March 25, 2015

Non-Sports Concussions

This concussion blog is NOT about football (at least for the most part).

Former Badger football standout Chris Borland announced that he was calling it quits after 1 year in the NFL with the San Francisco 49's.  His main concern: concussions and their long term health risks.  Repeated concussions can lead to severe cognitive impairment, problems with emotional instability, Alzheimer's-like dementia, permanent brain damage, long-term disabilities and even death (by the head injury itself or possible link to suicide, made famous by former NFLer Junior Seau and former Ohio State football player Kosta Karageorge). This has also brought youth football into the forefront — how can we make it safer for youth?  Important to think about, however this post is NOT about football (although, I am excited to report that there are only 164 days until Badger football season starts, but who's counting?).

There is a lot out there about concussions, but many people tune out when it comes to concussions because they feel "my kid doesn't play sports, so why do I care?"  In the past few months in my clinic, I have seen plenty of concussions (also called traumatic brain injuries or TBI), and none of them were sports-related. The causes coming into my office include car accidents, falls on ice, bike accidents, and injuries from physical altercation at school.  Anything that can cause the brain to get jarred around the inside of the skull can cause a concussion, including being hit in the head or a violent shaking (which is why we can see concussions in car accidents where there was no direct blow to the head or in soldiers who are near explosions but did not get hit by anything).

Patients with concussions present to the clinic a myriad of symptoms:  feeling "foggy" dizziness, headache, memory or concentration difficulties, and difficulties with light or sound. Some symptoms of concussions may be immediate; some may be delayed in onset by hours or days after injury. Similarly, these symptoms may resolve within minutes, but sometimes continue for months.

When talking about sports-related concussions, the focus is many times on "return to play" (i.e. how long after sustaining a concussion can the athlete start practicing and competing again). No matter how the concussion is delivered (sport- or non-sport-related), there are many consequences other than "return to the play."

  • School difficulties - A concussion can affect a student's ability to participate, learn, and perform well in school. You can see concentration problems, memory difficulties, slower mental processing, increased impulsive behavior, and increased fatigue. Headaches and sensitivity to sound and light might make just sitting in the school building tough.

  • Problems with extracurricular activities — Again, due to difficulties with light and sound, certain activities, like band practice, chorus, and gym class, may make the symptoms worse.

  • Driving problems — An often forgotten side effect of concussion is delayed reaction time, which can significantly impact one's ability to drive safely (akin to being under the influence of alcohol). There is not a lot of research regarding driving after concussion, but common sense would dictate that if you are having slow reactions on top of difficulty paying attention, and sensitivity to light and sound, you are not ready to return to driving. I repeat: Do not drive while mentally impaired no matter the reason you are impaired (drug or alcohol use or after concussion). Car accidents are the #1 cause of death in teenagers and young adults.

  • Mood changes — this is a less talked about side effect of concussions. Many people experience mood changes like irritability, sadness, and frequent bouts of anger.  Some people become more impulsive, some people become more withdrawn.  Some of the mood changes may be due to the brain injury itself, some may be in part related to the post-concussion treatment (being unable to participate in extracurricular activities and sports, difficulty returning to academics, etc.).  In rare cases, concussions have led to severe mental health problems and suicide (I already mentioned Junior Seau and Kosta Karageorge, and it is seen in non-sports concussions as well).

  • Cumulative effects of multiple brain injuries. Individuals who have had a concussion in the past are at higher risk of having another one (and it may take less impact/shaking to get repeat concussions). They may also find that it takes longer to recover from a repeat concussion. No one knows how many concussions it takes to cause permanent damage.

  • Second impact syndrome. Experiencing a second concussion before signs and symptoms of a first concussion have resolved may result in rapid and potentially fatal brain swelling.

  Research varies on the best way to treat concussions, but the current mainstay of treatment is brain rest (especially while having symptoms).  Brain rest is exactly what it sounds like: complete rest from all physical and mental activity and limiting sensory input to your brain.  Brain rest means NO watching TV, playing video games, texting, doing homework.  If you are really, super bored while on brain rest, then you're doing it right.  The duration of brain rest can be different for different people. We usually do a gradual return to activities of daily living, advancing to more activities as the symptoms improve.  Many times, we start a reduced school schedule and work with teachers and administrators for any necessary accommodations for homework and tests.  As symptoms improve, we advance to full days of school.  Only after the patient is tolerating full days of school do we add back extracurricular activities like chorus or band, or sports.

If you're concerned that your teen has the symptoms of a concussion, talk to their health care provider. Red flags in which you should seek immediate attention include seizures, persistent vomiting, worsening headaches, and any focal neurological signs (i.e., symptoms focused on one side of body, difficulty speaking, double vision, etc.). For more information on concussions, check out the Center for Disease Control and Prevention's Heads Up.