Concussion

A concussion is a mild traumatic brain injury (mTBI)

A concussion occurs after a strong blow to the head or significant shaking and the brain has been injured.

Advice for Patients Regarding Concussions:

Immediate Action Post-Injury:
– Rest: Take it easy for the first 24-48 hours after the injury. Avoid physical and cognitive activities that worsen symptoms.
– Observation: Ensure you have someone with you to monitor for any worsening symptoms or signs of a severe head injury.

Activity Modification:
– Gradual Return to Activity: After the initial rest period, start with light activities and gradually increase activity levels. Avoid activities that risk another head injury until fully recovered.
– Stepwise Progression: Increase activity levels step by step, waiting at least 24 hours between each increase. If symptoms recur, reduce activity until they improve.

Monitoring Symptoms:
– Track Symptoms: Keep a log of your symptoms, noting their severity and any new symptoms that arise.
– Delayed Symptoms: Be aware that symptoms can develop hours to days after the injury. Report any new or worsening symptoms immediately.

When to Seek Immediate Medical Attention:
– Severe Headache
– Seizures
– Loss of Consciousness
– Focal Neurologic Deficits (e.g., weakness, numbness)
– Worsening Symptoms or Deterioration of Mental Status

Return to Normal Activities:
– School/Work: Return to work or school gradually. Consider a part-time schedule initially, with frequent breaks as needed.
– Sports: Do not return to sports or recreational activities until cleared by a healthcare provider. Follow a return-to-play protocol under medical supervision.

Medications:
– Headache Management: Use over-the-counter pain relief like acetaminophen or ibuprofen if needed. Avoid aspirin due to bleeding risk.
– Avoid Certain Medications: Do not use medications that affect cognitive function, sleep, or mood unless prescribed by a healthcare provider.

Lifestyle and Preventive Measures:
– Stay Hydrated and Well-Nourished: Proper hydration and nutrition can support recovery.
– Sleep Hygiene: Maintain a regular sleep schedule and create a restful sleeping environment.
– Safety Measures: Use helmets for activities like biking or sports, wear seat belts in vehicles, and take steps to prevent falls, especially for older adults.

Follow-Up Care:
– Scheduled Appointments: Attend follow-up appointments to monitor recovery progress and address any persistent or new symptoms.
– Specialist Referral: Consider seeing a specialist (e.g., neurologist, neuropsychologist) if symptoms are prolonged or if there are complicating factors such as pre-existing conditions.

Education on Long-Term Risks:
– Awareness of Risks: Understand that repeated concussions can have long-term effects, including chronic traumatic encephalopathy (CTE). Avoid activities that risk further head injuries until fully recovered.
– Support Systems: Utilize available resources for support, including counseling for mood disturbances or cognitive-behavioral therapy if needed.

Patient and Family Education:
– Understand the Condition: Educate yourself and your family about concussion symptoms, management, and prevention.
– Watch for Complications: Be vigilant for signs of complications like post-concussion syndrome or second-impact syndrome, and seek medical advice if concerned.

Pathophysiology of Concussion:

• Functional Disturbance: Primary cause of acute symptoms; no structural injury.
• Neurochemical and Neurometabolic Events: Result in altered neurological function post-injury.
• Mechanisms:
  • Acceleration, deceleration, or rotation of the head causing acute axonal injury.
  • Disruption of neurofilament organization.
  • Ion channel depolarization leading to the release of neurotransmitters.
  • Changes in glucose metabolism decreasing cerebral blood flow.
  • Mitochondrial dysfunction.

History and Physical Examination:

• Information Gathering:
  • Mechanism of injury.
  • Symptoms, onset timing, severity, and persistence.
• Symptom Domains:
  • Affective/Emotional: Irritability, mood changes.
  • Cognitive: Confusion, disorientation, amnesia, mental fogginess, difficulty concentrating.
  • Physical/Somatic: Headache, dizziness, balance difficulties, visual changes.
  • Sleep: Drowsiness, sleeping more or less than usual, difficulty falling asleep.
• Assessment Tools: Sports Concussion Assessment Tool 6 (SCAT6) for symptom inventory.
• Loss of Consciousness: Rare (less than 10%), important for assessing severe head injury.
• Symptom Development: Can occur immediately or within hours to days post-injury.
• History of Prior Concussions: Predicts longer recovery time.
• Pre-existing Conditions: Mood disorders, learning disorders, sleep disturbances, migraines impact management.

Physical Examination Specific to Concussions:

• Head and Neck Examination: Check for structural injuries.
• Neurologic Exam: Assess strength, sensation, reflexes, ocular movements (saccades, nystagmus), balance, and vestibular system.
• Cognitive Function: Orientation and higher-level cognitive processing.
• Emotional State: Compare with baseline emotional state.
• Neuropsychological Assessment: Conducted by a trained neuropsychologist.

Evaluation:

• Clinical Diagnosis: Based on history and exam findings; no single pathognomonic finding.
• Diagnostic Tools: SCAT6, Child SCAT-6 for ages 5-12.
• Monitoring: Watch for symptom development or neurologic deterioration.
• Imaging:
  • CT Scan: For ruling out neurosurgical emergencies.
  • Clinical Decision Tools: PECARN head injury guidelines, Canadian Head CT Rule.
  • MRI: Consider for persistent symptoms post-concussion.
  • Other Imaging (Functional MRI, PET): Primarily for research.
  • Serum Biomarkers: Under development, potential future role.

Treatment / Management:

• What to expect
  • Many people cannot remember events before or after their head injury.
  • It can take some time for the brain to recover. 
  • During this time headaches and mild cognitive problems (such as difficulty concentrating, remembering things, performing complex tasks, and mood changes) are common. It is also normal to feel more tired than usual.
  • Average recovery time in adults is 10 days.

• Observation: Outpatient by a responsible individual educated on warning signs.
• Removal from Risk Environment: Immediate removal from activities that risk repeat head injury.
• Supportive Care:
  • Initial physical and cognitive rest (24-48 hours).
  • Gradual return to activity with monitoring for symptom recurrence.
• Stepwise Return to Activity:
  • At least 24 hours per activity increase, with reduction if symptoms recur.
  • Stages for Return to Activities:
    • Initial Rest (24-48 hours): Physical and cognitive rest.
    • Light Aerobic Exercise: Walking, stationary biking, avoiding resistance training.
    • Sport-Specific Exercise: Drills that don’t involve head impact.
    • Non-Contact Training Drills: More complex training drills, may start resistance training.
    • Full Contact Practice: Following medical clearance, resume normal training activities.
    • Return to Play/Work/School: Normal gameplay/work/school activities.
• Early Interventions: Vision training for oculomotor dysfunction, cognitive-behavioral therapy for mood disturbances.
• Medications:
  • Over-the-counter analgesics for headache.
  • Avoid medications altering cognitive function, sleep, or mood.
  • Preventive headache medications resumed if pre-injury.

Complications:

• Post-Concussion Syndrome (PCS): Persistent symptoms lasting weeks to months; somatic, emotional, and cognitive symptoms.
• Second-Impact Syndrome (SIS): Repeat injury before initial concussion resolution causing rapid brain swelling; severe complications possible.
• Chronic Traumatic Encephalopathy (CTE): Progressive neurodegeneration due to repeated head trauma; memory disturbances, behavioral changes, gait abnormalities.

Science behind Graduated Return to Activities

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4387881

Physical and Cognitive Rest

1. Consensus-Based Standard of Care
   • Developed by the International Concussion in Sport Group.
   • States: “The cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve and then a graded program of exertion prior to medical clearance and return to play.”
2. Rationale for Rest
   • During the acute post-injury period (1-7 days, possibly longer in youth), there is increased metabolic demand and limited adenosine triphosphate (ATP) reserves.
   • Non-essential activity draws oxygen and glycogen away from injured neurons.
3. Interpretation of Rest
   • Many clinicians interpret recommendations to mean all physical and cognitive activity should be restricted until symptoms resolve.
   • The “shut down” or “dark closet” approach has potential pitfalls, including hyperawareness of symptoms, somatization, and social isolation.

Evidence for Physical Rest

1. Risk Management and Animal Studies
   • Animal studies show impaired recovery with early onset of physical activity.
   • Restricting physical activity reduces the risk of a second injury (Second Impact Syndrome).
2. Metabolic Dysfunction
   • Altered cerebral metabolism lasting up to 30 days post-concussion.
   • Increased risk for secondary injury and prolonged recovery times.
   • Animal models demonstrate metabolic dysfunction and poorer cognitive performance with unrestricted activity immediately post-injury.
3. Clinical Observations
   • Athletes returning to play before symptom resolution report worsening symptoms.
   • Early exercise may draw energy (glycogen) away from the brain, inhibiting the recovery process.

Evidence for Physical Activity

1. Psychological Implications
   • Withholding injured athletes from exercise can increase reports of depression, anxiety, and lower self-esteem.
   • Injured high school athletes missing athletic participation show higher rates of depression.
2. Moderate Exercise Benefits
   • Some evidence suggests moderate levels of exercise may benefit recovery beyond the acute injury stage.
   • A progressively intensive exercise protocol can help athletes with prolonged symptoms return to sport.
3. Human Studies
   • One study found athletes engaging in medium levels of physical and cognitive activity performed better on neurocognitive tests than those with no or high levels of activity.
   • Exercise protocols have shown significant decreases in symptom reports and return to sport in symptomatic athletes.

Cognitive Rest and Academic Accommodations

1. Cognitive Impairment Post-Concussion
   • Cognitive impairment following concussion is common among student-athletes.
   • Cognitive rest theory posits that reducing brain-stimulating activities will enhance recovery.
2. Limited Data on Cognitive Rest
   • Few studies have evaluated cognitive rest.
   • Studies suggest increased cognitive activity delays symptom recovery.
3. Academic Accommodations
   • Temporary accommodations such as excused absences, lighter homework, and extended exam dates can help manage symptoms.
   • Formal accommodations (e.g., 504 Plan, IEP) may be needed for prolonged recovery cases.
4. Balancing Rest and Activity
   • Prolonged cognitive rest can exacerbate symptoms or cause negative mental health issues.
   • Medical teams should balance neurocognitive and behavioral accommodations to restrict activities that trigger symptoms while allowing involvement in school activities.

Returning to School

Returning to work

Returning to sport

Return immediately If the patient develops any of the following:

• unconsciousness or undue drowsiness
• frequent vomiting
• severe headache or dizziness that continues
• convulsion or fit or spasms of the face or limbs
• unusual or confused behaviour
• difficult to wake up
• weakness of the arms or legs
• abnormal or unsteady walking
• slurred speech
• blurred or double vision
• bleeding or discharge from ear or nose
• if you have any other concerns