There has been a great deal of research and changing medical management of treating people with a traumatic brain injury (TBI) or concussion. The simple reason for such a big focus on this issue is the increased incidence of kids with concussions and the media around the American professional football players. If a TBI goes undetected, it can result in long-term brain damage and may even prove fatal. While the first hit can prove problematic, the second and / or third can cause permanent long-term brain damage. We have all seen the top professional football quarterbacks that have stepped away from the game after too many TBI’s. Many of these professional athletes are getting well needed treatment for these multiple TBI’s with great results due to the recent recommendations from the experts in the management of TBI’s.
Incidence of TBI
Researchers have found a 60% increase in incidence between 2007 and 2014 (143% increase in 10-14 year olds and 87% in 15-19 year olds). Half of all concussions evaluated in the emergency room are sports-related in 8-19 year olds. American football has the greatest number of TBI’s and it also has the greatest number of participants. Forty-seven percent of all reported sports concussions occur during high school football. This is followed by Boys’ ice hockey. We don’t need to worry about these in Nevada County. Then Girls’ soccer, Boys’ lacrosse and girls’ lacrosse, boys’ soccer and finally boys’ wrestling to round out the top eight culprits of TBI.
Signs & Symptoms of a Concussion
Concussions are not always obvious. Some people may pass out, but most do not. Ninety percent of diagnosed concussions do not involve a loss of consciousness. The symptoms of concussion can range from mild to severe, and can last for days, weeks, or even months if not treated properly. If you, or anyone you know has sustained a head impact, it is important to look for signs of a concussion.
Here are a few of the common symptoms of concussion:
Physical symptoms of concussion: dizziness, problems with balance, nausea / vomiting, balance problems, sensitive to noise / light, blurred vision, and headaches.
Mental symptoms of a concussion: Confusion, difficulty remembering, difficulty concentrating, trouble paying attention and loss of focus.
Sleep symptoms of a concussion: a marked change in sleeping, either more or less than normal and / or unable to fall asleep.
Emotional symptoms of concussion: Easily angered or upset, nervousness and anxious feelings, sadness, crying more than usual, and depression.
Diagnosis and treatment of a TBI
The proper diagnosis of a TBI requires medical expertise and should incorporate as many professionals as necessary to support the return-to-play process. In our community almost all Medical Doctors are well versed in treating this patient population. A blow to the head resulting in a concussion causes a functional disturbance to the brain and not a structural injury to the brain. Therefore, the physical exam is the process of diagnosing a TBI and not by scans such as a CT or MRI.
Treatment for Concussion
Once a patient has been diagnosed with a concussion the treatment may vary depending on the severity. If the concussion is mild, they may need a few days rest, no sport and possible some mild pain reliever. A quick word about REST. This means the patient needs physical and cognitive rest until the athlete is symptom free. Mental rest from electronics, school and physical rest. However, there is no evidence that rest beyond 24-48 hours is needed. One study even showed that strict rest beyond 2 days post-injury does not improve outcomes and may contribute to increased symptom reporting. This goes against old protocols and has shown to be effective in slowly returning the athlete to become generally more active, staying below symptom threshold (cognitive and physical exertion). For the more severe concussions, a referral to a physical therapist may ensue.
Physical therapists are trained in managing patients with TBI’s. The neurological exam and treatment include an assessment of the mental (cognitive) status, reaction time, visual and verbal processing, sensory processing (e.g. vision & vestibular), motor function (e.g. coordination, gait, balance) and oculomotor (eye movement) function. The experts in concussion management recommend that acute intervention should be individually prescribed progressive physical therapy that includes manual techniques, vestibular rehabilitation, oculomotor and neuromotor retraining delivered to individuals while symptomatic, as early as 10 days after a sports-related concussion.
In summary, with the recent evidence in the management of concussions, there has been a change in the way we treat these patients. We are now intervening earlier with less time resting. This is reminiscent of how we changed our management of low back pain. One to two days of rest is ample time to rest an injured tissue and then progressive activity is indicated.