The first concern when any athlete is suspected of concussion is to rule out the really serious that could be deadly or constitutes an emergency. Once this is done, evaluation can begin. There are several areas to evaluate: symptoms (what the patient reports), memory and ability to process information, and signs (what the healthcare provider can identify).
Symptoms: The patient is asked to describe their symptoms (which do not always begin immediately after the injury).
Memory/Cognitive: There are a variety of tests. Asking the patient to count backwards, recite well-known facts, remember items that will be asked approximately 5 minutes later are all common aspects of this portion of the exam.
Signs: This is often a major area of focus because these items cannot be altered or "faked." Many athletes are anxious to return to the game, and this portion of the exam gives a clear answer to some of the damage that may be present. There are 12 cranial nerves inside the skull as well as nerves that exit the spinal cord that can be tested for changes in their function. Changes in pupil size, ability to smell or hear, tracking of your eyes with movement, changes in sensation in particular areas or strength in certain muscles can be indicators of changes in your central nervous system.
These three areas will be tested at rest. If these areas are all normal under resting conditions, retesting under "exacerbation" or after performing challenging athletic tasks is used to further identify problems. For football, the athletes are likely asked to sprint 25-50 yards, perform jumping jacks, pushups, squats, etc to elevate the heart rate then are retested immediately.
Based on the findings at rest and/or during activity, we can determine the degree of injury. Treatment is based and later, monitored, by these tests.
Stay tuned for the next post on Treatment Options.
Concussion itself is defined as a "mild traumatic brain injury" and its symptoms typically last fewer than 24 hours. It is important to realize that the head does not have to "hit" anything and there does not have to be a large force to cause a concussion. Our bodies are designed to absorb forces front-back better than any other direction, so a hit from the side or a jarring from an angle may be enough even under low forces.
The severity of a concussion and the severity of the after-effect are determined by a number of factors including the severity and length of the symptoms, previous history of head injuries, and severity of past injuries. The big concerns aside from initial complications are Post-Concussion Syndrome and Second Impact Syndrome.1
Post-Concussion Syndrome is a condition that causes significant aftermath following a concussion. These can range from personality and emotional changes (changes in anger, temperament, etc) to reduced response time, headaches, chronic pain, fatigue and a host of other problems. In many cases post-concussion Syndrome is short-lived but it may be a permanent change. These changes can quite literally be life-altering and must be taken seriously and treated properly.
Second-Impact Syndrome is a condition that can be deadly and is still not fully understood. First described in 1984, it involves a second head injury (typically prior to complete healing of the first). The brain swells and bleeds more severely than expected. There is a large hole in the base of the skull that the brainstem travels through on its way to becoming the spinal cord; as the pressure increases around the brain from the swelling the brain can actually be deformed and pushed through this hole. This is known as herniation and can be deadly. While still controversial, growing evidence supports higher risk with concussions that are not managed fully. This is the primary reason concussions are gaining so much more attention.
Stay tuned for the next post on Concussion Evaluation....
HOW LONG SHOULD I WAIT AFTER AN INJURY TO GET CARE?
Unless your injury is truly minor and will heal completely by itself in 2-4 days, the answer is almost always - DON'T WAIT! Evaluating an injury quickly will not only reduce the severity of the injury and speed healing, but will also typically save you money! Here's why: Inflammation. What's Really Wrong? Pain Cycles. Compensations.
INJURY AND INFLAMMATION 101
When you have any type of injury, some cells are broken open and damaged. This damage releases chemical messengers into the body and to the brain to "send reinforcements" to begin healing the area. Some of these chemical messengers are toxic and irritating- they irritate nerve endings causing pain and can irritate or damage the surrounding tissues. This is a process known as inflammation. Bruising, swelling, pain, redness and heat are all signs that inflammation is occurring.
Overall inflammation is a good thing. It causes nutrients, oxygen, blood and building blocks for new tissue to be sent to the area. The problem is controlling this inflammation.
The body goes into hyper drive! As all of these new products are sent to the area, the lymphatic system (the structures that work like sewers to drain away the "waste" and damaged tissue) can't keep up. You get one huge traffic jam. As congestion builds, pressure builds up and begins causing damage to the surrounding tissue (this is combined with irritation and damage still occurring from those previously released chemicals). As this damage occurs, more chemical messengers are released. Snowball!!!
REASON #1: Stop the inflammation and prevent Secondary Damage.
This is the premise behind RICE: Rest, Ice, Compress, and Elevate. These are very important to quickly control the inflammation and reduce the secondary damage!
There are also many additional treatment options to reduce inflammation quickly. Kinesiotape, electrical stimulation, lymphatic massage, ART....the list could go on and on. The sooner we are able to address a problem, the less inflammation is allowed to persist. Decreasing inflammation means decreasing secondary damage. Decreasing secondary damage means actually reducing how severe the injury could have been.
REASON #2: WHAT'S REALLY WRONG?
This one seems obvious, but many serious injuries are often overlooked thinking the injury is something else. Some of those more serious injuries may require special treatments, or may actually get worse with some treatments that are otherwise recommended. The longer the big injury goes untreated, the higher the risk of long-term problems and even disability over time.
For example....Did you know there are 5 common sites of ankle fractures connected with simple ankle sprains? And one isn't even in the ankle- it's in the knee! So if you aren't looking for it, it's likely to be missed. And contrary to popular belief, most people can walk on several of these fractures! There are also 6 commonly sprained ligaments in any ankle sprain. Treatment is very, very different depending on the location and severity of fracture or sprain. Three of these common injuries, if left untreated will result in needed surgery- when they could have been corrected simply with early treatment!
Needless to say: A quick exam to rule out the scary stuff is well worth your time and money!
REASON #3: PAIN CYCLES
Your body is much smarter than most of us give it credit. It actually learns patterns and forms habits. Two of these patterns are pain cycles and compensation patterns.
As your nerve endings are irritated with chemical messengers, or have been damaged themselves the obvious occurs- you experience pain. Like any information carried through your nervous system, the signal is transported up the nerve and "synapses" with the next nerve. It continues "leap frogging" or "synapsing" with each new nerve until it reaches the brain.
Every time a synapse is used to transport information, that connection becomes reinforced. That connection becomes stronger every time a signal is relayed. What happens when that signal is relayed constantly for 3 weeks, 3 months, 3 years, before you decide to do something about it? It becomes infinitely stronger and more difficult to break. This is known as a pain cycle.
This is one reason why we may be able to treat an injury completely in one visit immediately after the injury occurs, but the same injury may take weeks or months of treatment to respond if the condition has been there a long time. Needless to say, again, a quick evaluation and treatment early on will save you time....and money......in the long run!
REASON #4: COMPENSATIONS
As I said above, the body is smart! The second type of learning it does with an injury is learning compensations.
How many times have you sprained an ankle only to find your other leg begins to hurt, or your knee, or your back? Your body doesn't like pain and will do anything to get away from it- even without you knowing. Your gait with change, you will use your arm differently, etc.
These changes, known as compensations increase the amount of strain on other tissues, joints and ligaments. Similar to pain cycles, every time you use the new pattern- that pattern is strengthened. Overtime, the body forgets how to use "normal" patterns. Overtime those tissues are not designed to withstand the types of forces they are being subject to. Overtime they break down, stop working or cause pain themselves.
Controlling pain quickly and treating an injury appropriately and completely discourage compensations from occurring. The last thing you want to do is spend time, energy, pain and money addressing a second, third or fourth problem all because you didn't take care of a simple injury to begin with!
SUMMARY: Evaluating and treating an injury quickly and completely will save a lot of pain and hassle in the long run. If you are even unsure if an injury needs to be treated, assume that it does. At the very least, you will avoid future injuries and potentially costly treatments and learn something about your body in the process!
If you have not already seen my blog posts this past month regarding a knee case Elizabeth and I were working on, it's worth checking out (www/millerswc.com/blog.html). I received a call one day from a patient who had tripped and fallen, landing straight on her knee. Although she could walk on it, it was really bruised, swollen and stiff. She had put off getting care for injuries in the past- and had paid for it later; she wondered if there was anything we could and/or should do for it. Check out the blog for exactly what had happened, what we did to help her and the speedy recovery she was able to have! We hear stories like this all too often, and I myself have fallen victim to "it will just get better." After all, "do as I say, not as I do" could easily be my motto. More than once (three times in fact) I chose to keep competing on a fractured limb just so I wouldn't have to miss my sports season, or stop doing what I love. 16 major injuries in just 11 years has given me a very clear understanding of what my patients are going through! There is a reality there we must all acknowledge. The reality is that the longer an injury is left untreated, even if seemingly minor, the worse off it will be in the long run. This is for several reasons:
SECONDARY DAMAGE Stay tuned for upcoming posts on my blog which will go more in-depth into the cause and results of secondary damage. For now, we'll just touch on the basics. When the body sustains an injury, messages are sent to the brain about the damage and the need to "splint" the area and/or begin repair work. The body sends tons of materials to the area to provide support and "building blocks" for the construction to come. It also causes many surrounding muscles to spasm or in some cases "turn-off" in an effort to protect the area. Several problems occur. First, a traffic jam is created and the old, damage tissue struggles to clear the area. Second, as smart as the body is, it " kills an ant with a boulder" and completely overdoes repair work and tissue formation (scar tissue or adhesions sound familiar?) Thirdly, many joints get more nutrients through moving and increasing blood supply, if they are "splinted" unnecessarily they actually heal slower and with decreased quality of tissue. LEARNING PAIN As the neurological system sends messages to and from the brain, neurons must talk to each other to transmit these signals. Over time, these connections are strengthened and the body "learns" these pathways. These connections become increasingly more difficult to break the longer they are in place. COMPENSATIONS The body always finds ways to accomplish what it needs to. The question is what will it use to substitute for a damaged muscle, ligament or tendon; what other joints are overworking for the lack of movement in a "splinted" area. The structures and tissues forced to compensate and take the extra pressure are not designed to take on these extra loads. These tissues are at high risk of injury, and in addition, the body also learns these new compensation patterns. So something seemingly minor can create poor "mechanics" or body patterns even years down the road. So whether it's a new injury, or a chronic ache and pain you have been putting off treatment for, remember that its always better to be "safe than sorry"!
- Secondary damage is allowed to set up, which causes more damage.
- Your neurological system actually "learns" pain and new pathways to transmit it, which become increasingly more difficult to break.
- Last but certainly not least: compensations, compensations, compensations.