-week intensive program that works to integrate the brain and body and cause new neural pathways to form. Depending on the patient’s findings, treatments to obtain this goal consists of specific and gentle chiropractic adjustments (to help with increasing nerve and blood flow to the brain and body allowing better communication of our “super highway” or central nervous system for purposes of allowing the body to heal), specific eye and head movements, balance exercises, use of tools such as the Interactive Metronome to assist with reaction time and coordination as well as integration of hearing, vision, and movement, and recommendations on proper sleep hygiene, and give specific dietary and advise on nutritional supplements to support adequate brain glucose metabolism as well as decrease inflammation to name a few. I reassess at the end of the 6-week program and establish further recommendations and treatment at that point. Furthermore, I also coordinate care with other providers that I feel could still be of great help to the patient including neuropsychologists, acupuncturists, neuro-ophthalmologists, massage and craniosacral therapists, naturopaths, psychologists, and various rehab specialists. 

References:

1. Anders, David et al. 2019. The Essential Brain Injury Guide 5^th Edition. Brain Injury Association of America. 
2. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control: Report to Congress on mild traumatic brain injury in the United States: Steps to prevent a serious public health problem. September 2003. Available at www.cdc.gov/ncipc/pub-res/mtbi/report.htm
3. The Management of Concussion/mTBI Work Group. VA/DoD Clinical Practice Guideline for Management of Concussion/mild Traumatic Brain Injury. Available at www.healthquality.va.gov/mtbi/concussion_mtbi_full_1_0.pdf
4. Ropper AH, Gorson KC. Clinical practice. Concussion. New England Journal of Medicine. 2007;356(2): 166-172. Doi:10.1056/NEJMcp064645. PMID 17215534
5. McCrea MA. Mild Traumatic Brain Injury and Postconcussion Syndrome: The New Evidence Base for Diagnosis and Treatment. New York, NY: Oxford University Press; 2008
6. American Congress of Rehabilitation Medicine Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group. Definition of mild traumatic brain injury. Journal of Head Trauma Rehabilitation. 1993;8(3):86-87.
7. Anderson-Barnes VC, Weeks S, Tsao J. Mild traumatic brain injury update. Continuum Lifelong Learning Neurology. 2010;16(6):17-26.