For the past year, it seems anytime you open a magazine, newspaper or watch a television show, you see some reference to the raising awareness of the rate of traumatic brain injuries (TBI) or concussion in today’s youth. This information is mainly directed toward the adult population. Football has always been the sport of primary focus, but recent injuries to NHL star Sydney Crosby has made even more people sit up and take notice. For purposes of this article, our emphasis will be more on the adolescent.
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:
Concussion may be caused by either a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head.
Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.
Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.
Concussion results in a 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.
No abnormality on standard structural neuroimaging studies is seen in concussion.1
One of the most common mistakes in understanding concussion, at one time, was that it was believed you had to have been knocked unconscious to have suffered a concussion. Today, we know this is far from the truth. Actually, only 9 percent of all concussions result in loss of consciousness (LOC). As doctors of chiropractic, we understand how different stresses at one part of the neuromusculoskeletal chain can affect areas above and below the area of insult. Due to this understanding, we can biomechanically understand that an “impulsive” force to the body can be transmitted to the head. So, the damaging blow does not have to be a hit to the head, but can be anywhere within the neuromusculoskeletal chain and result in compromising the integrity of the brain, spinal cord and nerve roots.
Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.
You may say to yourself, “Concussions occur primarily in sports, and I do not treat many athletes and I’m not a team doctor.” This statement is about as false as the statement that you have to be knocked unconscious to have suffered a concussion. We all treat patients who—through falls, motor vehicle accidents, worker’s comp injuries—have entered our office with complaints of headaches, dizziness, nausea, balance issues, blurred vision, ringing in the ears, just to name a few. Are these signs and symptoms any different that those of a TBI, closed head injury, or concussion?
The reason for the increased awareness is the increase in two syndromes that are associated with concussion, the first being “post concussion syndrome.” Simply put, this is nothing more than continued symptoms that we mentioned above that last longer than 24 hours. The other is “second impact syndrome.” Second impact syndrome results from a patient or athlete who sustains a second head injury while the signs and symptoms of the first have not yet cleared. It has to be no more of a force that causes the brain to accelerate or quickly decelerate.
Diagnosing someone who is suffering from a traumatic brain injury can sometimes be difficult. Many times, it is simply listening to the patient (or someone who is close to the patient) tell you about changes they may be noticing. These symptoms include not sleeping in the same normal patterns, behavioral changes, and depression, speech or balance issues. They can all be clues that your patient maybe suffering from something more than just a vertebral subluxation complex.
In sports, there are three accepted guidelines for grading concussion and returning to play. Today, primarily the one developed by the American Academy of Neurology (AAN) is the preferred source.
Grade 1 or mild concussion is defined as no loss of consciousness, and post-concussive signs and symptoms that are lasting longer than 15 minutes.
Grade 2 or moderate is again no loss of consciousness but the post-concussive signs and symptoms last longer than 15 minutes.
Grade 3 or severe is defined as “any” loss of consciousness.
For the athlete to return to play, the considerations are based on several factors:
Patient must be “asymptomatic”
Patient must pass memory & neurological testing
NO signs and symptoms with exertional testing.
Additional assistance is used by many with the use of Sport Concussion Assessment Tools. These are tests that are given before an athlete participates and, again, once it is suspected that he/she may have received a head injury. The test involves a section the athlete fills out on post-concussion symptoms, grading them from 0 (none) to 6 (severe). The second part is filled out by a qualified healthcare professional. It involves scoring signs and symptoms, cognitive assessment and neurologic screening and, finally, a return-to-play recommendation. Examples of these tests can be found on the Internet.
These symptoms include not sleeping in the same normal patterns, behavioral changes, and depression, speech or balance issues.
So, why are adolescents having an increase in concussions? First and foremost is the increased level of competition. Today, most parents want their children to grow up healthy and happy. But, with the influence of increased pressure to participate and win, we have a tendency to overlook the environment in which we may be placing our children. Another consideration is the lack of properly trained healthcare professionals at adolescent events. Think of how many coaches there are for youth programs. Typically, they are moms and dads who want to be involved with their children, but who may know little to nothing about proper mechanics of the sport or have no training in first aid and CPR. Many youth organizations are starting to change this and make it mandatory for all coaches to have training in first aid and CPR, and it’s more common to have a defibrillator as part of the equipment mandated at events.
We mentioned that forces can be transmitted to the brain. We know that the heel-strike portion of the gait cycle produces transmitted forces that can travel the length of the neuromusculoskeletal system. To help improve these forces, you can: recommend the use of custom-made orthotics, make sure that the foot is going through a normal biomechanical heel-to-toe transition, and recommend the use of a good athletic shoe to help absorb and distribute shock. The use of mouth protectors has also been considered in helping reduce forces transmitted to the brain.
I recommend you do more research on traumatic brain injuries and concussion to help you better understand the signs and symptoms associated with it. Find a center that deals with traumatic brain injury patients. They often need additional occupation therapies to help them with activities of daily living that most doctors of chiropractic may or may not be able to provide. These types of injuries can be very scary, but having a good understanding of how and what is happening allows you to provide the best chiropractic care possible for your patients.
A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan.
1. Consensus Statement on Concussion in Sport, 3rd International Conference on Concussion in Sport, Nov 2008, Clin J Sport Med 2009; 19:185-200