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What is a Concussion, How To Test For One, and How To Treat It

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In 2015, actor Will Smith starred in the movie “Concussion,” which brought a broad awareness to the severe long-term effects of sports-related head injuries. In this movie, director Peter Landesman highlighted a type of brain degeneration called chronic traumatic encephalopathy (“CTE”), which appears to affect ex-NFL football players long after their playing days.

Now, more than ever, many medical practitioners and head injury survivors ask questions about the long-term damage of head trauma and what kinds of treatments exist. This article covers the topic of concussions thoroughly, considering the causes, consequences, available tests, and treatment options.

What is a Concussion?

A concussion is a disturbance of the brain’s neurological function induced by trauma. It is a neurologic injury and has different types and varies in severity depending on the impact. The symptoms can be very mild and transient, but some patients develop dramatic changes in their consciousness for an extended period. In most cases, the event will be mild and termed as a mild traumatic brain injury. Those in the sporting arena refer to them as “dingers,” but they are concussions, nonetheless.

Most patients will recover some neurologic function after a while, but these damages compound if there are multiple concussions over a lifetime. Symptoms will differ depending on the severity of the concussion. However, most of them require medical intervention to speed up recovery and to differentiate mild from severe traumatic brain injury with long-term consequences (1).

There are different types of concussions. For example (2):

  • Direct Head Impact: A direct hit in the head can potentially cause a concussion. In this type of concussion, the object is mobile and impacts the head, slamming the brain against the inside of the skull. Resistant covers typically protect the brain called meninges and are suspended in the cerebrospinal fluid to cushion any impact. However, an aggressive hit can overwhelm these protective mechanisms.

  • Coup-Contrecoup damage: This is also a very aggressive impact to the head, but the difference is that the head strikes the object, and the brain bounces back and forth in the skull. In doing so, two types of concussion injuries develop from a coup injury at the site of initial impact and a contrecoup injury on the opposite side of the brain resulting from the recoil. 

  • Mild head injuries: Milder head injuries can also cause a concussion lesion, especially in infants and young children with partially developed structures in the skull.

Symptoms – How to Recognize A Concussion or Traumatic Brain Injury

As noted above, a concussion is a disturbance of neurologic function. The severity varies depending on the intensity of head trauma. 

Concussions can be experienced differently depending on the type, the mechanics of traumatic brain injury, and individual traits. However, it will be beneficial to have an idea of what to expect:

Physical symptoms

  • Headaches of varying intensity

  • Visual alterations

  • Balance problems

  • Dizziness

Mental symptoms

  • Brain “fog”

  • Disorientation and confusion

  • Temporary amnesia

  • Difficulty in concentration

Sleep-related symptoms

  • Changes in the sleep pattern (sleeping more or less than usual)

  • Daytime drowsiness

  • Difficulty to fall asleep at night

Emotional symptoms

  • Mood swings

  • Irritability

Most Common Causes of A Concussion

Concussions in the United States are prevalent. There is an overall incidence higher than 500 people out of a population of 100,000 people. According to the Centers for Disease Control and Prevention, there is an estimate of near 4 million traumatic brain injuries every year. Infants and children younger than 14 years are very susceptible, and sport-related concussions are the most common type.

All of us can experience a concussion, and the cause depends on different tendencies and risk factors. The most common causes include (3):

  • Sport-related causes: Studies show that 54% of concussions in young patients are related to sports participation. They are usually full-contact sports such as football, ice hockey, rugby, lacrosse, basketball, and soccer. These sports have a very high risk of collision, and despite following security measures, concussions are always a possibility. This type of concussion is more common in males in a ratio of 3.5 to 1, but females playing the same sport are twice as likely to suffer a concussion. This is possibly because of neck strength differences or simply a higher rate of symptom reporting.

  • Car wrecks: In a car wreck, multiple forces work against the skull and the rest of the body. Patients often suffer a whiplash syndrome and develop coup-contrecoup damage simultaneously. This cause of concussion is common in chronic alcohol and drug users and patients with an underlying psychiatric ailment.

  • Falls and balance problems: The highest rate of concussions is found in the extremes of life. Young patients are very active, playing sports, and generally taking part in higher-risk activities, but older adults also have a very high concussion rate. The leading cause of concussions in patients older than 65 are falls and impacts due to issues with instability and balance.

  • Pediatric concussions: According to published data, being a child is by itself a significant risk factor. Similar to the elderly population, infants and children are prone to lose coordination or balance, leading to direct head trauma and falls.

Problem: Traditional Medicine’s Response

The premise of the movie cited above highlighted two reasons why concussions are often underreported and under-treated in conventional medicine: In sports, there is a conflict of interest in acknowledging the real long-term impact of concussions and mild head trauma. Additionally, our current medical approach is limited and often cannot detect small changes in brain structure that build up over time, triggering the symptoms listed above.

When a patient does not display concussion symptoms immediately, there is no plan contemplated in our healthcare system to follow-up concussions and detect their true extent. The patient is instructed to sleep it off and take Tylenol, an excellent recommendation to tackle immediate symptoms, but not enough to avoid long-term consequences. 

One of the most common complications is post-concussion syndrome which lasts weeks, months, or even years and features persistent alterations in the cognitive and emotional field. Post-concussion syndrome does not always correlate with the severity of the initial head injury, and the transition to this ailment is poorly understood. Thus, we cannot always follow the rationale that only a very severe injury will trigger a post-concussive disorder (1).

If that is the case, then what can we do about it? Later in this article, we will discuss a few treatment options we can try to relieve immediate symptoms and reduce the long-term impact of a concussion at the same time.

Current Tests for Concussion

When there is severe head trauma, a doctor needs to rule out a concussion. Depending on trauma mechanics and the severity of the lesion, one of the following tests may be required (1):

  • CT scan: This is typically the radiographic study of choice to assess concussions and determine if there is an emergency. These are good for seeing skull fractures and brain bleeds but lack in microscopic analysis of the brain tissue. Some CT scans come back normal after a concussion, but these types of imaging tests are not superior to a clinical assessment. Thus, typical CT scans do not rule out a concussion.

  • MRI: An MRI will be recommended for further investigation in some cases if more detail is required. It is usually requested for patients with persistent symptoms or a post-concussive disorder. These also show brain bleeds, skull fractures and brain abnormalities at a more detailed level.

  • Neurovestibular exam: After a concussion, patients typically experience some form of dizziness and trouble with overall balance. These symptoms will be very severe in patients with neurovestibular damage due to head trauma. In other words, when the inner ear is affected, the balance organ is compromised and requires a complete assessment of the inner ear and ocular/oculomotor function (4). These types of exams require the help of a neurovestibular specialist but it can make the difference between staying in bed all day or getting back to normal life. 

  • IMPACT test: ImPACT stands for Immediate Post-Concussion Assessment and Cognitive Testing. It is a computer-based tool that evaluates several brain functions simultaneously. There is a visual-motor speed component, a visual memory and reaction time score, and a verbal memory composite. They are all brought together in a helpful scale to evaluate patients immediately after a concussion. This tool is handy in athletes who attempt to hide their symptoms to get back to the game (5).

  • WAVi: The WAVi Research Platform is a brainwave test with EEG, and it is beneficial to assess the extent of damage and recovery of post-concussion patients. It is also a computer-based tool that measures electrical output, connectivity, disruptions to processing and provides an accurate, objective depiction of reaction time and other cognitive performance measures (6). It provides a heat map of the brain as to where the highest voltage is occurring and where there are electrical deficiencies. Lastly, it provides measurable, numerical data from each test that can be used for statistical analysis, which is imperative for an objective view of a patient’s recovery.

Keep in mind that concussions are usually a clinical diagnosis, and exam findings from the tests above complement the physician’s diagnosis. Thus, a patient can be diagnosed with a concussion and not require any test listed above, although it can provide supporting evidence of a sustained injury. 

What are the Current Traditional Treatment Methods for a Concussion?

In evaluating a concussion, there are many variants, and each patient is different. After diagnosing a concussion, the typical recommended management includes (1):

  • Patient observation: Observation can be completed in the emergency room for a few hours in cases of severe head trauma or as an outpatient by a relative previously instructed on the most critical warning signs.

  • Supportive treatment: This includes rest during the post-injury period, extending to 24-48 hours. The physician prescribes analgesics such as Tylenol, and a gradual return to activity is recommended.

  • Exercise therapy: Return to activity when the patient completes his post-injury rest period is essential to promote the blood flow to the brain and other tissues. This therapy includes light aerobic activity to be monitored by those in charge of managing the patient’s recovery.

  • Vestibular and visual rehab: It is led by a vestibular/physical therapist aiming at treating balance problems, vertigo, gaze stability, and eye coordination issues that may result from a concussion (7).

  • Manual therapy and neck rehab: There will be significant neck problems after a concussion in some patients. In cervical dysfunction and headaches caused by cervical problems, manual therapy is strongly recommended, and neck rehab aims to re-training neck proprioceptive signals (7).

Other Concussion Treatments to Consider

Medical treatments above do not follow a static protocol. They depend on each patient and the characteristics of the lesion. As noted above, supportive therapy is usually the main focus. In other words, the doctor aims at relieving the symptoms and returning the patient to their everyday life.

However, even if post-concussed and healthy people are not in immediate threat, biochemical changes can still happen in the hippocampus, prefrontal cortex, hypothalamus, and other sensitive structures. Long-term treatment of concussions should cover this critical issue immediately, but it usually does not (8).

What can be done to recover faster from a concussion and prevent these biochemical changes?

  • Diet and nutritional changes: Concussion causes several inflammatory stimuli in the hypothalamus, brainstem, and other brain structures. Nutrition can counter this trend by avoiding inflammatory foods and eating anti-inflammatory nutrients. It will be a good idea, post-concussion to avoid red meats, white bread, refined sugar, and artificial sweeteners. Instead, try to follow a Mediterranean diet with fresh fruits, vegetables, and rich sources of omega 3 and other healthy fats (8).

  • Supplements & Nootropics: It is also possible to counter the chemical changes with several supplements. Most of them are neuro-steroids with a very potent anti-inflammatory potential. For example:

    • DHEA: It is short for dehydroepiandrosterone. It is a hormone naturally produced by the adrenal glands and has an anti-inflammatory effect on the brain. Normal levels can also prevent cognitive decay and mood problems (9). This hormone can provide amazing benefits to reducing inflammation from a head injury.

    • Pregnenolone: This neurosteroid has a potent protective effect and helps dampen the sequela of brain injury in different regions. It also has memory-enhancing properties and other exciting applications (10).

    • Phosphatidylserine: This is a phospholipid that couples with the cell membranes to perform different functions. Studies have shown that it is linked with improved cognitive function after undergoing stressful situations (11).

    • Curcumin: Also known as turmeric, it contains anti-inflammatory properties as well. After a concussion, turmeric improves membrane function and restores neuroplasticity. In other words, it facilitates recovery and prevents memory loss, learning problems, and more (12).

    • Omega 3 (Fish Oil): These healthy fats are essential after a concussion. They prevent learning problems by boosting neuroplasticity and maintain homeostasis and gene stability in the brain (12).

There are also other supplement options that provide relief from a head injury that I use in my practice as a neuroscientist.

My Concussion Protocol

Considering the above recommendations for testing and nutritional supplementation, I have developed a protocol consisting of a mixture of the items listed above and others required for concussion recovery.

Due to the thousands of head injuries I have seen over the years, I am able to assess the severity of someone’s head injury and related post concussion syndrome fairly quickly. After a series of questions and assessment of physical symptoms, I utilize the WAVi EEG technology to obtain an accurate reading of the patient’s baseline electrical activity and neural connectivity. Over the past few years, the WAVi team has performed studies on collegiate athletes before and after concussions and the mapping capabilities of the brain’s electrical performance and connectivity is second to none. Depending on the severity of the symptoms, other tests might be required but establishing a snapshot of the patient’s brain health and performance can be done with just the WAVi tool.

After establishing the baseline result, I will institute a number of interventions that include nutritional supplementation and a mixture of physical/vestibular therapies. This is done on a patient-by-patient basis and closely monitored over the course of 30, 60 and 90 days. Sometimes I will monitor patients for years after a serious head injury. My team will perform follow-up WAVi tests to track the recovery of specific, objective markers that measure voltage, connectivity and speed. I have posted on my website the WAVi results and recovery of some of my patients who not only had head injuries, but exhibited brain disease type symptoms as well.

Conclusion

Head injuries are complicated and unpredictable. Concussions are often unnoticed, and they do not always behave as expected. We can use the traditional medical approach to prevent complications, but other methods listed are necessary to track and treat traumatic brain injuries.

It is also essential to recognize the chemical changes in the brain tissue during a concussion. One of the first chemical events we need to manage is the release of neurotoxins from the damaged cells.  Then we need to arrest inflammation. We want to stop the inflammatory cascade with appropriate nutrition and anti-inflammatory aids while giving the brain a chance to heal.

Lastly, it is imperative to get immediate attention from a qualified, trained physician after sustaining a severe head injury to have the best chance of reducing the long-term effect it might have on the patient’s quality of life.

References:

  1. https://www.ncbi.nlm.nih.gov/books/NBK537017/

  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4023660/

  3. https://www.sciencedirect.com/science/article/pii/S1071909119300117

  4. https://link.springer.com/article/10.1007/s40279-020-01409-2

  5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5802754/

  6. https://content.iospress.com/articles/journal-of-pediatric-rehabilitation-medicine/prm190620

  7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5119544/

  8. https://www.xiahepublishing.com/m/ArticleFullText.aspx?sid=2&jid=2&id=10.14218%2FERHM.2017.00029

  9. https://www.sciencedirect.com/science/article/abs/pii/S0960076014000983

  10. https://europepmc.org/article/nbk/nbk326734

  11. https://www.tandfonline.com/doi/abs/10.1179/147683008X301478

  12. https://journals.lww.com/acsm-csmr/fulltext/2016/01000/the_role_of_nutritional_supplements_in_sports.9.aspx