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| Focus on: Concussion
Each year there are over 4.5 million traumatic brain injuries(TBIs) 4. Over 80% of TBIs are mild in severity4. Despite being rated as mildly impaired, individuals who sustain a mild TBI or concussion can endure significant physical, social, and psychological problems that can detrimentally influence their daily functioning. Physicians can play a key role in appropriately identifying, diagnosing, and treating concussions. In fact, the majority of mild TBI patients do not seek medical treatment in emergency rooms; instead they often present for treatment with their primary care physicians4. The aim of this issue is to address the clinical issues physicians face when working with mild TBI patients.
What is a Concussion?
The terms ‘mild TBI’ and ‘concussion are’ used interchangeably to describe a blow to the head that disrupts brain functioning. The neuropathological changes associated with mild TBI often results in a constellation of physical, emotional and cognitive symptoms.
Signs and Symptoms of a Concussion4
Headache
Dizziness
Fatigue
Sleep disturbances
Vision problems
Reduced taste/smell
Sensitivity to light, noise, medications
Seizures
Vomiting
Gait disturbances
Slowed thinking
Memory problems
Difficulty multitasking
Forgetting or confused about recent events
Asking questions repeatedly
Feeling mentally foggy
Trouble speaking Increased irritability
Feeling sad
Increased anxiety
Feeling overwhelmed
Disease Course and Prognosis
A majority of individuals with mild TBIs recover in the weeks and months following their injury. Typically, mild TBI related impairments in athletes recover more quickly (2 to 28 days) while trauma patients recover more slowly (3 months)9-10. One multi-site study found many mild TBI patients continued to experience significant memory impairments one week post injury 12. However, most individuals with a mild TBI make a full recovery within 1 to 3 months after their initial injury8.
10 to 20% of individuals with mild TBIs continue to experience persistent cognitive and emotional symptoms post injury1. Gender, age, repeated TBIs, premorbid psychopathology, structural intracranial injuries, increased stressors, and substance use have all been associated with poorer outcomes in individuals who have sustained a mild TBI 5-7, & 10- 11. Sports Concussion
Premature return to play has been linked with second impact syndrome which can prove to be fatal. Athletes who have sustained a concussion should be taken out of the game and not be allowed to return to play until their symptoms have resolved4. Also, return to play should be gradual and evaluated at each stage as they increase their exertion.
There are many ways to reduce the chance of sustaining a concussion. Wearing protective equipment such as a helmet when doing sports such as skateboarding, riding a bicycle, playing football, riding horses, and skiing is very important. Protective equipment should fit properly and playing the game safely is vital.
Myths about Concussions
• No loss of consciousness= No concussion. The diagnostic guidelines for concussion do not require a loss of consciousness 2-3.
• The CT was negative, they must be exaggerating. Only 15% of patients with confirmed concussions have positive CTs.
• It’s all emotional. Concussion symptom presentations are commonly a constellation of physical, cognitive and emotional sequelae 1.
• It has been a week, they should be recovered by now. Recovery from a concussion varies. Typical recovery ranges from 1 to 3 months 9-10.
Brain Injury Resources
TBI support group:
Free to TBI patients and their caregivers. The first Thursday of every month in the San Francisco General Hospital Library building 30. Contact Christine Martin 415-206-4476 for more information.
Caregiver assistance:
www.caregiver.org: Offers education, support, financial and legal assistance, respite care, and consultation services.
General TBI Resources:
www.janetpomeroy.org: Provides activities, fitness, community reintegration, and programs for TBI survivors.
Tel. 415-665-4100 x1728.
www.cdc.gov/injury: Excellent website for physicians dedicated to assessment and management of mild TBI. Provides physicians with free evaluation forms, patient educational materials, and toolkits.
www.sfdistrictattorney.org/faqs: Provides information for victims of crime in San Francisco. Victim’s compensation office helps individuals who have been the victim of crime with access to legal services, crisis intervention, referrals for mental health treatment, victims fund financial renumeration, and other services.
www.tbimatters.org: Community Education Series designed for community, professionals, patients, caregivers, family members.
References
[1] Alexander, M. (1995). Mild traumatic brain injury: Pathophysiology, natural history, and clinical management. Neurology, 45, 1253-1260.
[2] American Academy of Neurology. (1997). Practice parameter: the management of concussion in sports. Retrieved February 4, 2008 at: http://www.aan.com/professionals/practice/guidelines/pda/Concussion_sports.pdf.
[3] Carroll, L., Cassidy, J., Holm, L., Kraus, J., & Coronado, V.G. (2004). Methodological issues and research recommendations for mild traumatic brain injury: the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. Journal of Rehabilitation Medicine, 43, 113-25.
[4] Center for Disease Control and Prevention. (2006). Traumatic brain injury in the United States: Emergency department visits, hospitalizations and deaths. Retrieved July, 31, 2007, from http://www.cdc.gov/ncipc/tbi/TBI_in_US_04/TBI_ED.htm. and www.cdc.gov/injury
[5] Edna, T., & Cappelen, J. (1987). Late post-concussional symptoms in traumatic head injury. An analysis of frequency and risk factors. Acta Neurochirurgica. 86, 12-17.
[6] Hibbard, M., Bogdany, J., Uysal, S., Kepler, K., Silver, J., Gordon, W., et al. (2000). Axis II psychopathology in individuals with traumatic brain injury. Brain Injury, 14, 45-61.
[7] Iverson, G. (2006). Complicated vs uncomplicated mild traumatic brain injury: Acute neuropsychological outcome. Brain Injury, 20, 1335-1344.
[8] Levin, H., Amparo, E., Eisenberg, H., Williams, D., High, W., McArdle, C., et al. (1987). Magnetic resonance imaging and computerized tomography in relation to the neurobehavioral sequelae of mild and moderate head injuries. Journal of Neurosurgery. 66, 706-713.
[9] McCrea, M. (2008). Mild traumatic brain injury and postconcussional syndrome: The new evidence base for diagnosis and treatment. Oxford, UK: Oxford University Press.
[10] Ponsford, J., Willmont, C., Rothwell, A., Cameron, P., Kelly, A., Nelms, R., et al. (2000). Factors influencing outcome following mild traumatic brain injury in adults. Journal of the International Neuropsychological Society, 6, 568-579.
[11] Rapoport, M., & Feinstein, A. (2000, August). Outcome following traumatic brain injury in the elderly: A critical review. Brain Injury, 14, 749-761.
[12] Ruff, R., Levin, H., Mattis, S., High, W., Marshall, L., Eisenberg, H., et al. (1989). Recovery of memory after mild head injury: A three-center study. Mild head injury (pp. 176-188). New York, NY, US: Oxford University Press.
This newsletter is informational in nature only and should not take the place of medical advice.
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