Concussion: Runners’ Fall Recognizing Head Trauma Symptoms

0

 

Running may not be immediately synonymous with head injuries, but runners often participate in other sports that carry the risk of concussion. Additionally, invisible obstacles can pose a threat to runners with their eyes on the finish line. Low hanging tree branches, falling debris, and even a rogue shoelace can lead to a fall on a hard surface, which can result in a traumatic head injury or concussion.

Running can also benefit those who are seeking a return to a higher level of activity after suffering a head injury. A gradual return to light aerobic exercise like jogging or running after concussion symptoms have subsided can make the recovery process faster according to recent research. The healing and recovery process is made easier by keeping mind, body, and spirit active and alert, and running can contribute greatly toward having that effect on your body.

Concussion symptoms can be mild or severe depending on the force of the injury. While the symptoms of a mild TBI often resolve with rest, moderate to severe head injury can require much more thorough methods of treatment. Sometimes, particularly bad cases can even lead to permanent brain damage. It is important to recognize the warning signs following a head injury in order to mitigate the damage and to prevent repeat injuries.

What is a Concussion?

In the broad sense, a concussion is defined as a transient disturbance of brain function due to a pathophysiological process that takes place after head trauma is sustained. It is a form of traumatic brain injury, but while all concussions are forms of brain injury, not all brain injury can be defined as a  concussion.

The brain is a soft, vulnerable collection of matter with millions of nerve fibers. It is encased in a protective skull and floats in cerebrospinal fluid or CSF. Any force or mechanical blow to the head is first diffused through the skull itself, with further shock being absorbed by the CSF. However, head impacts sustained that are powerful enough to carry more force than can be absorbed by these body parts will transmit the impact to the brain through the fluid. The transmitted force results in movement of the brain tissue that can cause it to knock against the skull, injuring some of the brain nerve cells in the process. Stretching and tearing forces work to cause this damage to the brain. The development of bruises that result in injury to neurons, the brain’s white matter, or the vasculature of the brain, are what cause clinical symptoms that we commonly refer to as a concussion.

Concussion terminology

A Persian physicist by the name of Razes first used the term concussion to describe an abnormal appearing brain. However, until the 1960’s, there were two separate definitions for the concept of brain injury following mild trauma.  The physical structural damage, secondary to brain bruising, was defined as contusion cerebra, while the transient disruption of cerebral function was termed commotion cerebri. In 1966, a head injury committee named The Committee to Study Head Injury Nomenclature merged these two into one broad official definition: a clinical syndrome characterized by immediate and transient impairment of neural function resulting in a change of consciousness, disturbance of vision, or disturbance of equilibrium. In 2013, The American Academy of Neurology redefined concussion as “a clinical syndrome of biomechanically induced” change of brain function, affecting memory or orientation with or without the loss of consciousness. This is the definition that we currently use when referring to a concussion, and it is this definition of a concussion that this article will be focused around.

Epidemiology

Today, most concussions are sports related and are common in both helmeted and non-helmeted sports. These days, according to the Center for Disease Control and Prevention, between 1.6 and 3.8 million sports-related concussions are estimated to occur in the United States each year. Unfortunately, these are particularly prevalent in youth athletes, which can cause some major problems in the future if treated improperly. In recent years, there has been an increased reported incidence of concussions. This may be due to a greater awareness and education regarding the injury, which means that the actual amount of concussions hasn’t increased, but simply that we are now able to recognize the condition in situations where it may have gone unnoticed in the past. Although the incidence of mild TBI has grown, there does not appear to have been a similar increase in the incidence of sports-related catastrophic brain damage such as brain bleeds.

In sports with comparable rules, females have twice the rate of concussion as males. This has been theorized to be largely due to the difference in neck strength between the two sexes, with weaker necks being related to the greater force of impact being sustained to the head as a reaction to trauma. However, males generally sustain more concussions on average due to the fact that male dominated sports have the greatest risk of concussion.

Grading

Classification of TBIs, or Traumatic Brain Injuries, grew from the need to provide a fast sideline assessment in injured athletes. Although no grading system is universally accepted, three have gained popularity. The broadest classification is based on the Glasgow score, a scale commonly used to measure the length of time when an individual experienced loss of consciousness after an injury. According to this system, TBIs with a Glasgow score of 13-15 without loss of consciousness or with a loss of consciousness for less than 30 minutes are classified as mild. Those with a score of 9-12 and a loss of consciousness between 30 minutes to 24 hours are considered moderate. Scores below 8 and loss of consciousness for over 24 hours put the head injury in the severe category, as this may result in permanent brain damage and even death.

The Colorado Medical Society developed another system for classifying TBIs, based on the presence of amnesia and loss of consciousness. In this system, TBIs are grouped as Grade 1, Grade 2, or Grade 3. A concussion resulting in confusion without amnesia and no loss of consciousness is Grade 1, one with the presence of confusion with amnesia but no loss of consciousness is Grade 2. Any loss of consciousness classifies the brain injury as Grade 3, which is the most severe form on this scale.

Finally, the American Academy of Neurology has its own scale. Grading is based on the resolution of symptoms and whether there was also a loss of consciousness at the time of the injury. The first draft of this scale required the resolution of symptoms within 15 minutes in Grade 1 traumas, while Grade 2 usually lasted over 15 minutes. Grade 3 injuries meant that there was a complete loss of consciousness.

The grading was later updated to include post concussive symptoms because these correlated with performance on neuropsychological tests and therefore long term outcomes. Brief amnesia with post concussion symptoms for a few days but without the loss of consciousness is Grade 1. Post concussion symptoms lasting up to 7 days with a brief loss of consciousness and brief post traumatic amnesia up to 24 hours is classified as a Grade 2, or moderate brain injury. Amnesia over 1 day, with post concussion symptoms lasting for longer than 7 days is classified as Grade 3, or severe.

The most recent distinction that has been made is between simple and complex trauma, depending on the post concussive symptoms. A simple brain injury and post concussive symptoms resolve within 10 days. In complex brain injuries, symptoms last over 10 days and may be accompanied by concussive convulsions, loss of consciousness that is prolonged, or cognitive impairment in the weeks following a concussion. There is some debate about the appropriateness of terminology when it comes to defining TBIs, as many of the symptoms do not have objective data but are instead subjective. The jury is still out on the best grading system.

Mechanism and Causes of Concussion

There are two major ways a concussion can occur. One is through direct physical contact to the head, usually by means of an object or with a hard surface during a fall. The other way is through rapid acceleration/deceleration when the brain can’t keep up with the forward or backward movement of the skull, as the body is thrown suddenly and unexpectedly at a high speed. The brain bumps against the inside of the skull when the head moves at a faster rate, such as during a motor vehicle accident. The physical trauma typically then leads to biochemical changes in the form of a neurobiochemical cascade. These biochemical changes are the result of the shearing and distortion of neurons and their membranes.

Disruption of cellular membranes leads to shifts in ions across neuronal cell membranes that affect neuronal transmission. At the time of injury, neurons depolarize, leading to a release of potassium and the influx of sodium and calcium. This then leads to a widespread release of glutamate, altering the surrounding biochemistry in the vicinity of the neurons and potentially affecting signal transmission. This phenomenon is what can cause bouts of unconsciousness during a concussive episode.

An initial decrease in blood flow following the trauma also worsens the metabolic functionality of brain cells. As a result, when the disruption of the ionic balance and normal metabolism of the brain requires energy to establish homeostasis, there is not enough of it because of decreased blood flow in the area and mitochondrial dysfunction (the powerhouse of the cell). This results in a mismatch of energy supply and demand, and it is also why repetitive injury makes neurons more sensitive and susceptible to any kind of subsequent trauma. A second injury sustained before the brain has fully recovered results in more significant cognitive decline, and a greater chance of unconsciousness.

The brain cell’s ability to produce structural proteins for the nerve along its axon, through which neural signals travel, is compromised as a result of a concussion. This is due to the decreased blood flow and low energy stores. These are the reasons why medical professionals theorize there may be a delay of symptoms after the initial injury, as the injured nerve needs time to recover before it can register pain signals.

Symptoms

Symptoms following a concussion can range from mild and discrete to extremely debilitating, depending on both the patient and the level of injury. Since the brain is responsible for essentially all bodily functions, any damage sustained to it will cause a variety of symptoms affecting the entire body. These symptoms can be grouped into four categories:

Physical symptoms

These symptoms are the ones that affect physical characteristics, such as balance, digestion, and vision. Physical symptoms will most likely come about if any damage is sustained to the cerebellum or frontal lobe of the brain, as these parts are responsible for physical functions.

  • Headaches
  • Nausea and vomiting
  • Dizziness
  • Vertigo
  • Vision or balance problems
  • Sensitivity to light or noise

Cognitive symptoms

Cognitive symptoms are problems with mental functionality that may result from a concussion. As opposed to physical symptoms, these symptoms affect mental characteristics such as concentration and memory. If the parietal lobe or temporal lobe are damaged during a concussion, these symptoms are more likely to occur.

  • Slow or foggy thought processes
  • Decreased attention
  • Difficulty concentrating during school or work
  • Memory problems  

Emotional symptoms

These symptoms affect the individual’s emotional temperament and occur most commonly if any damage is sustained to the frontal lobe. Although depression may be the most common, any mood disturbance is possible in this situation. If mood issues persist beyond 6 to 12 weeks as part of a post concussion syndrome or secondary to a previous diagnosis of a mood disorder that has been exacerbated by a concussion, cognitive therapy and medication may be necessary in order to treat it.

  • Irritability
  • Depression
  • Anxiety
  • Frequent or sudden mood swings

Sleep-related symptoms

Sleep disturbance is also common in those who recently suffered a traumatic brain injury. Damage to the brain stem is the most common cause of these symptoms. Sleep is incredibly important for the brain to rest and recover from the events of the day, so any disturbance to normal sleeping can be incredibly debilitating and potentially lead to worse symptoms in any of the other categories.

  • Irregular sleep patterns
  • Sleeping more or less than usual
  • Increased drowsiness
  • Insomnia

Good sleep hygiene is the most important intervention in these cases, as taking medications such as sleeping pills or benzodiazepines may worsen sleep problems. Sleep difficulties may continue for weeks to months following a concussion, and if post concussion syndrome results, medication can be considered as a treatment option.

Early vs. Late symptoms

Categorizing symptoms as early or late is also important because it is essential to consider imaging if the symptoms of a concussion are worsening over time. Early symptoms are to be expected and can be treated quickly in order to prevent worse injury, but late symptoms can be indicative of more serious problems. This is why it is important to schedule follow-up visits with a medical professional in order to ensure a full recovery.

  • Early Symptoms: Dizziness, Immediate or worsening headache, nausea with or without vomiting, amnesia, and memory deficits
  • Later Symptoms: Persistent headaches, irritability, poor concentration, increasing difficulty in school or work, worsening fatigue, increased sensitivity to light (photophobia), ringing in the ears, increasing feelings of sadness or depression

Risk Factors

It is difficult to predict exactly when a concussion will occur since they can happen in a variety of circumstances. However, there are some situations and predetermined factors that can influence the likelihood of injury. Here are some things to consider that can put you at risk of sustaining a concussion.

  • Gender: There is a greater risk of head injury among males, due mostly to the types of sports they participate in. However, when the rate of concussion was assessed between both sexes in similar sports, the rate was higher in females. This may be due to less strength or mass in females’ neck muscles on average, which serve an important role in preventing head injury from sudden impacts.
  • Type of Sport: The sports that carry the highest risk of causing head trauma include contact sports like rugby, football, ice hockey, and wrestling in males. In females, the sports with the highest rates of TBI are soccer and basketball. American football and Australian rugby carry more risk than all other sports, so if you regularly engage in these high-impact activities, you may want to take some safety precautions such as wearing a helmet.
  • Equipment: Refusing to wear a helmet, or wearing inappropriate equipment for whatever sport you are engaged in, can be a risk factor for head injury. However, there is an insufficient amount evidence to say the same for mouth guards, so lacking one doesn’t seem to increase your risk of concussion. In addition, equipment failure due to poor construction, overuse, or non-timely replacement may play a role. Equipment is a valuable investment in your health and your safety, which is the most important thing. Always conduct research from credible sources on reviews and buying guides to locate the best products needed for your sporting activities.
  • Position: Depending on the sport being played, a player’s position may or may not play a role in the risk of TBI. Among football players, the risk is greater among linebackers, offensive linemen, and defensive backs, as compared to positions that engage in less physical contact during play such as receivers and kickers. Although there is insufficient data to characterize concussion risk by position, these specific positions can be more dangerous to play.
  • BMI: A body mass index greater than 27 kg/m2 may increase the risk of concussion. This is due to extra weight gathered on the head, which is inversely associated to head and neck circumference ratio.
  • Training –Training for less than 3 hours weekly likely can also increase the risk of concussion. Devoting an adequate amount of time for training is important in order to build up strength in the body through muscle growth. Failing to train enough, or training too much without resting for an appropriate amount of time, can greatly increase the possibility of head trauma.
  • History: A history of TBI is associated with a higher risk of sustaining another injury. Athletes who have sustained concussions in the past will consequently need to take greater precautions in order to avoid repeat injury.

Complications

While a concussion is usually mild and can be treated in a short amount of time, the possibility of more severe head injury is high. This is why it is incredibly important to visit a doctor for a diagnosis and seek treatment as soon as possible if you suspect that you have received a concussion. Here are some potential injuries that can come about if you do not properly treat this condition.

  • Post concussive syndrome: Post concussive syndrome is a constellation of neurobehavioral impairments that occur after a concussion. These are usually prolonged, taking place after the acute phase has ended. Physical symptoms such as headaches or dizziness occur within the first 7-10 days and can last for weeks or sometimes months after the injury. Physiological, emotional, and psychological changes following brain trauma play a role in the development of symptoms of post concussive syndrome. It is almost always guaranteed that victims of a concussion will suffer from post concussive syndrome, but what can be mitigated is the time it takes to recover from it, by gradually exercising.
  • Chronic traumatic encephalopathy: Chronic traumatic encephalopathy is a neurodegenerative disease that can result from repetitive brain trauma. CTE is a rare condition that results in brain degeneration, which can lead to difficulty thinking, control emotions, and controlling other behaviors. CTE can lead to serious disability due to dementia or other physical impairments like the inability to swallow (dysphagia) or motor impairments. It is characterized by the accumulation of tau protein in specific areas of the brain, similar to the buildup that leads to dementia.
  • Second Impact Syndrome: A premature return to play after sustaining a mild TBI is risky. Second impact syndrome occurs when a second head injury is sustained before the symptoms of the first concussion have fully resolved. The auto regulatory properties of the brain’s blood supply are disturbed and in disequilibrium, leading to a swelling of the veins. This subsequently leads to brain swelling, pressure, and brain herniation, and it can ultimately result in coma or death.

Following the first concussion, the injured brain cells are temporarily living in an altered biochemical environment as a result of the trauma. They are also operating on fewer resources and diminished energy for repair. Studies suggest that due to these biochemical changes, there is an increased window of brain vulnerability after a concussion because of this impairment of cellular energy metabolism. For these reasons, make sure to follow the instructions from your doctor to the letter in order to decrease your risk of sustaining a worse injury.

Diagnosing a Concussion

If you suspect that you are suffering from a concussion, it is important to receive an official diagnosis. Consulting a doctor or other medical professional is important because they can provide you with valuable information about the nature of your condition and how to properly treat it. This is true with any injury, but head injuries deserve an even greater level of caution and attention. Failure to properly treat a head injury can result in catastrophic and permanent damage to your most important body part: your brain. For this reason, there are many ways a doctor will assess you in order to properly ascertain the nature and severity of any TBI you may have sustained. Here are some of the tests a medical professional will conduct in order to diagnose your concussion.

The Post-Concussion Symptom Scale (PCSS) and Graded Symptom Checklist (GSC)

The PCSS and GSC are tests that consist of simple checklists of symptoms and may be administered by trained personnel or self-reported by patients. These tests are 91-100 % specific for a clinical concussion. Both the GSC and PCSS can be self-administered due to their simplicity, but a doctor may fill it out themselves while interviewing the patient. These tests involve the patient judging their symptoms on a grade of 0 to 6, with 6 being the most severe. This can be done up to three separate times, with the idea being to observe if any symptoms persist or develop over time. Included on the list are minor symptoms such as headaches and dizziness, and more debilitating symptoms such as memory and vision problems. After the questionnaire is completed, the doctor will tally up the scores of each category in order to determine if the patient is suffering from a concussion.

The Standardized Assessment of Concussion (SAC)

The Standardized Assessment of Concussion (SAC) assesses orientation, immediate memory, delayed recall, and other aspects of brain activity. It can be conducted by non-clinicians, meaning that a coach can attempt this assessment if a player sustains a head injury during a sports event. This tests can identify the presence of concussion in the early stages of injury with an accuracy of 80%–94%. It takes approximately 5-7 minutes to administer. It involves asking the subject to perform basic mental tasks, such as arranging numbers into descending order or repeating lists of objects that are spoken to them.

Standardized Concussion Assessment Tool (SCAT)

The SCAT, SCAT2 or Child-SCAT3 are other tests that combine cognitive and special assessments in athletes and child athletes. If standardized tests are not immediately available, coaches and parents can use a set of questions to assess for acute cognitive changes or confusion. It is a comprehensive test that incorporates elements of the SAC, PCSS, and GSC. In addition to grading symptoms and rearranging numbers, the SCAT contains a few questions the test conductor is supposed to ask the subject in order to assess their short term and long term memory.

A brief sideline assessment includes questions like:

  1. Which field/stadium/ track are we at?
  2. Which team are we playing?
  3. Who is winning?
  4. Who scored last?
  5. Which team/school did we compete against last week?
  6. Who won?

Neuropsychological testing

Neuropsychological tests have been used since the 1980s to test athletes for cognitive impairment following a brain injury. Today both paper tests and electronic forms of testing are available. During this series of assessments, a neuropsychologist administers tests and later interprets results that ascertain levels of mental ability in areas such as orientation, memory, attention, concentration, language, spatial perception, mathematical reasoning, problem-solving, and social and emotional judgment. There is not yet sufficient evidence to support the use of neuropsychological testing in identifying post concussive changes in all age groups, but it has been effective in diagnosing some people with TBIs.

The Balance Error Scoring System (BESS)

The BESS is a clinical balance assessment tool for postural stability that can be completed in under ten minutes. Evaluators assess three stances on two different footing surfaces to test an individual’s balance.  The narrow double leg stance, the single leg stance, and the tandem stance are assessed both on a hard surface and on foam. Each stance is held, with hands on hips and eyes closed, for 20 seconds. “Errors” during this test include specific behaviors like opening eyes, lifting hands off hips, stepping, stumbling, or falling. Discrepancies in the tested individual’s balance ability may be indicative of head trauma, including a concussion.

The Sensory Organization Test (SOT)

The SOT involves using a force plate to measure orientation information, as well as other aspects of the individual’s mental abilities. The SOT assessment tool is more specific for concussion symptoms, with an estimated sensitivity of 48%–61% and a specificity of 85%–90%. In addition to testing balance, the SOT will also assess visual senses and somatosensory (touch) abilities. Finding any issues in these senses is a way to identify the presence of TBIs such as a concussion.

Glasgow Coma Scale (GCS)

Once a concussion has been identified, the most traditional way of measuring severity is through the use of the Glasgow Coma Scale. The GCS is a clinical rating with a maximum of 15 points, determining how serious a head injury is based on the individual’s level of consciousness. It observes and assesses aspects of eye movement, speech, and motor response in order to determine if consciousness has been affected. Mild TBIs will generally fall under a GCS of 13 to 15, with more serious cases having a lower score and increased periods of time where the subject was observed as being unconscious.

Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) Tests

CT scans and MRIs may not show any changes, even immediately after a mild traumatic head brain injury. However, these imaging tests can usually pick up other effects from head trauma such as skull fractures, focal brain injury, and intracerebral bleeding in moderate to severe brain injury. Ultimately, these standard imaging procedures are insensitive to subtle vascular or white matter changes that impact the axons which can be seen in mild TBIs like a concussion. Therefore, a normal CT or standard MRI scan can be falsely reassuring, and should really only be performed if symptoms get worse or more serious injuries are suspected to have occurred, such as brain bleed or a skull fracture.

Positron Emission Tomography (PET)

This technique allows markers of inflammation and neurodegeneration to be seen in vivo. It involves injecting a tracer fluid with radioactive elements in a vein, which can then be observed during the scan. The tracer will flow through your blood stream and can be used to observe any discrepancies in your circulatory system, such as a clot or a rupture. This procedure is similar to nuclear bone scans, or fluoroscopy, which is often used to diagnose bone injuries such as stress fractures.

Single Photon Emission Computerized Tomography (SPECT)/Functional Magnetic Resonance Imaging (fMRI)

fMRIs can provide evidence of physiological changes following a mild brain injury and changes in blood flow after trauma. Single-photon emission CT can show alterations in cerebral blood flow after mild TBI, even if the initial CT appear normal. These techniques are currently not widely used in the clinical setting but can be implemented during special cases. These cases can include a sensitivity to radioactivity, which would negate the ability to perform a PET scan, or the need for further testing in order to rule out false positives due to the inaccuracy of standard MRIs and CT scans.

Treatment

It can take weeks to months to recover from a concussion, even if the injury is mild. Recovery periods vary from 2 weeks to several months. Some individuals require significantly longer times, and some can even have permanent effects. Rest is the primary conservative treatment for a concussed patient. During recovery, the level of physical and mental exertion should be kept low. This not only includes major strenuous physical activity and intensive school work but also minimizing activities that involve high mental stimulation such as using a smartphone or playing video games. It should be noted that substances like caffeine, alcohol, and nicotine can affect someone with a brain injury much more severely, so these should also be limited. Here are some additional methods for treating specific symptoms:

Headaches

It is common for headaches to persist for many months after a mild TBI. Additionally, a reactivation or worsening of migraine frequency is also common with post-concussive headaches. Therefore, the medication that is typically used for migraine headaches can be effective. Migraine headache medication that can be used for post-concussive syndrome include:

  • Amitriptyline: This is a tricyclic antidepressant that can help with irritability, dizziness, and depression.
  • Topiramate: This is an anticonvulsant that is also used for the treatment of migraine headaches.
  • Gabapentin: This can be used to treat some types of seizures, as well as postherpetic neuralgia or nerve pain associated with shingles. It is also used for migraines and other debilitating headaches.
  • Beta-Blockers: These types of medications are used sometimes when treating headaches. They work by inhibiting your body’s production of adrenaline, which slows your heart and lowers your blood pressure.
  • NSAIDs: Short for Non-Steroidal Anti-Inflammatory Drugs, the effect these medicines have on swelling and pain can be helpful as well.

Cognitive Ability

There are some treatment methods that can be used in order to recover any loss in cognitive ability, such as memory or organization skills. These commonly involve tests and games that can improve these mental faculties if they have deteriorated. However, time should be allotted for cognition to improve on its own, as this is the most effective method of treating these issue. In prolonged circumstances, catecholaminergic and cholinergic agents can be used to help with concentration and slowed cognition. Some potential medications that can help improve cognitive ability include:

  • Methylphenidate: This is a central nervous system stimulant, used most commonly for treating ADHD. It has also been used in patients with TBI and post-concussive syndrome in order to treat similar symptoms.
  • Amantadine: Amantadine is an indirect dopamine agonist and N-methyl-D-aspartate (NMDA) antagonist, and two double-blind RCTs support its use in the first 6 months after severe TBI. The effects it has on dopamine receptors can help retrain important mental aspects such as risk-reward systems and motivation.
  • Sertraline: This is a SSRI used mainly for treating depression, and it can be used in this way when recovering from a concussion. However, recent studies have revealed that this antidepressant can also improve mental capabilities, such as memory and reaction time.

Sleep Disturbances

Some medications can be useful for treating symptoms having to do with sleep. If an individual recovering from a concussion has difficulty sleeping through the night, feels drowsy during the day, or is unable to engage in deep and restful sleep, these medicines can be used to assist them in recovery.

  • Melatonin: This is a naturally occurring hormone in the body that is responsible for restful sleep. It can be supplemented in cases where individuals recovering from TBIs have difficulty sleeping or have irregular sleeping patterns. It is used to induce drowsiness and has been known to cause vivid dreams. Be careful not to take melatonin regularly, as a potential side effect of overuse is losing the ability to sleep normally.
  • Trazodone: This anti-anxiety medication also has the effect of a sleep aid. It is sometimes used to treat sleep discrepancies as a result of a TBI but can cause some unintended side effects such as dizziness or a fever.
  • Benzodiazepines: Also known as benzos, these are sometimes prescribed to patients with anxiety and trouble sleeping. It is rare that these will be prescribed to an individual with a concussion, but it has been done in very specific circumstances. These should only be considered as a last resort, as they are very addictive and can cause more damage to the brain in the long-term.

Mood Changes

Depression and anxiety, as well as increased irritability, are common in patients who have suffered a concussion or TBI. Antidepressants in the forms of SSRIs, short for Selective Serotonin Reuptake Inhibitors, are first-line choices in these cases. Some common SSRIs used in this treatment include fluoxetine and Prozac. Post-concussion syndrome is a psychiatric diagnosis that has used to describe the range of residual symptoms that can persist 12 months and beyond, sometimes even for years after the injury. It can manifest as attention deficits, fatigue, irritability, impulsivity, a lower frustration threshold, temper outbursts, inflexibility, lack of initiative, and dissociation between thought and action. Some common SSRIs used for treating concussion-related emotional issues include:

  • Fluoxetine: This antidepressant is commonly used for treating depression and obsessive-compulsive disorder. It has been used very effectively to treat mood-related symptoms from TBIs such as concussions. It is also known as Prozac.
  • Citalopram: Taking citalopram can be useful in treating depression, especially after a TBI. However, some negative side effects have been reported while taking these, including suicidal thoughts, so it is important to exercise caution when taking this SSRI. It is most commonly referred to as Celexa.

When to return to play:

Return to competitive athletic activity should be progressive, and considered only when symptoms subside. An example of a gradual return to play includes:

  • Day 1: Low-level activity, such as walking or slow jogging.
  • Day 2: Increasing the intensity by jogging, running or biking.
  • Day 3: Non-contact exercises that are more challenging, including sprinting and high-intensity interval training.
  • Day 4: Possible return to contact activity in a controlled practice situation.
  • Day 5: Back to full participation.

When to return to jogging/running after a concussion:

The athlete should be evaluated within the first week of head injury by having a normal neurologic exam, and a normal cognitive and balance evaluation, with no worsening symptoms. If acute physical symptoms following a head injury have completely subsided, slow jogging or walking can be resumed. If light activity like this is tolerated and the patient remains symptom-free, running pace and distance can then be increased.

Other Therapies

These are methods of treatment that don’t necessarily cover specific symptoms or are used for special circumstances. They can be useful for treating unconventional side effects from TBIs, or for gradually retraining athletes in order to continue playing contact sports. Some of these therapeutic methods may be performed by a physical therapist, while others can be done at home.

Vision therapy

Vision therapy is conducted in-office in a one-to-one environment with the therapist, once or twice weekly for 30 minutes to an hour and includes visual-vestibular, perception therapy, accommodative therapy, and hand eye coordination exercises. It may also incorporate phototherapy, a form of treatment which involves exposing the eyes to various light waves in order to trigger certain responses in the nervous system. Studies have shown phototherapy to be effective in treating a form of depression known as Seasonal Affectiveness Disorder (SAD), but it is still unclear if this makes it effective at treating depression from TBIs.

Relaxation Therapy

Often used to relieve stress, certain techniques also referred to as relaxation training and relaxation technique can be very effective in treating a vast array of symptoms associated with TBIs. Many claims have been made about the positive effects relaxation therapy can have on the body; it’s been said to lower blood pressure, improve digestion, relieve chronic pain, and improve blood flow to the body, alongside many other claims. However, the only positive effects that have been proven in scientific study is its ability to reduce anxiety. Some techniques commonly used in relaxation training involve meditation, massage, and Eastern physical arts such as Yoga, Qi Gong, and Tai Chi.

Running

Can running or jogging improve post concussive symptoms? According to some studies, aerobic exercise training may help concussion related physiological dysfunction. It is theorized that this is because exercise improves cerebral blood flow, increases parasympathetic activity, and reduces sympathetic activation. Studies now show that non-contact activity during a post concussive period when acute symptoms subside may actually improve recovery. Light physical activity can restore the brain’s auto-regulation mechanism and even stimulate neurogenesis, or the growth of new brain cells. In those with vestibular symptoms that lead to dizziness when running or jogging, other light activity like walking or stationary cycling should be considered.

Prevention

With new awareness about the frequency of head trauma, prevention is key. Precautions should be made in order to prevent both sports and vehicle-related injuries. The danger of head injury is often only considered during contact sports, but this is not the only time an individual is at risk. Even during physical activity that doesn’t involve contact, such as running, the possibility of TBI is present if, for instance, a runner loses their balance and takes a nasty fall. In fact, falls are the leading cause of TBIs, according to an article from the Center for Disease Control. The risk of serious damage from a concussion or any other head injury makes it a very good idea to practice effective prevention habits at all times. Here are some practices and techniques you can implement in order to prevent a concussion.

Seatbelts: Car accidents, in addition to contact sports, are a major source of head injuries. In the same article that cited falls as the #1 cause of TBIs, motor vehicle accidents were cited as the #3 cause, with approximately 14% of all cases having to do with it. For this reason, it is incredibly important to wear a seat belt at all times, even when only driving a short distance. Some other safety procedures you can do to prevent trauma from car accidents is to make sure your air bags work properly and to keep young children in the back seat of the car, rather than the passenger seat.

Carseats: Children under the age of 2 should be placed in a rear facing car seat in the middle of the back seat. This will help to reduce any movement they experience during a potential car accident, as they are at greater risk of injury. What’s worse is that infants and young children are very sensitive to head trauma, meaning that experiencing a concussion at such a young age could potentially cause permanent brain damage.

Helmets:  Roller-blading, bicycling, horseback riding, skate boarding: essentially any activity where your feet are not fully contacting the ground typically requires a helmet. The same is also true for intense contact sports such as football, which is the second most common cause of TBI in younger individuals. Even during training sessions, you should wear a helmet for full-contact football. If you do not have access to head protection, like in pickup games, consider playing touch football or flag football instead.

Clean play. Consistent modeling of the rules by coaches and rigorous education and officials reinforce the importance of playing fair. Ensuring that there are serious consequences for hitting another player too hard during a sporting event will help dissuade athletes from making rash decisions, and will force them to consider these consequences before every play.

Legislation Concussion-related legislation in many states requires education of athletes, parents or guardians, and coaches, removal from play if a concussion is suspected, and written clearance for return to practice by a health care provider. If you are concerned about the way a local institution handles head safety, especially if their decisions affect young children, you may wish to push for legislation to address these issues. For more information on how to go about doing this, you can check websites for organizations like Safe Kids Worldwide and the National Council of Youth Sports.

New innovations and discoveries in the fields of biochemistry, neuroscience, and brain plasticity are on the horizons. These advances continually shape our culture and global perceptions and grant us more control over our bodies, as well as methods to treat and prevent injuries such as concussions.  As we look to the future, more and more digital technologies will be available for the identification, diagnosis, successive prevention, treatment and recovery of people with TBIs.

Conclusion

Traumatic brain injuries require a multifaceted approach to diagnosis and management. The rates of concussion are especially high in the pediatric and adolescent population, secondary to sports injuries. Most patients recover from the clinical manifestation of concussion symptoms; however, multiple concussions may lead to chronic post concussive changes and neurodegeneration. Real biochemical changes in the brain after a TBI have been found that may alter the brain cell environment and significantly impact the recovery period. A slow return to activity is recommended when symptoms of a concussion subside at rest, and jogging may be therapeutic once it is safe to return to activity. 

The risk of head injury is serious and sustaining one poses a threat to an athlete’s future both on and off the field. Campaigns to educate physicians, athletes and coaches have been successful in promoting the necessity of rest and recovery, safe play, proper equipment, as well as screening for any head injuries as soon as the player is off the field or the track. Risk reduction is also stressed, with a great deal of literature and scientific studies available for researching methods to avoid these injuries. Although the competitive edge may take over and tempt injured players to resume athletic participation too early, it is crucial to understand the risk of head re-injuries and how an early return may mean a lifetime of setbacks.

The sources cited in this article are reputable publications with information from medical professionals. However, this article is not meant to be taken as professional medical advice. It is important that you always consult a doctor before trying anything listed in this article.

Co-written by Mike Valverde, Medical Research Journalist

Curated by Diana Rangaves, PharmD, RPh

Sources

  1. American Academy of Neurology,
  2. American College of Sports Medicine,
  3. The Brain Injury Association of America,
  4. Giza et. al. , Summary of evidence-based guideline update: Evaluation and management of concussion in sports. , Neurology: June 11, 2013 vol. 80 no. 24 2250-2257.,
  5. Centers of Disease Control and Prevention., Traumatic Brain Injury and Concussion.,
  6. Giza et al. , An Introduction to Sports Concussion,
  7. Mayo clinic., Concussion ,
  8. Harmon et al., merican Medical Society for Sports Medicine Position Statement: Concussion in , Clin J Sport Med 2013;23:1–18,
  9. Mott. et al. , Concussion , Future Medicine: March 2016 ,Vol. 1, No. 2,
  10. Sharp et al. , Concussion is confusing us all. , Pract Neurol. 2015 Jun; 15(3): 172–186,
  11. Staff Writer, Physician Research Site Up To Date.com,
  12. US National Library of Medicine, Post Concussion Syndrome.,
  13. AmericanPsychological Association ,
  14. Canisius College, Exercise may be best medicine to treat post-concussive syndrome, Article, Jan 27, 2014
  15. Puni, Vishal, Head & neck circumference ratio and body mass index as possible risk factors for concussions, Journal, Aug 17, 2017
  16. Tonya Hines, CMI, Anatomy of the Brain, Website, Apr 01, 2016
  17. Kalajainen, Amy, Comparison of the Balance Error Scoring System and the NeuroCom Sensory Organization Test in healthy, physically active adults, Journal, May 29, 2015
  18. Gian Mauro Manzoni, Francesco Pagnini, Gianluca Castelnuovo, Enrico Molinari, Relaxation training for anxiety: a ten-years systematic review with meta-analysis, Journal, Jun 02, 2008
  19. William P. Meehan, III, MD, Medical Therapies for Concussion, Journal, Jan 30, 2011
  20. Fann JR, Uomoto JM, Katon WJ., Cognitive improvement with treatment of depression following mild traumatic brain injury., Journal, Feb 01, 2001
  21. Magnusson A, Kristbjarnarson H., Treatment of seasonal affective disorder with high-intensity light. A phototherapy study with an Icelandic group of patients., Journal, Feb 21, 1991
  22. Center for Disease Control, TBI: Get the Facts, Website, Jul 25, 2017
  23. Luke M Gessel, BS, Sarah K Fields, JD, PhD, Christy L Collins, MA, Randall W Dick, MS, FACSM, R. Dawn Comstock, PhD, Concussions Among United States High School and Collegiate Athletes, Journal, Dec 01, 2007