Sports Concussion

Dr David Popoli

Hey, athletes and families. I'm Dr. David Popoli. I'm a sports medicine physician within the Department of Orthopedics and Rehabilitation. Thanks for watching this video. We hope it answers the questions you might have about concussion detection, treatment, and prevention. What is a concussion? Taken in its most short form, a concussion is a form of traumatic brain injury. Now, it's a little bit different than other brain injuries because by definition, concussion does not involve things like a skull fracture, it's not bleeding, it's not bruising. What happens is there's an initial mechanical injury, now that can be certainly a blow to the head, that can also be a blow to the chest, that can then force can be transmitted up into the head, and that mechanical injury then has an effect on the chemical function of the brain. And the way that I could kind of summarize this would be your brain functions quite a bit like a cell phone. It stores a bunch of charge, and then everything you want to do during the day is going to cost you a certain amount. So let's say you want to sit down and take a standardized test, that might cost you a 15% charge, or you want to run wind sprints on the sideline, that might cost you 25% charge. And normally, our brain stores a lot more sort of charge than we would ever use during the day, but after a concussion, there's a disruption and then it's kind of like starting your day with a 50% battery charge. And whereas normally, you'd store more charge than you'd ever use, if you've had a concussion, you might end up running low on charge. I don't know about you, but I can tell you that when my cell phone's at 10% battery charge, it does very strange things. The flash on the camera doesn't work. The apps open really slow or don't really work, and that's what happens after a concussion is that you start to bump into that barrier where you will start to have symptoms. So you run your day as normal, but then you might run into things like headache, nausea, dizziness, problems with concentration and focus. And that's kind of what happens after the concussion is there's an initial mechanical injury that then causes a chemical change, and then the change in symptoms that we think of as being concussion. What are the symptoms of concussion? Concussion symptoms tend to fall into four different bins. There are physical symptoms. That's the headache, the nausea, the dizziness, the feeling off balance. There's cognitive symptoms. That's going to be the issues with concentration, focus, memory, ability to multitask. Emotional symptoms. So that might be aggression for some people, it might be depression, it might be just feeling kind of down. And then sleep, and that might be disruptions in sleep, difficulty getting to sleep, difficulty staying asleep, just feeling fatigue during the day. How is the concussion diagnosed? The diagnosis of concussion is a clinical one. At least at present, there is no test that we can do for concussion. Now, you may see, on occasion, if person's had a very severe injury or if their symptoms tend to be getting a lot worse, things like a CT or an MRI may be done, but that's not to confirm concussion, it's to rule out other things that could be going on. There's no blood test for concussion. The research community is definitely working on something like that because it would simplify our jobs a whole lot to say, "Yes, you have a positive blood test for this, you therefore definitely have a concussion." But we don't have that yet. So we really rely on the story. What do we hear? Do you have the right constellation of things that we think of as being concussion, that combination of physical symptoms, cognitive symptoms, emotional symptoms and sleep changes? And then were you injured "in the right way"? So did you have some kind of injury that we think about as causing trauma either directly to the head or to the chest with the force transmitted up into the head? What is the treatment for concussions? Man, I wish I had a really nice template that I can give you that would say all of concussions need to be treated this way. Unfortunately, that's not true, and that's part of the reason that we have a clinic is to make sure that we're really treating each individual as unique because even though you and I may have the same injury on the same day, we're going to have different symptoms and therefore our treatments may be slightly different. Number one, for athletes who are sort of school age, we want to make sure that we give them academic support. And that kind of gets into treating those cognitive symptoms. We want to make sure that they're supported at school. They might need extra time to take tests, they might need to take tests by themselves or not take more than one in a day. We try to reduce their workload. What we're trying to do is match the workload to how much brain reserve they have. So if they're only functioning about 70 or 80% of normal, I cannot expect a student to do a hundred percent of his or her normal activity. For physical activity, we ask that we really dial it back. Now, it doesn't mean activity level of zero, but it does mean that they're not going to be participating in any form of contact or collision athletics, they're not going to be practicing necessarily with their team. We still want them to do things like walk around. We don't just want to sit them that can sometimes actually make their symptoms worse. We want to treat their sleep disturbances, we want to make sure we give them, I mean, it sounds kind of ridiculous, but we want to give them a bedtime and a wake up time. Now, maybe not specific, but mostly what we want to do is ensure that that's as repeatable as possible. We want to provide some guidelines because if we don't give the body any sort of indications of what time it should go to sleep and what time it should wake up, particularly in the set of a concussion, that can actually make things a lot worse because the body says, "I don't really know." And it will sort of wake up and go to sleep whenever, and that can make the symptoms feel a whole lot worse to the student or to the athlete. And then lastly, we want to take care of those emotional changes. Concussion is a very challenging injury because it can be very isolating. We're taking the athlete off of his or her team, we're asking them to make changes in school, we're asking them not to hang out with large groups of friends, and so that can make an athlete feel kind of down, and we want to make sure if they start experiencing that at a higher level, that we're treating that also, that we're getting them support, and that can be from me, the physician, that can be from a sports psychologist that we have as part of our concussion clinic, that can be with a pastor if that's something that that patient identifies with, we want to make sure that we're treating that piece as well. What happens if a concussion is not diagnosed or sort of picked up early and treated correctly? People do still tend to get better even in the setting where they're not immediately diagnosed and started on treatment, but sometimes that recovery period is longer. And so one of the key things that families can do and coaches can do and that our certified athletic trainers can really help out with is the immediate detection of concussion. So what happened? What type of injury occurred? What type of symptoms are you seeing? Is that a concussion? If yes, we want to make sure that the team knows about it early so we can really get them started on those treatments that we talked about and make sure that they're not getting symptoms that become prolonged. How long does it take to get better and get back to sports? If I had a perfect answer to that question, I would start playing Powerball. I don't, unfortunately, have a perfect answer for this. What I would say is that we want to make sure that we're treating each athlete as an individual and that we're trying to get on top of that diagnosis early and then the treatment early. A good portion of people will sort of feel better by 10 days to two weeks, although it's not uncommon for sort of the middle school and high school athlete to sometimes take a little bit longer than that. But again, key factor here is early detection, early treatment to get people back to sports in a way that they're not waiting months and months to do so. Is a student athlete more likely to get a concussion if they've already had one? Sadly, the answer is yes. We know that one of the risk factors for concussion is prior concussion. There's all sorts of statistics out there, but I'll throw some at you just for those of you that like numbers. Usually we say after a first concussion, you're about twice as likely to get a second, after a second, you're about six times as likely to get a third, and after a third, you're about 28 times more likely to get a fourth. So there does seem to be this propensity for the threshold for injury to become lower. How many concussions are too many? The American Academy of Pediatrics used to say three concussions and you're out, you're sort of been retired. We've come to the understanding that not all concussions are the same. There is certainly a severity spectrum within concussions. Some are a little bit more mild, some are a little bit more severe, and so we don't necessarily put a total number of concussions on for retirement, but we do talk about that if people are having a decreasing threshold, right? I didn't even need to get hit in the head, I was just brushing my teeth and I kind of came up and hit my head on the back of the cabinet and that gave me a concussion. So if we're seeing that decline in threshold or if we're seeing symptoms that last for a longer period of time, it's been two weeks with my first concussion, I'm working on my third and now it's 8, 12, 16 weeks before I get better, those things are concerning and we start talking about, is it worth the risk of continued participation if the threshold is lower, the symptoms are more severe and it takes longer to get better? How is Atrium Health Wake Forest Baptist dedicated to keeping athletes safe? Well, first and foremost, one of the things that we've done is install athletic trainers into a lot of the local high schools. And this really came out of a desire to get into the clinic early, or at least get detected early. Sometimes athletes don't even necessarily need to come to see one of us "concussion specialists". They can be treated with their certified athletic trainer, they can be treated through their primary care physician if that primary care physician feels comfortable with seeing concussion. Now, we certainly don't turn people away, and our goal is really to serve the community with whatever they might need, and so that's the reason we have a concussion clinic. There's also a lot of education that happens both from the athletic trainer to the athlete, but then if you are seen in concussion clinic, there's a lot of education about what concussions are, how we detect them, how they're treated, and sort of things that you can do to help prevent them, and one of the big things there is following the rules. I think all of you are probably familiar with the rules changes that happened in the NFL. There's a reason that they move the kickoff, there's a reason you can't blindside hit somebody, there's been rules changes in FIFA about the way that the game is played. And so those are all designed to keep athletes safe, so following the rules is a big deal, and then properly fitted equipment. Now, there's no helmet in the world that can necessarily prevent you from getting a concussion, but a poorly fitted helmet that allows for sort of the brain to be rattled around. So that certainly does not help. So we want to make sure that our athletes are following the rules, that they're properly fitted for the equipment and that they're sort of reporting injury when it occurs. Thank you for watching this video. We hope it was helpful in terms of answering questions you might have about diagnosis, treatment, and prevention of concussion. We here at Atrium Health Wake Forest Baptist are always here to be a resource to our community, to athletes, to parents, to families, to coaches.