“We’ve learned that each concussion acts differently, so trying to use a template just doesn’t work for individual patients,” says Andrew Gregory, MD, an associate professor of orthopedics, neurosurgery, and pediatrics at the Vanderbilt University School of Medicine in Nashville, Tennessee. “Usually it’s only in retrospect that you can say how severe a concussion is.” Even the level of impact in a head injury or the location of the impact can’t predict symptom severity or recovery time, according to a study of collegiate football players’ concussions published in February 2018 in the Journal of Neurotrauma. In fact, the researchers concluded that biomechanical forces that are associated with blows to the head produce different injury presentations in different people. Complicating matters, “it seems the more concussions you have, the longer it takes you to recover and the less injury it takes to cause concussion,” Dr. Gregory says. There is, however, a consensus on the nature of a concussive head injury, according to a statement by the Concussion in Sport Group, published in May 2017 in the British Journal of Sports Medicine:
Concussions can be caused by a direct blow to the head, face, neck, or an impact to another part of the body if it transmits an impulsive force to the head.Concussion typically leads to a rapid onset of temporary impairment of neurological function, one that resolves naturally over time.The acute signs and symptoms of concussion reflect a functional disturbance, not a structural injury.These signs and symptoms may or may not involve loss of consciousness.
The benefit of the grading system was that “it made it clear to clinicians that concussion was something to be taken seriously,” says Prin Amorapanth, MD, a clinical instructor of rehabilitation medicine at the Rusk Rehabilitation Center at New York University’s Langone Medical Center. “But at the end of the day, it turned out not to have a lot of prognostic value.” Since use of the classification systems was cast aside in 2013, concussion is now categorized as a type of mild traumatic brain injury (TBI), and it’s up to a clinician to gauge its severity.
Current Practices for Diagnosing a Concussion
Today, Dr. Amorapanth explains, doctors typically assess concussion severity with a symptom inventory such as the SCAT5 (Sport Concussion Assessment Tool), which asks patients to rate 22 symptoms on a scale from 0 to 6 (with 6 being severe), or the Acute Concussion Evaluation (ACE), which tracks the presence of symptoms and whether they worsen with physical or cognitive activity, as well as risk factors for protracted recovery. “Then, we can generate a total score of severity and count the domains in which the person has symptoms,” Amorapanth says. Concussion symptoms generally fall into four categories: “The greater the number of symptoms and the more severe they are might predict how long recovery takes,” Gregory says, but there aren’t clear cut-offs or boundaries for this, either. The combination of symptoms reported by the patient and a neurological exam — in which the doctor evaluates the patient’s vital signs, visual performance, balance, memory and cognitive functioning — guides how the patient’s concussion is treated. If there’s concern about a skull fracture or bleeding inside the skull, a CT or MRI scan may be recommended. Red flag symptoms that warrant more extensive evaluation include:
Neck pain or tendernessDouble visionWeakness or tingling in the arms or legsVomitingSevere headacheSeizure or convulsionsLoss of consciousnessAltered mental status
Otherwise, for an acute blow to the head that results in mild to moderate symptoms, “we might watch to see if the symptoms are time limited,” Amorapanth says. The mainstay of treatment for concussions is physical and cognitive rest for 48 hours, followed by a gradual return to activities or a graded aerobic exercise regimen under clinical supervision, he notes. Until the person is symptom-free, “we recommend avoiding triggers — such as bright lights, loud noises, physical or mental exertion — that make symptoms worse,” Gregory says. ”But some light activity, such as going for a walk or riding a stationary bike, can be good for recovery. It decreases symptoms and helps people feel better,” thanks largely to the exercise-induced release of endorphins. If symptoms worsen during physical activity, patients are instructed to stop what they’re doing. If your concussion symptoms are not getting better after three to four weeks, “we may be more aggressive with interventions to facilitate recovery,” Gregory says. For example, if you have ongoing vision impairment or light sensitivity, you may be referred for ocular or occupational therapy. If balance problems persist, vestibular therapy may be warranted. If cognitive problems persist, cognitive therapy may be in order. The goal is to help you get back to full functionality as soon as possible.
