Concussion 

Definition
Concussion is a trauma-induced change in mental status, with confusion and amnesia,
and with or without a brief loss of consciousness.

Description
A concussion occurs when the head hits or is hit by an object, or when the brain is
jarred against the skull, with sufficient force to cause temporary loss of function in the
higher centers of the brain. The injured person may remain conscious or lose
consciousness briefly, and is disoriented for some minutes after the blow. According to
the Centers for Disease Control and Prevention, approximately 300,000 people sustain
mild to moderate sports-related brain injuries each year, most of them young men
between 16 and 25.
While concussion usually resolves on its own without lasting effect, it can set the stage
for a much more serious condition. "Second impact syndrome" occurs when a person
with a concussion, even a very mild one, suffers a second blow before fully recovering
from the first. The brain swelling and increased intracranial pressure that can result is
potentially fatal. More than 20 such cases have been reported since the syndrome was
first described in 1984.

Causes and symptoms

Causes
Most concussions are caused by motor vehicle accidents and sports injuries. In motor
vehicle accidents, concussion can occur without an actual blow to the head. Instead,
concussion occurs because the skull suddenly decelerates or stops, which causes the
brain to be jarred against the skull. Contact sports, especially football, hockey, and
boxing, are among those most likely to lead to concussion. Other significant causes
include falls, collisions, or blows due to bicycling, horseback riding, skiing, and soccer.
The risk of concussion from football is extremely high, especially at the high school
level. Studies show that approximately one in five players suffer concussion or more
serious brain injury during their brief high-school careers. The rate at the collegiate level
is approximately one in 20. Rates for hockey players are not known as certainly, but are
believed to be similar.
Concussion and lasting brain damage is an especially significant risk for boxers, since
the goal of the sport is, in fact, to deliver a concussion to the opponent. For this reason,
the American Academy of Neurology has called for a ban on boxing. Repeated
concussions over months or years can cause cumulative head injury. The cumulative
brain injuries suffered by most boxers can lead to permanent brain damage. Multiple
blows to the head can cause "punch-drunk" syndrome or dementia pugilistica, as
evidenced by Muhammaed Ali, whose parkinsonism is a result of his career in the ring.
Young children are likely to suffer concussions from falls or collisions on the playground
or around the home. Child abuse is, unfortunately, another common cause of
concussion.
Symptoms
Symptoms of concussion include:

 headache
 disorientation as to time, date, or place
 confusion
 dizziness
 vacant stare or confused expression
 incoherent or incomprehensible speech
 incoordination or weakness
 amnesia for the events immediately preceding the blow
 nausea or vomiting
 double vision
 ringing in the ears

These symptoms may last from several minutes to several hours. More severe or
longer-lasting symptoms may indicate more severe brain injury. The person with a
concussion may or may not lose consciousness from the blow; if so, it will be for several
minutes at the most. More prolonged unconsciousness indicates more severe brain
injury.
The severity of concussion is graded on a three-point scale, used as a basis for
treatment decisions.

 Grade 1: no loss of consciousness, transient confusion, and other symptoms

that resolve within 15 minutes.
 Grade 2: no loss of consciousness, transient confusion, and other symptoms
that require more than 15 minutes to resolve.
 Grade 3: loss of consciousness for any period.

Days or weeks after the accident, the person may show signs of:

 headache
 poor attention and concentration
 memory difficulties
 anxiety
 depression
 sleep disturbances
 light and noise intolerance

The occurrence of such symptoms is called "post-concussion syndrome."

Diagnosis
It is very important for those attending a person with concussion to pay close attention
to the person's symptoms and progression immediately after the accident. The duration
of unconsciousness and degree of confusion are very important indicators of the
severity of the injury and help guide the diagnostic process and treatment decisions.
A doctor, nurse, or emergency medical technician may make an immediate assessment
based on the severity of the symptoms; aneurologic exam of the pupils, coordination,
and sensation; and brief tests of orientation, memory, and concentration. Those with
very mild concussions may not need to be hospitalized or have expensive diagnostic
tests. Questionable or more severe cases may require computed tomography scan (CT)
or magnetic resonance imaging (MRI) scans to look for brain injury.

Treatment
The symptoms of concussion usually clear quickly and without lasting effect, if no
further injury is sustained during the healing process. Guidelines for returning to sports
activities are based on the severity of the concussion.
A grade 1 concussion can usually be treated with rest and continued observation alone.
The person may return to sports activities that same day, but only after examination by
a trained professional, and after all symptoms have completely resolved. If the person
sustains a second concussion of any severity that same day, he or she should not be
allowed to continue contact sports until he or she has been symptom-free, during both
rest and activity, for one week.
A person with a grade 2 concussion must discontinue sports activity for the day, should
be evaluated by a trained professional, and should be observed closely throughout the
day to make sure that all symptoms have completely cleared. Worsening of symptoms,
or continuation of any symptoms beyond one week, indicates the need for a CT or MRI
scan. Return to contact sports should only occur after one week with no symptoms, both
at rest and during activity, and following examination by a physician. Following a second
grade 2 concussion, the person should remain symptom-free for two weeks before
resuming contact sports.
A person with a grade 3 concussion (involving any loss of consciousness, no matter
how brief) should be examined by a medical professional either on the scene or in an
emergency room. More severe symptoms may warrant a CT or MRI scan, along with a
thorough neurological and physical exam. The person should be hospitalized if any
abnormalities are found or if confusion persists. Prolonged unconsciousness and
worsening symptoms require urgent neurosurgical evaluation or transfer to a trauma
center. Following discharge from professional care, the patient is closely monitored for
neurological symptoms which may arise or worsen. If headaches or other symptoms
worsen or last longer than one week, a CT or MRI scan should be performed. Contact
sports are avoided for one week following unconsciousness of only seconds, and for
two weeks for unconsciousness of a minute or more. A person receiving a second
grade 3 concussion should avoid contact sports for at least a month after all symptoms
have cleared, and then only with the approval of a physician. If signs of brain swelling or
bleeding are seen on a CT or MRI scan, the athlete should not return to the sport for the
rest of the season, or even indefinitely.
For someone who has sustained a concussion of any severity, it is critically important
that he or she avoid the possibility of another blow to the head until well after all
symptoms have cleared to prevent second-impact syndrome. The guidelines above are
designed to minimize the risk of this syndrome.
Prognosis
Concussion usually leaves no lasting neurological problems. Nonetheless, symptoms
of post-concussion syndrome may last for weeks or even months.
Studies of concussion in contact sports have shown that the risk of sustaining a second
concussion is even greater than it was for the first if the person continues to engage in
the sport.

Prevention
Many cases of concussion can be prevented by using appropriate protective equipment.
This includes seat belts and air bags in automobiles, and helmets in all contact sports.
Helmets should also be worn when bicycling, skiing, or horseback riding. Soccer players
should avoid heading the ball when it is kicked at high velocity from close range.
Playground equipment should be underlaid with soft material, either sand or special
matting.
The value of high-contact sports such as boxing, football, or hockey should be weighed
against the high risk of brain injury during a young person's participation in the sport.
Steering a child's general enthusiasm for sports into activities less apt to produce head
impacts may reduce the likelihood of brain injury.

concussion of the brain  loss of consciousness, transient or prolonged, due to a blow

to the head; there may be transient amnesia, vertigo, nausea, weak pulse, and slow
respiration.
concussion of the labyrinth  deafness with tinnitus due to a blow on or explosion near
the ear.
pulmonary concussion  mechanical damage to the lungs caused by an explosion.
concussion of the spinal cord  transient spinal cord dysfunction caused by
mechanical injury.

A cerebral concussion is a brain injury caused by jarring of the brain inside the skull as a
result of a head injury. The most common cause of a concussion is a blow or impact
which causes the brain to slam into one part of the skull. Often, a so-called “contrecoup”
injury is sustained when the brain bounces back against the opposite side of the skull
after the initial impact. The severity of a concussion can vary, and it may be necessary to
see a neurologistfor evaluation and treatment.
 Do Mouthguards prevent concussion?
One of the most commonly held myths in sports medicine is the premise that wearing a
mouthguard will prevent concussion. The origins of this contention are obscure, but an
evidence based review of the scientific support for this concept has not been previously
published.Mouthguards or “gum shields” were originally developed in 1890 by Woolf
Krause, a London dentist, as a means of protecting boxers from lip lacerations. Such
injuries were a common and often disabling accompaniment of boxing contests in that
era.1–3 These gum shields were originally made from gutta percha and were held in place
by clenching the teeth. Philip Krause, his son, who was both a dentist and amateur boxer,
subsequently refined the design of the gum shield and made them from vella rubber.1 In the
United States, the first mouthguard was probably manufactured by Thomas Carlos, a
Chicago dentist, in 1916.1, 4

By the 1930s, mouthguards were part of the standard boxers' equipment and have
remained so since that time. Jack Dempsey and Gene Tunney, before the second world
war, were probably the last of the heavyweight champions to fight without a mouthpiece.

There are several distinct types of mouthguard. The simplest are the stock mouthguards,
which may be purchased from sporting goods stores. The second type are the mouth
formed or boil and bite guards, which are heated and immediately worn by the athlete
allowing some adaptation to the dentition to occur. 

Does history of concussion affect current cognitive status?

 Accepted 7 June 2005
The association between self reported history of concussion and current neurocognitive
status is controversial. Some football studies suggest that athletes with a history of
concussion display cognitive impairment relative to athletes with no history of concussion,
but other studies have not been able to reproduce such findings. This study shows that
there is no relation between the number of previous self reported episodes of concussion
and current cognitive state, directly contradicting the findings of previous research.

Post-concussion symptoms: is stress a mediating factor?

The Oxford Head Injury Service is a new service investigating the benefit of providing
early follow up, including information, advice and support, initially at seven to 10 days
post head injury, with continued intervention as needed. The intention is to reach those
patients who would normally receive no formal follow-up service. This study is a pilot
investigation into the initial presentation of post-concussion symptoms and the influence
of stress, in the form of return to normal activity, to see whether this aggravates the
symptoms. Twenty-one patients were initially seen in hospital between one and four
days post injury and then followed up six to 19 days after discharge. A post-concussion
symptom questionnaire was completed on each occasion and on the second
assessment the presence or absence of stress, as defined above, was ascertained. At
follow up it was found that 71 % (n = 15) were still experiencing symptoms and in 29%
(n = 6) of the total sample the symptoms had become worse. The study reveals that it
would be clinically unwise to rely on an assessment taken in the relatively protected
hospital ward environment as an indicator of future recovery. The influence of stress
was not found to be significant but our measure was crude and the sample small and
therefore we would suggest that this question is still open.

When to retire after concussion?

The decision to retire after repeated concussive injuries remains a complex and
controversial area. For the most part, there are no evidence based recommendations to
guide the practitioner. In the absence of scientifically valid guidelines, good clinical
judgment and common sense remain the mainstay of management.

It is difficult for a team doctor when an athlete, professional or otherwise, has suffered a
number of concussive injuries but has no residual neurological or cognitive symptoms.
Concern expressed by the doctor, the patient, and other medical or coaching team
members is often raised as the prelude to this decision making process. Far more difficult,
and sadly far too common, is the trial “by media” in which anecdotal cases of athletes with
poor outcomes following repeated “concussions” are described, often with little or no
supporting medical evidence, as the basis for recommendations about the playing future of
the player concerned.

Is there a gender difference in concussion incidence and outcomes?

Accepted 7 February 2009
Objective: To determine if there is a gender difference in the incidence and outcomes of
sport concussion.
Design: Critical literature review of sport concussion by gender.
Intervention: PubMed and major sports medicine journals were reviewed using the
keywords concussion and gender. Articles included in this paper were English prospective
surveillance that included concussion as an injury option conducted over the past 10 years,
involved data collected by qualified medical personnel (athletic trainers/therapists or
medical doctors) and used injury rates as opposed to raw counts. Only data from sports
(soccer, basketball and ice hockey) where actions, equipment and most rules were similar
between genders were reviewed.
Results: For the PubMed search, using “concussion” and “gender” as keywords, there were
51 articles. Ten studies (four in football (soccer), four in basketball and two in ice hockey,
including high school, college and professional athletes) were included in the incidence
portion of the paper. Nine of the studies showed higher absolute injury rates for female
concussion compared to their male counterparts with four of them reaching statistical
significance. Five of the studies (two football (soccer), two basketball and one ice hockey)
examined concussion mechanism and in all cases, males had a higher absolute percent of
player contact concussions while females had a higher absolute percentage of surface or
ball contact concussion episodes. Two brain injury and four sport concussion outcome
papers were reviewed. Traumatic brain injury outcome was shown to be worse in females
than in males for a majority of measured variables; females also are shown to have different
baseline and post-concussion outcomes on neuropsychological testing.
Conclusions: After evaluating multiple years of concussion data in comparable sports, the
evidence indicates that female athletes may be at greater risk for concussion than their
male counterparts. There also is some evidence that gender differences exist in outcomes
of traumatic brain injury and concussions. Because concussion is a clinical diagnosis often
depending on self reporting and with no established biological marker or consistent
symptoms/definitions, and because there is evidence that females are more honest in
reporting general injuries than males, it is unclear whether the concussion incidence data,
while generally consistent in showing a higher risk in females as compared to males in
similar sports, is a true difference or is influenced by a reporting bias.