Heads Up: Concussions Aren't Part of the Game

Sports fans admire the tough injured players who decide to stay in the game. But when cheers no longer echo in athletes' ears, what effect did their choice have on their long-term health? For those who have had a concussion, it can mean behavioral changes, headaches, and the possibility of permanent memory loss.

The Journal of the American Medical Association reports an increased likelihood of long-term neurological damage and learning disability among athletes who have had multiple concussions. This risk of permanent brain damage has led high profile athletes such as football players Al Toon and Steve Young and hockey greats Pat LaFontaine and Geoff Courtnall to retire rather than risk further injury. Yet others, such as Dallas Cowboy Troy Aikman and Philadelphia Flyer Eric Lindros, are determined to keep playing.

Concussion Is a Brain Injury

"Post-concussive disorders" can develop after a concussion, which is a mild form of traumatic brain injury (TBI). Although medical experts disagree over the precise definition of a concussion, its effects on the brain can be serious.

TBI affects people of all ages and is the leading cause of long term disability among children and young adults. It can result in physical impairment, and some of its more damaging effects are permanent changes in an individual's emotions, cognition (e.g., inability to pay attention), and behavior. Every year more than 80,000 Americans sustain brain injuries during recreational activities such as football, hockey, and horseback riding.

"The most common outcome after a concussion is that people get better," says Nathan D. Zasler, MD. "We see the people who don't get better." Dr. Zasler is a physical medicine and rehabilitation (PM&R) physician who diagnoses and treats individuals recovering from TBI.

Because the symptoms of a concussion may be mild, many cases go unreported. More alarming is the fact that they may be ignored by the injured person or clinicians not familiar with the treatment of this special patient population. The fact that some people with TBI can still rate in the "normal" ranges of a neurological exam, CT scans, and other measurements complicates the diagnosis.

About 10-15% of people with mild TBI end up with more persistent symptoms that cause longer term effects if left untreated. "If we see these patients early, the majority will end up doing fine,"says Dr. Zasler, who has treated over 2000 post-concussive patients as the CEO and medical director of Concussion Care Centre of Virginia, Ltd. in Glen Allen.

Symptoms Don't Diagnose a Concussion

The most common physical symptom of a concussion is a headache. Other symptoms can be:

• dizziness

• problems with sleeping or insomnia

• fatigue

• behavioral change

• changes in emotions, irritability, unexplained crying, etc.

• changes in cognition, loss of memory, lack of attention, etc.

But symptoms alone can't confirm if you have had a concussion—only a physician can. Experts recommend that if any of these symptoms persist beyond two weeks, you should see a physician.

"It is the patient's personal history plus or minus the symptoms a patient presents with that tell a physician if there is a post-concussive disorder," explains Dr. Zasler. In some cases the "symptoms" might be due to other injuries that happened at the same time as the concussion. A physician isn't able to properly treat a patient until the correct diagnosis is made.

It is believed that pre-injury vulnerability, such as emotional or learning disabilities, can complicate recovery after a concussion. Such individuals, who may not have even known they had pre-existing conditions, may do poorly long term.

Getting Down to Treatment

After the acute treatment of a concussion, such as in an emergency department, Dr. Zasler believes there are several reasons why a PM&R physician might be the most appropriate specialist to treat patients with TBI, "PM&R physicians take a more functional approach to patient care. They tend to be more holistic, and their training gives them an understanding of neurological problems AND the knowledge to treat any associated musculoskeletal injuries."

Dr. Zasler stresses that post-concussive disorders do not all appear alike. There is no consistent set of symptoms, and there is no one formula to treat every patient. PM&R physicians create individualized treatment plans to address each patient's specific problems.

Why pursue treatment? Because the patient may need to learn how to compensate for the cognitive and behavioral impairments the TBI has caused. A PM&R physician can coordinate that person's re-entry into work, driving, educational, and recreational activities; teach compensation strategies; modify prescriptions; and manage non-drug treatments for pain, cognition problems, and sleep disruptions.