Concussion is a term that most of us know, but many do not fully understand. It happens when somebody experiences a severe head injury, and is very common in sports such as rugby and boxing. The Rugby World Cup last year has helped to raise awareness of concussion in Europe; it was something all players wanted to avoid, and is so dangerous that England rugby officials severely tightened the rules surrounding concussion protocol. They decreed that players must be examined for at least 10 minutes by a doctor before a decision on a whether he is concussed can be made. Memory and balance tests previously used have been adjusted to improve accuracy. Additionally, any players with a suspected concussion must be removed from play immediately.

In American Football, however, the rules are much less stringent. The NFL employs ‘concussion spotters’ who have the power to immediately stop a game if they spot a player exhibiting the symptoms of a concussion, but the player must only miss one play whilst they undergo an examination. One play could easily be less than a minute long. In fact, the Wall Street Journal discovered that an average length of play in the NFL is just four seconds long; this is simply not enough time to assess for a concussion.

Rugby players with concussion usually recover well due to the expert medical teams they work with on a daily basis. For the general public, however, this support is not always available. The CDC reports that concussions have doubled over the last 10 years, and have nearly quadrupled in 14 to 19 year old teenagers.

So What Is A Concussion?

A concussion is the mildest and most common form of traumatic brain injury. It occurs when a blow to the head disrupts a function in the brain known as the Reticular Activating System (RAS). The RAS is located deep within the center of the brain and is responsible for awareness and consciousness. Some of its more specific functions include regulating sleep and helping to make stimuli salient (i.e. noticeable) in a busy environment. An example of this would be hearing your name mentioned across the room at a crowded party, which is known as the Cocktail Party Phenomenon (Cherry, 1953).

When the RAS is disrupted by a blow to the head (i.e. when a concussion occurs), electrical signals in the area are also disrupted. This can cause confusion, memory loss and even loss of consciousness. Other symptoms of a concussion include headache, dizziness, nausea, loss of balance and problematic vision. Usually these symptoms are very short-lived, but they can last for days, weeks or even months after the initial injury. Prolonged experience of symptoms is known as Post-Concussion Syndrome and although the exact cause is unknown, theories suggest it may be due to prolonged neuronal damage or a chemical imbalance triggered by the initial injury. It is more common in people who have had previous concussions in the recent past.

When Should Medical Treatment Be Sought?

Although most concussions clear up in a few days, it is always wise to seek medical treatment following a head injury. Symptoms of concussion may not manifest until hours or days after the initial head injury, so vigilance is necessary. It is important to go to A&E as soon as possible if the injured person has any of the following symptoms (NHS, 2014):

• loss of consciousness from which the person then recovers
• amnesia (memory loss), such as not being able to remember what happened before or after the injury
• persistent headaches since the injury
• changes in behavior, such as irritability, being easily distracted or having no interest in the outside world – this is a particularly common sign in children under the age of five
• confusion
• drowsiness that goes on for longer than an hour when you would normally be awake
• a large bruise or wound to the head or face
• prolonged vision problems, such as double vision
• reading or writing problems
• balance problems or difficulty walking
• loss of power in part of the body, such as weakness in an arm or leg
• clear fluid leaking from the nose or ears (this could be cerebrospinal fluid, which normally surrounds the brain)
• a black eye with no other damage around the eye
• sudden deafness in one or both ears

An ambulance should be called if the patient:

• remains unconscious after the initial injury
• is having difficulty staying awake, speaking or understanding what people are saying
• is having a seizure or fit
• has been vomiting since the injury
• is bleeding from one or both ears

What happens if a concussion is not treated?

Most concussions are not dangerous, but an untreated concussion can lead to permanent brain injuries. These can cause significant cognitive or neurological impairments such as decreased academic/work performance, emotional instability and social difficulties, mental health problems, and physical health problems.

Dr Bennet Omalu discovered this when he performed the autopsy of famous Pittsburgh Steelers player Mike Webster, a hero of American Football who, following retirement, suffered  from amnesia, dementia, depression, acute bone and muscle pain, and lived out of trucks and trailers.

 

Following Webster’s death, Dr Omalu surmised that, despite no obvious signs of brain damage, there must have been something wrong with Webster’s brain. Funding the research himself, he arranged for a battery of tests on Webster’s brain matter, and discovered that the neurons (brain cells) had been strangled by large clumps of tau proteins. These proteins are supposed to support the transport of nutrients across cells but in Webster’s brain they had formed tangles which interrupted this transport system, leading to cell death.

He named the condition chronic traumatic encephalopathy, or CTE. This is a very similar process to that of Alzheimer’s disease; in fact, before Dr Omalu’s research it was believed that many players displaying symptoms were developing Early Onset Alzheimer’s Disease.

Following his discovery, Dr Omalu attempted to make his work known to the public, which proved much more difficult than he ever suspected. Everything he said suggested that football, America’s most loved sport, was killing its players. What’s more, CTE didn’t show up on brain scans. In fact, it could only be diagnosed post-mortem.

To find out what happened to Dr Omalu and his research, you’ll have to watch the film ‘Concussion’ starring Will Smith. It provides an excellent portrayal of both the man and the disease.

How To Treat A Concussion

Following a concussion the brain needs time to heal. This means that rest is absolutely vital. Any activities which involve significant cognitive or physical effort or may lead to further injury (e.g. playing sports) must be avoided at all costs. Recreational drugs and alcohol must not be consumed as these can cause irreparable damage to the brain.

Paracetamol may be used to treat pain, but non-steroid anti-inflammatory drugs such as ibuprofen and aspirin should be avoided as they can cause bleeding around the injured area. A cold compress or ice pack can be used to reduce inflammation and swelling around the head injury. Due to the risk of delayed-onset symptoms, anybody who has suffered a concussion must be constantly monitored for at least 48 hours after the initial injury.

For individuals who are regularly involved in sports or physical activity, consultation with your GP should be sought before returning to these activities. Detailed guidelines of returning to sport can be found here, but briefly it is recommended that a graduated reintroduction program of 5 steps is followed:

1. Light aerobic activity
   The Goal: Only to increase an athlete’s heart rate.
   The Time: 5 to 10 minutes.
   The Activities: Exercise bike, walking, or light jogging.
   Absolutely no weight lifting, jumping or hard running.
2. Moderate activity
   The Goal: Limited body and head movement.
   The Time: Reduced from typical routine.
   The Activities: Moderate jogging, brief running, moderate-intensity stationary biking, and moderate-intensity weightlifting
3. Heavy, non-contact activity
   The Goal: More intense but non-contact
   The Time: Close to typical routine
   The Activities: Running, high-intensity stationary biking, the player’s regular weightlifting routine, and non-contact sport-specific drills. This stage may add some cognitive component to practice in addition to the aerobic and movement components introduced in Steps 1 and 2.
4. Practice & full contact
   The Goal: Reintegrate in full contact practice.
5. Competition
   The Goal: Return to competition.

Although following these conditions can cause significant disruption to your routines, ignoring them may cause permanent and irreversible damage to the brain.

Is It Safe To Sleep Following A Concussion?

Contrary to popular belief, it is perfectly safe to sleep following a concussion as long as the victim was awake following the initial injury, is able to hold a conversation, and doesn’t have dilated pupils or issues with walking (University of Arkansas for Medical Science). If in doubt, however, seek advice from a medical professional.

Although a concussion can be a serious problem if not effectively dealt with, proper treatment will in most cases lead to a full recovery.

Further information can be found in the following links:

NHS Choices England 

The Centers for Disease Control and Prevention (CDC)