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Concussion

Concussion

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We specialize in providing help in areas that other foundations often miss or leave unaddressed. When a family member is diagnosed with Concussion or TBI, a cascade of questions and concerns materialize that can easily overwhelm a family. Most often the patient’s primary caregiver will be a family member and the issues of on-going therapy and training on how to be an effective caregiver will be need to be addressed.

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Beyond the issues of on-going therapy and caregiver training, there are other adjustments that need to be considered. Specific concerns, that most often arise in a progression of unanswered questions, can have an overwhelming impact on a family’s sense of security and self-worth.

  1. Why is this happening?  What caused this?  How difficult is this going to be?  How will this impact my loved one and my family?  How do I deal with all of the emotions I’m feeling?  (Mental Health & Well-Being Services).
  2. If this condition persists long-term, how will I be able to provide for my loved one in the future?  (Financial Planning & Retirement Services).
  3. How can I protect my assets so that they will be available as a resource for my family and loved one when I’m unable to do so or when I die?  (Legal Assistance & Estate Planning Services).
  4. If our family needs to relocate to receive better care for our loved one or to reduce our expenses who can I turn to for help?  (Housing, Relocation & Real Estate Services).
  5. Will I be able to help with my loved one’s education expenses in the future?  (If the affected individual is a child.)  (Education Planning & Tuition Assistance).
  6. When will they find a cure?  What health steps can I take to help my loved one in the meantime?  (Medical Research & Information Services).

When an impacted individual or family is faced with making these decisions on their own and without help from qualified individuals familiar with the impact of neurological diseases, the task list can be overwhelming.  Why make things more difficult by going it alone when you can contact an experienced Find Neuro Help representative and allow them to assist you?  Our services are free of charge.  The consultation costs you nothing and should you choose a service we offer, the cost, if any, is subsidized by the donations we receive.

Also known as Mild Traumatic Brain Injury (mTBI), Traumatic Brain Injury (TBI), and Shaken Baby Syndrome.  For the purposes of this article we will use “Concussion”, “mTBI” and “TBI” interchangeably.

A collection of medical works from ancient Greece called the Hippocratic Corpus makes reference to concussion as a “commotion of the brain” and sited some of its symptoms as being loss of speech, hearing and sight.  This idea of disruption of mental function by “shaking of the brain” remained the widely accepted understanding of concussion until the 19th century.[2]  https://en.wikipedia.org/wiki/Concussion#History

According to the Centers for Disease Control and Prevention (CDC) TBI is a leading cause of death and disability in the United States, contributing to about 30% of all injury-related deaths.  Concussion, is a form of acquired brain injury.  It occurs when a sudden trauma causes damage to the brain.  Concussion can result when the head suddenly and violently hits an object, is violently shaken, or when an object pierces the skull and enters brain tissue.  The severity of TBI may range from “mild” (i.e., a brief change in mental status or consciousness) to “severe” (i.e., an extended period of unconsciousness or amnesia after an injury).  Mild traumatic brain injury (mTBI) accounts for nearly 75% of all TBIs.[1]   This disorder frequently results in a temporary loss of brain function and causes a variety of physical, cognitive, and emotional symptoms all of which may be subtle and may therefore go undetected for some time.  Health care professionals may describe a concussion as a “mild” brain injury because most concussion symptoms typically resolve in days to weeks, but all TBIs – mild, moderate, or sever – are serious injuries and have the potential for long-term consequences.

The field of traumatic brain injury has evolved since the time of the Civil War in response to the needs of patients with injuries and disabilities resulting from the war.  Before the 20th century, severe TBI was generally considered fatal.[3], [4]  During the Civil War (1861 – 1865), a gunshot wound to the head was seen in large numbers, and although accurate statistics for mortality rates are not available for the 19th century, survival was known to be poor because of infection.[3], [5]

Because of the development of improved antiseptic techniques in the later 19th century and more effective neurosurgical techniques, the mortality of a head wound with dural penetration was 35% during World War I (1917–1918).[3], [4]

The increased survival rate of individuals with TBI prompted the need for rehabilitation services.  Some of the earliest TBI rehabilitation units were established in Germany.[3]   These rehabilitation units were based on providing coordinated services and community reentry in the form of vocational workshops.[3]  Early United States rehabilitation attempts were closely modeled after the German system.

Unfortunately, by the start of World War II (1941–1945), most of these TBI rehabilitation centers, and general rehabilitation hospitals, had closed.  Early in the course of World War II, TBI casualties received only physiotherapy for motor difficulties; patients with significant cognitive or behavioral impairments were sent to mental institutions.[6]  However, with the acute neurosurgical mortality from brain wounds having dropped to 10%–13%, there was once again a need for specialized TBI centers.[7]

In 1943, a speech disorder unit was established in affiliation with a neurosurgical center at Brooke General Hospital in Fort Sam Houston in San Antonio, TX, which included an interdisciplinary treatment regimen of physical therapy, physiotherapy, vocational therapy, and occupational therapy; there were 13 more such units by 1944–1945.[3]  A psychiatrist named, John Aita, established a post-acute head injury rehabilitation program in a military general hospital that used the interdisciplinary system of care, in which patients were treated by a team of physical and occupational therapists, psychologists, vocational specialists, a social worker, a physician, and a case manager; the program also incorporated participation from relatives and therapeutic trials at home.[8]  Job therapy was established, which resulted in 60% of patients having enrolled in school or returned to work on follow-up.  Once again, at the conclusion of the war, these rehabilitation programs were shut down.[3]

By the Vietnam War, it was established that 40% of combat fatalities were because of head and neck injuries, and 14% of those surviving had TBI.[9], [10]  Moreover, survival of these soldiers was improved as a result of the establishment of air evacuation of the wounded.[11]  At the same time, an increased incidence of high-speed motor vehicle accidents propelled a more rapid development of rehabilitation for TBI in the private sector.[12]

During the Persian Gulf War (1991), brain injuries made up 17% of casualties.[13]  In 1992, there were many admissions for TBI in military medical centers.[14]  It was noted that the military population was at higher risk for TBI because of combat, with certain military occupations such as parachuting incurring an even greater risk.[9]  To address the need for TBI rehabilitation, in 1992 the Defense and Veterans Head Injury Program, later renamed the Defense and Veterans Brain Injury Center (DVBIC), was established as a collaboration between the Department of Defense (DOD), the Department of Veterans Affairs (VA), and civilian partners, with the goal to integrate specialized TBI care, research, and education across the military, veteran, and civilian medical care system.[9], [15]

The War on Terror commenced in October of 2001 with Operation Enduring Freedom in Afghanistan followed by Operation Iraqi Freedom in May of 2003.[16]  Nearly two million military personnel have been deployed to Iraq or Afghanistan, and TBI has been labeled a “signature wound” of our current conflict.[17]

The combat operations in Iraq and Afghanistan have resulted in a complex pattern of blast-related injuries from artillery, improvised explosive devices, mines, and rocket-propelled grenades.[18]  More than 60% of blast injuries result in a TBI.[19]  There have been 2700 surviving casualties of these blasts with moderate to severe TBI, and it is estimated that up to 20% of deployed service members may have mild TBI from blast injury.[18]  For this reason, although initial rehabilitation treatment efforts were aimed at moderate to severe brain injury, the focus of rehabilitation efforts has shifted to include less severe cases with no radiologic evidence of brain injury as well.[20]  Blast-related mild TBI (mTBI) has been found to be associated with several common concurrent conditions, such as vestibular, auditory, visual, and communicative disorders, which have been an additional focus of research and novel treatment approaches.[21],

A sports-related traumatic brain injury is a serious accident that may lead to significant morbidity or mortality. Traumatic brain injuries (TBIs) have reduced in frequency and severity from years past due to the development of standardized rules and organized athletics.  TBI in sports are usually a result of physical contact with another person or stationary object, these sports may include boxing, football, field/ice hockey, lacrosse, martial arts, rugby, soccer, wrestling, auto racing, cycling, equestrian, rollerblading, skateboarding, skiing, or snowboarding.  The most common TBIs in sports are cerebral contusions, second impact syndrome concussions, dementia pugilistica, and hematomas.[23]

Most cases of traumatic brain injury are concussions.  A World Health Organization (WHO) study estimated that between 70 and 90% of head injuries that receive treatment are mild.[24]  However, due to underreporting and to the widely varying definitions of concussion and mTBI, it is difficult to estimate how common the condition is.[25]

Incidence – In 2006 the CDC issued a report that provided the following estimated average annual number of TBI incidents in the U.S.

  • 52,000 deaths
  • 275,000 Hospitalizations
  • 1,365,000 Emergency Department Visits
  • ??? Receiving other medical care or no care

These estimates of the incidence of concussion may be artificially low, for example, due to underreporting.  At least 25% of mTBI sufferers fail to get assessed by a medical professional.[26]  The WHO group reviewed studies on the epidemiology of mTBI and found a hospital treatment rate of 1–3 per 1000 people, but since not all concussions are treated in hospitals, they estimated that the rate per year in the general population is over 6 per 1000 people.[24]

Up to 5% of sports injuries are concussions.[27]  The U.S. Centers for Disease Control and Prevention estimates that 300,000 sports-related concussions occur yearly in the U.S., but that number includes only athletes who lost consciousness.  Since the loss of consciousness is thought to occur in less than 10% of concussions,[28] the CDC estimate is likely lower than the real number.[29]  Sports in which concussion is particularly common to include football and boxing (a boxer aims to “knock out”, i.e. give a mild traumatic brain injury to, the opponent).  The injury is so common in the latter that several medical groups have called for a ban on the sport, including the American Academy of Neurology, the World Medical Association, and the medical associations of the UK, the U.S., Australia, and Canada.[30]

  • There were an increase in TBI-related emergency department visits (14.4%) and hospitalizations (19.5%) from 2002 – 2006.
  • There was a 62% increase in fall-related TBI seen in emergency departments among children aged 14 years and younger from 2002 – 2006.
  • There was an increase in fall-related TBI among adults aged 65 and older; a 46% increase in emergency department visits, a 34% increase in hospitalizations, and a 27% increase in TBI-related deaths from 2002 – 2006.
  • Children aged 0 to 4 years, older adolescents aged 15 to 19 years, and adults aged 65 years and older are most likely to sustain a TBI.
  • Almost half a million (473,947) emergency department visits for TBI are made annually by children aged 0 to 14 years.
  • Adults aged 75 years and older have the highest rates of TBI-related hospitalization and death.
  • Every day, 138 people in the U.S. die from injuries that include TBI.
  • Direct medical costs and indirect costs of TBI, such as lost productivity, totaled an estimated $82 billion in the United States in 2009.[32]
  • Cognitive
    • Memory loss (amnesia)
    • Inability to speak or understand
    • Mental confusion
    • Difficulty concentrating
    • Difficulty thinking and understanding
    • Inability to create new memories
    • Inability to recognize common things
  • Behavioral
    • Abnormal laughing and crying
    • Aggression
    • Impulsivity
    • Irritability
    • Lack of restraint, or persistent repetition of words or actions
  • Whole body
    • Balance disorder
    • Blackout
    • Dizziness
    • Fainting or fatigue
  • Mood
    • Anger
    • Anziety
    • Apathy
    • Loneliness
    • Depression
  • Eyes
    • Dilated pupil
    • Raccoon eyes
    • Unequal pupils
  • Gastrointestinal
    • Nausea or vomiting
  • Speech
    • Slurred speech or impaired voice
  • Visual
    • Blurred vision or sensitivity to light
  • Also common
    • Persistent headache
    • Temporary moment of clarity
    • Bleeding
    • Loss of smell
    • Post-traumatic seizure
    • Ringing in the ears
    • Sensitivity to sound
    • Stiff muscles
    • Infants may cry persistently or be irritable

There is no specific cure for concussion. Rest and restricting activities allow the brain to recover.  This means one should temporarily reduce sports, video games, TV, or too much socializing.

  • Medications
    • Acetaminophen (Tylenol) – For pain relief.
    • Mannitol (Osmitrol) – A diuretic to increase urine production to get rid of excess salt and water.
    • Ondansetron – Or other anti-nausea medication.
    • for headache pain or anti-nausea medications can be used for symptoms.
  • Surgery
    • Decompressive craniectomy: Surgical removal of part of the skull so that an injured brain can swell without being squeezed.
  • Therapies
    • Rehabilitation – Retraining the brain’s pathways to improve mental and physical functioning.
    • Cognitive-behavioral therapy – Talk therapy that focuses on changing a person’s thoughts in order to change their behavior and feelings.
    • Anger management – Practicing mindfulness, coping mechanisms, and trigger avoidance to minimize destructive emotional outbursts.
    • Counseling psychology – A branch of psychology that treats personal problems related to school, work, family, and social life.
  • Specialties typically needed to treat concussion/TBI
    • Critical care doctor
    • Emergency medicine doctor
    • Neurologist
    • Neurosurgeon
    • Occupational therapist
    • Physical medicine and rehabilitation
    • Primary care provider (PCP)
    • Sports medicine

Those who survive a TBI can face effects lasting a few days to disabilities which may last the rest of their lives. Effects of concussion can include impaired thinking or memory movement, sensation (e.g., vision or hearing), or emotional functioning (e.g., personality changes, depression).  These issues not only affect individuals but have lasting effects on families and communities.

  • Potential complications of concussion/TBI include:
    • People who have had a concussion double their risk of developing epilepsy within the first five years after the injury.
    • Cumulative effects of multiple brain injuries – Evidence exists indicating that people who have had multiple concussive brain injuries over the course of their lives may acquire lasting, and even progressive, an impairment that limits their ability to function.
    • Post-concussion syndrome – Some people begin having post-concussion symptoms — such as headaches, dizziness, and thinking difficulties — a few days after a concussion. Symptoms may continue for weeks to a few months after a concussion.
    • Post-traumatic headaches – Some people experience headaches within a week to a few months after a brain injury.
    • Post-traumatic vertigo – Some people experience a sense of spinning or dizziness for days, weeks, or months after a brain injury.
    • Second impact syndrome – Experiencing a second concussion before signs and symptoms of a first concussion have resolved may result in rapid and usually fatal brain swelling.

After a concussion, the levels of brain chemicals are altered.  It usually takes about a week for these levels to stabilize again.  However, recovery time is variable, and it’s important for athletes never to return to sports while they’re still experiencing signs and symptoms of concussion.

  • CDC has up-to-date TBI, violence, and injury prevention resources available free to the public online.

For more in-depth information please refer to these resources:

Older Adults:

Children:

Health Communication and Social Media:

  1. Centers for Disease Control and Prevention. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths, 2002-2006.Atlanta (GA): CDC; 2010.  Available from: http://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf
  2. Masferrer R, Masferrer M, Prendergast V, Harrington TR (2000).  “Grading scale for cerebral concussions”.  BNI Quarterly. Barrow Neurological Institute. 16 (1). ISBN 0894-5799.
  3. Boake C:  A history of cognitive rehabilitation of brain-injured patients, 1915–1980. J Head Trauma Rehabil 1989; 4:1–8
  4. Walker AE:  Prognosis in post-traumatic epilepsy: A ten-year follow-up of craniocerebral injuries of World War II.  JAMA 1957; 164:1636–41
  5. Kaufman HA:  Treatment of head injuries in the American Civil War.  J Neurosurg 1993; 78:838–45
  6. Eldar R, Jelic M:  The association of rehabilitation and war.  Disabil Rehabil 2003; 25:1019–23
  7. Carey ME, Young HF, Rish BL, et al:  Follow-up study of 103 American soldiers who sustained a brain wound in Vietnam.  J Neurosurg 1974; 41:542–9
  8. Aita JA:  Men with brain damage.  Am J Psychiatry 1946; 103:205–13
  9. Schwab K, Warden D, Lux W, et al:  Defense and veterans brain injury center: Peacetime and wartime missions.  J Rehabil Res Dev 2007; 44:8–11
  10. Schwab K, Grafman J, Salazar AM, et al:  Residual impairments and work status 15 years after penetrating head injury: Report from the Vietnam Head Injury Study.  Neurology 1993; 43:95–103
  11. Ruff R:  Two decades of advances in understanding of mild traumatic brain injury.  J Head Trauma Rehabil 2005; 20:5–18
  12. Lewin W:  Rehabilitation after head injury.  Br Med J 1968; 1:465–70
  13. Dillingham TR:  Physiatry, physical medicine and rehabilitation: Historical development and military roles.  Military Trauma Rehabil 2002; 13:1–16
  14. Ommaya AK, Salazar AM, Dannenberg AL, et al:  Outcome after traumatic brain injury in the U.S. Military medical system.  J Trauma 1996; 41:972–5
  15. Salazar AM, Zitnay GA, Warden DL, et al:  Defense and veterans head injury program: Background and overview.  J Head Trauma Rehabil 2000; 15:1081-91
  16. Clark ME, Bair MJ, Buckenmaier CC, et al:  Pain and combat injuries in soldiers returning from Operations Enduring Freedom and Iraqi Freedom: Implications for research and practice.  J Rehabil Res Develop 2007; 44:179–94
  17. Lew HL, Cifu DX, Sigford B, et al:  Team approach to diagnosis and management of traumatic brain injury and its comorbidities.  J Rehabil Res Develop 2007; 44:7–11
  18. Sayer NA, Cifu DX, McNamee S, et al:  Rehabilitation needs of combat-injured service members admitted to VA polytrauma rehabilitation centers: The role of PM&R in the care of wounded warriors.  Phys Med Rehabil 2009; 1:23–8
  19. Sayer NA, Chiros CE, Sigford B, et al:  Characteristics and rehabilitation outcomes among patients with blast and other injuries sustained during the global war on terror.  Arch Phys Med Rehabil 2008;89: 163–70
  20. Samson K:  Increasing Iraq injuries spur demand for rehab services and high-tech research and development.  Neurol Today 2006; 6:21–2
  21. Fausti SA, Wilmington DJ, Gallun FJ, et al:  Auditory and vestibular dysfunction associated with blast-related traumatic brain injury.  J Rehabil Res Dev 2009; 46:797–810
  22. Lew HL, Garvert DW, Pogoda TK, et al:  Auditory and visual impairments in patients with blast-related traumatic brain injury: Effect of dual sensory impairment on functional independence measure.  J Rehabil Res Dev 2009; 46:819–26
  23. Perret, Danielle Marie:  Traumatic Brain Injury in Sports.  Essential Sports Medicine; Retrieved 1 April 2013
  24. Cassidy JD, Carroll LJ, Peloso PM, Borg J, von Holst H, Holm L, et al. (2004).  Incidence, risk factors and prevention of mild traumatic brain injury: Results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury.  Journal of Rehabilitation Medicine. 36 (Supplement 43): 28–60.
  25. Petchprapai N, Winkelman C (2007).  Mild traumatic brain injury: determinants and subsequent quality of life. A review of the literature.  Journal of Neuroscience Nursing. 39 (5): 260–72.
  26. Iverson GL (2005).  Outcome from mild traumatic brain injury.  Current Opinion in Psychiatry. 18 (3): 301–17.
  27. Herring SA, Bergfeld JA, Boland A, Boyajian-O’Neil LA, Cantu RC, Hershman E, et al. (2005).  “Concussion (mild traumatic brain injury) and the team physician: A consensus statement” (PDF). Medicine and Science in Sports and Exercise. American College of Sports Medicine, American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine. 37 (11): 2012–6.
  28. Cantu RC (1998).  Second-impact syndrome.  Clinics in Sports Medicine. 17 (1): 37–44.
  29. Langlois JA, Rutland-Brown W, Wald MM (2006).  The epidemiology and impact of traumatic brain injury: A brief overview.  Journal of Head Trauma Rehabilitation. 21 (5): 375–8.
  30. Solomon GS, Johnston KM, Lovell MR (2006).  The Heads-up on Sport Concussion. Champaign, IL: Human Kinetics Pub. p. 77.  ISBN 7360-6008-1. Retrieved 2008-03-06.
  31. Faul M, Xu L, Wald MM, Coronado VG.  Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002–2006.  Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.
  32. Centers for Disease Control and Prevention.  Injury prevention & control: data & statistics (WISQARSTM) [Internet]. CDC.gov.Atlanta (GA): CDC; [updated 2013 Aug 29]. Available from: http://www.cdc.gov/injury/wisqars/index.html

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