CONCUSSION AND HEAD INJURY: WALKING WOUNDED
Football season is once again upon us, and increasingly, each year, the media provides us with more information about concussions related to sports injuries. Awareness is a good thing.
A concussion can be caused by many types of injuries, the vast majority of which can be prevented. Sports injuries, bicycle and car accidents, as well as falls, are the most frequent causes of a concussion. Sports injuries have been in the spotlight lately, and for good reason: the long-term effects can continue to compound and worsen over the athlete’s lifetime. The cumulative effect of multiple impacts on the head can contribute to mental decline characterized as dementia.
There have been many advancements made regarding the prevention, treatment and diagnosis of concussions related to sports injuries. New technology that allows sensors to be placed in football players helmets provides feedback regarding the impact and injury mechanisms. New rules in football are being considered for implementation , including those against “head-down tackling” or “spearing,” which is associated with a high injury rate. Rules that reduce such actions that have long been in place are getting more attention and enforcement.
Traditionally, the term “walking wounded” refers to those who are injured, but not so badly that they cannot walk. Often, this term is used for battlefield injuries. For those who have concussions and head injuries, their symptoms can be almost invisible, thus creating the illusion that they are “okay.” They may indeed be “walking wounded.”
They are not “okay.”
The term “concussion” may be used interchangeably with “brain injury,” and “mild traumatic brain injury.” In medical literature, concussion is frequently defined as “a head injury with a temporary loss of brain function, causing a variety of physical, cognitive and emotional symptoms, which may not be recognized if subtle.”
DIAGNOSIS: Concussion victims are typically assessed initially first to exclude a more severe head injury such as hemorrhaging or neck injuries. Symptoms that would indicate such increased severity include persistent vomiting, increasing headache, decreasing consciousness and increased disorientation, seizures and unequal pupil size. Brain imaging is typically implemented to detect lesions when these symptoms are present. When the symptoms are mild, concussion may be under-diagnosed. The memory loss may not be immediately noticed, and athletes often minimize their symptoms in order to remain in competition.
PREVENTION: Outside of sports injuries, concussions typically occur as a result of an accident or a fall. In motor vehicle accidents, there are several important safety rules to keep in mind in order to prevent a head injury, or any bodily injuries:
- ALWAYS wear seat belts. Statistics show that only one in ten people without seatbelts fare better than those who wear seatbelts. Stated in question form, “Would you rather play Russian Roulette with one bullet, or nine bullets?”
- Most newer-model cars have airbags. You have no choice but to use them if necessary, unless they are disabled.
- This one bears repeating: Don’t text and drive. Better yet, don’t engage in any distracted driving habits. This includes texting, and using your cell phone only for emergencies. Focus on the road and not on other matters.
- Always have a designated driver if you have been drinking or plan to drink alcohol.
- Remind yourself—and especially teenagers—that no one is invincible. Accidents can and do happen, and they happen usually because one party could have prevented it.
- Respect weather conditions. Adjust your driving speed, focus and habits when necessary.
- Follow the posted speed limits—they are there for a reason. So too are the reduced speeds in school and construction zones. One moment of inattention can be tragic when children and construction workers are close to your moving vehicle.
- ALWAYS wear a helmet when driving or riding on a motorcycle or scooter.
Many falls occur in the home. There are simple rules to keep in mind to reduce the risk of falling:
- Keep floors free of clutter
- Be aware of your pets or oxygen tubing/hoses underfoot.
- Throw rugs increase the risk of falling. Be more aware of your step when walking on them, or get rid of them.
- Wear low-heeled, smart and comfortable shoes.
- Many falls occur in the bathtub because it is slippery. Install grab bars or rubber mats. (Towel bars do not constitute grab bars.)
- Be aware of any diagnoses that can affect balance such as Parkinson’s Disease. Medications can also affect balance. Take the extra time and effort you need to remain safe when you move about your home.
- Age brings its own challenges with balance and stability. Use stairway railings, and respect the natural slow-down of the human body. Slow down with it and enjoy.
TREATMENT: If a neck injury or more severe head injury has been ruled out, and concussion is suspected, observation should continue for several hours. Be aware of these warning signs that it is more severe than concussion:
- worsening headache
- repeated vomiting
- seizure activity
- excessive drowsiness
- double vision
- slurred speech
- unsteady gait
If these signs are observed during the period of several hours after a concussion, immediate medical attention in an emergency room is advised.
Traditionally, it has been advised to awaken the concussion victim several times throughout the night. Recently, however, there is discussion that perhaps it is more beneficial to let the victim sleep uninterrupted. Ask for medical advice from the physician regarding this.
Most symptoms resolve after seven-ten days, but recovery time may be greater in children and adolescents. Physical and cognitive rest is advised during this period. Activities that require attention and concentration such as school work, video games, text messaging and even leisure reading can over-tax the concussed brain. Time off from school may be necessary, either whole or half days. Increasingly, the education of school personnel regarding the treatment of these necessary measures for treatment will allow the victim a more efficient recovery.
Physical and cognitive rest should be continued, both daytime and nighttime rest are important. If prior activities are resumed, and symptoms do not recur or worsen, then it is likely that the victim can continue to increase their amount of activity slowly, and as tolerated.
The 2008 Zurich Consensus Statement on Concussion in Sport recommends that participants be symptom free before restarting in sporting practice after a concussion, and then progress through a series of graded steps. When one step in passed, 24 hours should pass before the next step is undertaken:
- complete physical and cognitive rest
- light aerobic activity (less than 70% of maximum heart rate)
- sport-specific activities such as running and drills
- non-contact training drills (exercise, coordination and cognitive load are the intended stimuli)
- full contact practice
- full contact games
Following these guidelines, and careful, watchful progression of activity is crucial to ensure complete recovery. The risk of re-injury poses a greater chance of even further brain injury if the initial concussion is not fully healed. Sustaining another injury when the brain is still recovering exponentially increases the chances of permanent injury, and in the most extreme cases, death.
“I remember the car accident, and I remember asking my brother —my passenger— three questions over and over: ‘What happened?’ ‘Are you okay?’ and ‘Where are we?’ He said I asked him about five times, and I do now remember repeating them. He was not injured, and was becoming quite frustrated with my repeated questions. I remember the feeling that I had just woken up, or became aware of my new surroundings, as if I had been dropped out of the sky into this new place. I remember then that I snapped out of it, and I began wailing, not from the pain, but from the awareness that I had just wrecked our other brother’s pickup. There was no physical pain at that point, even though my forehead and arm were full of glass. The physical pain would come later. The pain at that moment when I snapped out of my concussion was from the realization that we had been in a bad wreck, but luckily everyone recovered. I was wearing my seatbelt; I know I would have been killed without it. I remember vividly now coming to, and crawling out of the pickup. My brother tells me that, seeing the blood and my limp body at first, he thought I was dead. He was 14. I know that image has never left him.”
– Lynn, a female concussion victim, recalling the concussion years later.
James, a survivor of a life-threatening head injury, is able to answer simple yes/no questions about his accident. He was riding his scooter without a helmet, and was struck by a car going through an intersection as he was turning left. He had the right-of-way, but the car didn’t see him because he was behind a truck. The car struck him. He was two blocks from a major trauma center in a large city. This proximity has been credited with saving his life, because he was given a slim chance of survival. He underwent emergency surgery with his parent’s consent, and then began a two-month period of hospitalization; first, in surgical ICU, then acute, then to a specialized rehabilitation facility. James’s speech is now halted, and limited to simple one or two word utterances. This has improved from only a thumbs-up or thumbs-down gesture to indicate yes and no. He understands fully, and can comprehend these questions:
Interviewer A.J.: “ Do you remember the accident?”
James: (delay as he processes his answer) “No.” (Research shows most traumatic brain injury victims do not remember the moment the accident occurred.)
A.J.: “Do you remember not being able to speak a word?”
James: “Yes.” Hesitates, appears to be thinking. “Hard.”
A.J.: “What else do you want to tell us?”
James: (several second delay) “Lucky.”
Lynn and James are not walking wounded. They couldn’t walk after their accidents. They are both walking now. They are lucky.
Both accidents could have been prevented. Most can. BE CAREFUL.