CONCUSSIONS! What's the big deal?

Johnny comes home from soccer practice and says he had a bit of a fall today and that he is feeling odd. He later adds that his vision seems a little blurry and that he is feeling a tired and heading to bed. As a concerned parent, what do you do? Perhaps you think nothing of it because it’s just like last week when he got dehydrated. You may even tell him to toughen up and that he needs to work on his conditioning. Or maybe you rush him to the emergency room because you just read this article about concussions and the potentially serious side effects. Sometimes it is hard to know which choice is the most appropriate next step. We’ll get back to Johnny later.

What is a concussion?

Concussions are a type of brain injury resulting from trauma to the head that affects brain function. It may or may not involve loss of consciousness or even a direct blow to the head. The symptoms of a concussion demonstrate dysfunction of the brain rather than any structural abnormality – at least as far as we can see on traditional CT and MRI scans. For this reason, having a negative scan at an emergency room visit does not rule out a concussion.

What causes a concussion?

It is due to mechanical forces being transmitted to the brain, essentially a change in direction of movement that results in damage to nerves. This can be a result of a hit directly to the head – from a tackle or fall from a skateboard or it can be related to a sudden change in direction of head movement.

Who is at risk?

Everyone! While most of the publicity revolves around athletes and concussions in sports, concussions can happen to anyone. Sports associated with higher risk include basketball, soccer and football. Certain occupations such as construction or dock work can also bring increased risk. Studies have estimated 3-4 million concussions occur annually from sport and recreational activities with around 50 percent going unreported – so it likely happens much more often than many of us think. Additionally, a history of previous concussions, female gender, younger age and sport position all appear to increase the risk.

Why is recognition of the presence of a concussion important?

Recognition determines how the injury is managed, helps minimize future risk and results in modification of activities in either work or school. Recognition also frequently involves ruling out other acute injuries that may require emergent intervention – as may be the case with bleeding within the brain. We are also learning more about potential long term consequences of concussions and, depending on the situation, there may be reason to consider more permanent restrictions based on an individual’s concussion history.

What are the symptoms?

Concussions can present in a wide variety of ways but symptoms are acute in onset and may evolve over minutes to hours after the initial injury. Some of the most common symptoms include headache, feeling slowed down or ‘in a fog’, repeating questions, having sensitivity to light or sound and being more emotional. While the average concussion is reported to resolve in 7-10 days each case is unique and management decisions regarding return to activities must be individualized.

How do you treat a concussion?

The most important treatments are limiting risk of additional injury by not allowing return to play or risky activities the same day or before symptoms resolve. Activity restriction is crucial with the recommendation being to rest both physically and mentally - avoiding physical exertion and minimizing mental demands to allow the brain to rest. Increased sleep, avoiding loud sounds and bright lights, and possibly limiting work and school attendance are other components of treating a concussion. No medication is required for treatment of concussions and the use of non-steroidal anti-inflammatories (such as ibuprofen and naproxen) are discouraged initially due to increased complication risk. Decisions regarding medication use should be made under the direction of a medical provider – ideally one experienced in concussion management. In complicated or prolonged cases a multi-disciplinary team (potentially including neurologist, psychiatrist, neurosurgeon or others) may be beneficial.

As far as we know at this point there is no piece of equipment that reduces the risk of concussion. Concussion prevention is an issue of risk reduction by modifying behavior. Examples of tools that facilitate behavior modification can include requirements for preseason education of athletes, parents and coaches, and changes in rules within sports with accompanying penalties that discourage high risk behavior, such as spearing or helmet to helmet contact in football.

Over the past decade there has been a significant increase in coverage of concussions and potentially related consequences. This has resulted in improved awareness but more is required. Athletes, parents, coaches, everyone must remain vigilant for potential injuries and encourage and seek appropriate medical evaluation.

Now back to Johnny. While there is no clear cut answer for the situation described earlier, added information that a medical provider would ask about or obtain on examination, will determine the most appropriate next step. If the injured person is getting progressively worse emergency room evaluation should be considered. In most cases hospital based evaluation is not required and you should start with protecting the injured from additional injury, discontinuing activity and seek out medical care within the next 1-2 days to clarify diagnosis and treatment.

Consider the possibility of concussion after a trauma regardless if that involves you, your child, or anyone suffering a trauma to the head. Remember that symptoms such as those mentioned above may be related to brain injury and dysfunction. Consider seeking out a provider who is comfortable with concussion diagnosis and treatment such as a primary care/sports medicine physician or neurologist. In the meantime, stay active and healthy.

Sources:
Harmon KG, Drezner JA, Gammons M, et al. “AMSSM position statement: concussion in sport”. Br J Sports Med 2013, 47, 15-26.
McCrory P, Meeuwisse W, Johnston K, et al. “Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurizh, November 2008”. Gr J Sports Med 2009, 43, 76-84.

Winter 2015

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