August 12, 2021
Concussions are Complicated – Treatment Recommendations Evolve
By: Ilan Danan, M.D.
Concussion is a significant topic of conversation among athletes, sports organizations, and parents of youth sports participants. But what was known as customary for treating concussion symptoms in the past, and subsequently what was required for an athlete to return to play post-concussion, continues to evolve. This evolution of understanding, and as a result, treatment recommendations, can create confusion in athletes, their coaches, and athletic trainers, and parents. So, it is our job as trained physicians, and in my case, as a trained and board-certified neurologist, to help educate. Concussions are serious, and they are also complicated. Understanding what a concussion is and what is recommended when an athlete sustains one deserves our time and attention. So let’s dive in together.
If you find yourself a bit confused by or overwhelmed about what the word concussion means, you’re not alone. When searching the definition online, you might come away with varying degrees of understanding. For example, the Oxford Languages definition (which Google offers first when you search the definition for a word) states that the word concussion can have two possible definitions: 1. “temporary unconsciousness or confusion caused by a blow on the head;” or 2. “a violent shock as from a heavy blow.” Neither of these definitions addresses any effects of concussion on the human brain, nor do they consider that unconsciousness and confusion aren’t always experienced by people who sustain a concussion.
The Centers for Disease Control (CDC) on the other hand, defines concussion much more extensively as: “…a type of traumatic brain injury – or TBI – caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back-and- forth. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells.” While the CDC’s definition is robust in explaining the physiological mechanics of what happens when a concussion occurs, it doesn’t necessarily help a person come away with an understanding of the signs or symptoms they might look for to determine whether a concussion has occurred.
None of the above definition examples is wrong, necessarily, but they both highlight a significant point about brain injuries – they are rarely one-size-fits-all. Not every blow to the head results in a concussion, and not every concussion is the result of a blow to the head. Further, each person who suffers a concussion may experience a set of symptoms and effects unique to them. In fact, no two concussions are likely to present the same, even in the same patient. The notion that concussions can tailor how they present themselves in patients requires medical providers to tailor and update guidance on how those concussions are treated, especially in special populations – including athletes.
Historically, something called a “cocoon theory” was abided by when it came to treating concussions in athletes. The basic premise of this theory was that doctors advised an athlete to avoid all physical activity until all concussion symptoms resolved. Of course, it is essential to recognize that early rest is understandable and certainly within reason immediately following a concussion. However, extended rest and the concept of the cocoon theory towards ultimate concussion recovery are no longer in favor. With new research and professional consensus statements on the topic recently published, an emphasis on early, graduated, and monitored physical activity is considered an ideal approach towards concussion recovery. The operative word in this approach is “monitored.” What monitored means is: watched closely by a medical professional – ideally a neurologist or sports neurologist who has sports medicine experience.
The medical monitoring of athletes who have sustained a concussion is imperative. It isn’t enough to have a concussion diagnosed in an emergency room and then the patient athlete to go on about their business after a few days of “rest.” Because concussions are brain injuries, they must receive the adequate follow-up they deserve. Patients should never decide on their own when it’s “ok” to return to play. We, as clinicians, have spent decades evaluating concussions and brain injuries. This extensive work has enabled us to identify predictors of possible prolonged recovery from a concussion. The sooner we can do that – potentially employing medications and therapies known to help – the sooner we can help our patient athletes return to the sports they love both healthy and free from concussion symptoms that can put them at further injury risk.