Concussion 101: Everything You Need To Know About Concussions

What Is A Concussion?

Many people use the term “getting your bell rung” as a way to describe a concussion. However, if that statement is used, it should be taken seriously. For years, “getting your bell rung” was something that was normal after a hard tackle in football and it was expected that a player should get back up, shake it off, and keep playing. You were considered “weak” or “soft” if you sat out. It was normal to have headaches during practices and games and you just played through it. We now know after extensive research has been conducted, that continuing to play through a head injury is a very serious concern and can be fatal if proper precautions are not taken.

The true definition of a concussion according to the Center for Disease Control is a mild traumatic brain injury caused by a sudden jolt or hit to the body that causes the brain to move rapidly back and forth. It is believed to potentially cause functional impairments. Concussions can occur by a direct blow to the head, face, neck, or elsewhere on the body with an “impulsive” force transmitted to the head. This means that an athlete can get a concussion without actually hitting their head! This is a huge misconception! Another misconception in today’s world is whether a head injury is considered a concussion based on the individual losing consciousness. The latest research shows that losing consciousness does NOT determine the diagnosis or severity of a concussion, however, it has been shown that losing consciousness actually allows for a quicker recovery time with symptoms associated with the concussion. Having that very brief moment of the brain “shutting down” while losing consciousness ends up creating slightly less symptoms or impairments.

What Are The Symptoms of a Concussion?

This is probably the most interesting topics regarding concussions because the list of symptoms can be so vastly different from person to person or even concussion to concussion! An individual may experience one or many of the following symptoms:

headache, dizziness, nausea, vomiting, disorientation, blurred vision, confusion, poor coordination, hearing loss, loss of balance, ringing in the ears, difficulty remembering or concentrating, unresponsive or abnormal pupillary response, seizure, increased or decreased emotions, inability to sleep or excessive sleepiness, drowsiness, slurred speech, sensitivity to light, sensitivity to sound.

This list really could go on and on, but ultimately, any of the above symptoms or the individual complaining of “being in a fog or cloud” or “just feeling off or not right” are all symptoms of a concussion. And if ANY of these symptoms are reported, it SHOULD be taken seriously. The symptoms can last anywhere from minutes to months depending on the amount of damage that has occurred to the brain. Another good thing to monitor for are signs of a concussion. Signs are different from symptoms in that they are visual changes that another person can detect rather than the individual reporting what they feel. Common signs of a concussion are stumbling, rubbing of their head as if in pain, shaking of the head, or “acting out of it or possibly drunk”.

What Type of Damage Happens To The Brain?

A concussion results in the rapid movement of the brain inside the skull which ultimately leads to bruising of the brain. This bruising can be UNDETECTABLE in an x-ray, MRI, or CT scan. Because of this, many concussions are misdiagnosed because the imaging results came back as negative. The reason for the negative result is because the imaging did not show any bleeding within the skull or possibly a skull fracture. Just because there is no bleeding within the skull or a fracture, does NOT mean that the individual did not sustain a concussion. With that being said, it IS important to have imaging of the brain performed if a concussion is suspected to rule out the possibility of a hematoma formation. With severe brain trauma, this can lead to either an epidural or subdural hematoma, which if not found quickly, can result in permanent brain damage and/or death.

I Think I Have A Concussion, What Should I Do?

If any of the above signs or symptoms are present, the individual needs to be monitored to determine if the symptoms are getting worse over time. If the individual has an increase in the amount of symptoms or severity of the symptoms within 1-2 hours of the incident, they should be taken to the emergency room for further evaluation. If symptoms are present, but not getting worse, it is not always necessary to be seen in the emergency room. If you are ever unsure, it is better to be safe than sorry and go get checked out!

The very BEST thing someone can do after having sustained a concussion is to do ABSOLUTELY NOTHING! What does this mean? To do nothing means to lay down in a dark room alone and sleep. Many people get concerned when they hear this advice! What if they do not wake up!? Well, by the time you have determine the individuals symptoms are not worsening, the chance of a hematoma formation is much less and the more the brain can “shut down”, the quicker the healing process can begin. You can compare this to an ankle sprain… if you injure your ankle, you are going to REST it and not use it so it does not hurt as much and can heal. The same thing goes for the brain!

So What Should I NOT Do?

You should NOT use your phone, drive or operate a motorized vehicle, go to class, study, read a book, watch television, listen to music, play video games, talk to your family/friends, be in a noisy environment, be woken up. These are CRITICAL in order to decrease the recovery time after a concussion. The more that the brain has to do, the longer the healing process with take. You do NOT need to wake the individual every few hours to check on them. The more uninterrupted sleep the individual has, the better their recovery. It is a misconception that people should be woken up every 2 hours after a concussion. This will only delay healing. Let…them…sleep!

Also, you do NOT want to give the individual any pain medication unless they are just unable to handle to pain of the headache. If you are going to give them pain medication, GIVE THEM ACETAMINOPHEN (tylenol) ONLY! Let me explain why. First off, it is best to not give any medication at all because you do not want to mask the symptoms of a concussion. You want to know if their headache is improving or getting worse to determine how they are recovering. Second, tylenol is a pain reliever and does not have any blood thinning properties. If someone has a concussion and is given an anti-inflammatory (Ibuprofen, advil, excedrin, motrin, aspirin, naproxen, etc.), this could potentially change the outcome of recovery if a hematoma is present. When in doubt, do not give any medication and take them to be further evaluated by a medical professional.

How Long Does It Take To Heal?

This is where the controversy comes into play. And the answer to this question is… it depends. It depends on the severity of the concussion. It depends on the individual and how well they are able to do nothing and rest. It depends on previous head trauma history. It depends on how many symptoms the individual has. It depends on the age of the individual and the type of sport or activity they do. Typically, the recovery time for a concussion can be anywhere from 1 week-3 months. There are some cases that fall outside of that timeline though.

What Does The Concussion Recovery Process Look Like?

The first step to the concussion recovery process is REST. The individual should be working with a certified athletic trainer or other healthcare professional that has extensive knowledge of concussions and the return to play protocols. Athletic trainers are the most qualified and trained healthcare professionals to handle the treatment and return to play of a concussed individual.

The first phase of the return to play protocol is that the individual MUST be symptom free for at least 24 hours. Once this has been established, the individual can move on to phase two which allows for about 15-20 minutes of LIGHT activity. Examples would be walking or riding a stationary bike. Note that this activity is to be done outside of a team practice or where any contact could be had. So long as the individual is able to remain symptom free for 24 hours following phase two, they can continue through the protocol. If symptoms do return at any point, the individual needs to again be symptom free for 24 hours and begin back at the previous phase. Phase three involves about 1 hour of activity in which the individual is performing exercises to increase the heart rate and changes in direction. The purpose of this phase is to cause some movement of the brain within the skull to see if symptoms are provoked. Examples of activity in this phase could be jogging, performing push ups or sit ups, performing burpees, changing direction while running, etc. All of these options create movement of the brain and an increase in blood flow. Again, the individual must remain symptom free to continue on and this phase is still performed outside of a practice situation with no contact. Phase four involves about 1 hour of activity in which more sport specific drills can be added. This could be participating in football drills WITHOUT contact, but within a practice. It could also be playing an hour of volleyball, tennis, gymnastics, etc. The main rule to this phase is to still have NO contact within the sport (meaning no hitting/tackling/touching of the athlete). The final phase would be a full practice with the team including any contact drills. Once the individual has made it through all 5 phases without any return of symptoms, the final step in the recovery process is to complete some type of concussion testing. The ImPact test is a typical software program used to handle post concussion testing. This test goes through a serious of questions involving memory, images, colors, numbers, delayed recall, etc. Most athletic teams will have done a baseline ImPact test prior to the start of a sport season so there is a comparison of what their normal brain activity is. The athletic trainer can then compare the baseline test to the post concussion test to ensure the brain activity has returned to normal. Once this test has been passed, the athlete is then considered “cleared” from the concussion.

Some concussion protocols may differ slightly from this described phases and some protocols will require a physician clearance in order to return to play. This is all based on the healthcare setting and the agreed upon protocols of the medical professionals. All in all, an athlete SHOULD ALWAYS complete some type of return to play protocol following a concussion. It is NEVER a good idea to return back to a sport or activity without a progressive plan. The reason for this is the risk of what is called Second Impact Syndrome (SIS). SIS happens when the brain swells rapidly shortly after an individual has suffered a second concussion before the symptoms of an earlier concussion have subsided. Although this can be rare, if it does occur, it is most often fatal. Working with an athletic trainer or another qualified medical professional is essential in preventing SIS. This is why ALL concussions or symptoms of a concussion MUST be taken seriously. Any sport or activity is never more important the health and safety of an individuals brain.

References:

Johna K. Register-Mihalik, PhD, LAT, ATC; Kelly Sarmiento, MPH; Christina B. Vander Vegt, MS, ATC; Kevin M. Guskiewicz, PhD, ATC, FNATA, FACSM. Considerations for Athletic Trainers: A Review of Guidance on Mild Traumatic Brain Injury Among Children From the Centers For Disease Control and Prevention and The National Athletic Trainers’ Association. J Athl Train (2019) 54 (1): 12–20.

Landon B. Lempke, MEd, LAT, ATC; Julianne D. Schmidt, PhD, LAT, ATC; Robert C. Lynall, PhD, LAT, ATC. Athletic Trainers’ Concussion-Assessment-Management Practices: An Update. J Athl Train (2020) 55 (1): 17–26.