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Prescription for Life
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Concussions are a very hot topic in the media and a topic that has become heavily debated in regard to treatment protocols and, for the athlete, returning to play. As many know, the NFL has changed its policies on concussions in light of the growing research behind the long-term morbidity and mortality. The long-term outcomes of improperly diagnosed or improperly treated concussions can be very severe and should not be taken lightly.

It is important to realize that while a majority of concussions occur in sports, they can, and do, also occur in the workplace. The treatment is the same no matter the cause of the concussion.

First, what is a concussion?

The 2009 Zurich conference on concussions defined concussions as:
Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include:
1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an ''impulsive'' force transmitted to the head.
2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.
3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.
4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course; however, it is important to note that, in a small percentage of cases, post-concussive symptoms may be prolonged.
5. No abnormality on standard structural neuroimaging studies is seen in concussion.
(Taken from Clinical Journal of Sports Medicine, May 2009 Volume 19, Issue 3)

There are a multitude of symptoms associated with a concussion, and as the definition eludes to, loss of consciousness is only one of the many symptoms that may occur, but may, in fact, not be present. The severity of the concussion does not depend on loss of consciousness. In fact, symptoms of fogginess, anterograde amnesia, and confusion are some of the more predictive symptoms of a prolonged recovery. Other symptoms can include any or many of the following:

• Headache
• Dizziness
• Problems focusing
• Pressure in the head
• Neck pain
• Nausea or vomiting
• Blurred vision
• Feeling slowed down
• Light/sound sensitivity
• Difficulty concentrating/remembering
• Fatigue/low energy
• Drowsiness
• Trouble falling asleep
• Sleeping more than usual
• More emotional than usual
• Irritability
• Sadness
• Not feeling “right”
• Nervous/anxious.

These symptoms combined with an abnormal cognitive evaluation and balance assessment all constitute a concussion and obligate the doctor to begin a treatment regimen.

The treatment itself is very complicated and very individually dependent. Factors such as previous concussions, time between previous concussion, and activity level before diagnosis can affect an individual’s return to activity. As the recent conference in Zurich discussed using the most recent studies on concussions, there is a graduated return to activity that starts with complete rest of the brain until symptoms described above resolve completely. Once this happens, a gradual increase in activity over the course of 24 hours between activity levels, coupled with no worsening of symptoms, allows the patient to return to previous level of play/work. It requires frequent follow ups on the physician’s part to assess symptoms, balance and cognition and to temper activity levels if symptoms develop in the meantime.

There have been some technological advances in the diagnosis of concussion to prevent the patient from falsifying information and to assess improvement. These are, however, only tools and should not be used in place of a physician’s discretion regarding return to play.

The most important change in the guidelines is related to the time of removal from activity. There are no set times anymore, and the grading of concussions is no longer done. A concussion can take anywhere between five days to six weeks to recover, and in many cases with multiple concussions, can lead to post-concussive syndrome, which requires long-term management like vestibular rehabilitation, neuropsychological evaluation and treatment, and medical management over the course of six weeks to years.

The bottom line is that the management of concussions has changed dramatically. It is recommended that you see a qualified doctor if you think you have suffered a concussion.

Posted by MMessmer on 04/04/2012 at 3:37 PM Add Comment

Contributor Profile
 Michael Messmer, D.O.
 Sports Medicine Physician
 Dr. Messmer, board certified in family practice and sports medicine, is a physician at St. Francis Family Medicine at Hunter's Ridge. He enjoys martial arts, hockey, sucba diving, weight lifting, backpacking and camping. He also speaks Spanish.