In 2017 Dr. Friesen had the honour to serve as the invited guest editor of a special CONCUSSION issue for the Canadian Psychological Association’s national magazine, Psynopsis. To see Dr. Friesen’s introductory article (The Role of Psychology in the “Concussion Crisis”) and the other articles in the magazine, click HERE. To download the PDF version click HERE.
Concussions (aka mild traumatic brain injuries or MTBI) are diagnosed based on the injury characteristics. As can be seen below, for a concussion to be diagnosed, there has to be a minimum of a significant alteration of consciousness (i.e., dazed, confused, incoherent, disoriented, or significant incoordination) if there is not outright loss of consciousness or complete amnesia for at least a few minutes.
There are four TBI classifications based on the level of severity. These are determined by what happens immediately following an injury, not the symptoms that develop or endure after the acute phase. These factors include: Glasgow Coma Scale (GCS; a measure of consciousness) ratings at the scene of the injury or in hospital, length of loss of consciousness (LOC), length of alteration of consciousness (e.g. being dazed, confused, incoherent, disoriented, or having significant incoordination), and length of posttraumatic amnesia (PTA; inability to form memories after the injury). See Table 1 for more detailed classification criteria.
Table 1: TBI Severity Classification
|GCS||LOC||Alteration of Consciousness||PTA||CT or MRI|
|Severe||< 9/15||> 24 hours||> 24 hours||> 7 days||Positive or Negative|
|Moderate||9-12/15||> 30 minutes, < 24 hours||> 24 hours||> 24 hours,
< 7 days
|Positive or Negative|
|Complicated Mild||13-15/15||< 30 minutes||< 24 hours||< 24 hours||Positive|
|Mild (Concussion)||13-15/15||< 30 minutes||< 24 hours||< 24 hours||Negative|
The severity classification is typically a good indicator of expected outcomes. Generally, individuals who suffer a severe TBI have significant and permanent functional deficits. In contrast, though many individuals who suffer a moderate TBI also have some permanent functional deficits, a good percentage of them make significant recovery and go on to lead relatively normal lives. As the name suggests, MTBI is the mildest form of TBI – individuals who experience an uncomplicated MTBI tend to have the best outcomes. Researchers have estimated that more than 80% of all TBI’s are categorized as MTBI/concussion.
As seen in Table 1, within MTBI, there are two levels of severity. A complicated mTBI has the same injury characteristics of an MTBI/concussion, except brain imaging (i.e., head CT or MRI) reveals visible structural damage to the brain. In addition, the recovery trajectories of complicated MTBI patients can be more consistent with those of moderate TBI than MTBI/concussions.
For a concussion to occur from a biomechanical perspective, it is estimated that a minimum threshold of approximately 70-100 g of translational acceleration force is required. The force typically required is estimated to be the equivalent of hitting a stationary object, such as a goalpost or another motor vehicle, at 40 kph; however, such force does not always lead to a concussion.
Neurophysiologically, in the acute phase, a concussive impact causes a “neurometabolic cascade” that essentially results in a mismatch between the brain’s increased need for glucose in the presence of decreased cerebral blood flow.
The symptoms following a concussion, or what is commonly referred to as “postconcussion syndrome” generally involve a combination of headaches, dizziness, memory loss, poor concentration, anxiety, depression, irritability, sleep problems, fatigue, and noise and light sensitivity. However, as highlighted by a number of authors in this issue, researchers have noted that many of these symptoms are highly non-specific to concussions. They are also commonly reported after other types of injury (e.g. orthopedic injuries) and in “healthy,” “normal,” or non-injured individuals. Contributors to this issue further point out that the measured effects of concussion during the first few days to weeks post-concussion are quite mild and typically resolve within this timeframe in the vast majority of people.
Concussions in Sports: A concussion (a.k.a., mild traumatic brain injury; MTBI) is a common injury in amateur and professional athletics, particularly in contact sports. It is the least severe type of TBI. This injury can be very distressing for the athlete, his or her family, coaches, and school personnel. Making return to play decisions is difficult and often requires the input from a physician and neuropsychologist. Neuropsychologists possess the background knowledge and training to understand brain-behaviour relationships and are specialists in the identification and treatment of cognitive impairment. Neuropsychologists are uniquely qualified to objectively evaluate the neurocognitive and psychological effects of concussion. Neuropsychologists interpreting neuropsychological test data assist athletes by identifying and tracking post-concussion symptoms and sequelae, lending valuable information for managing return to play decisions, and focusing on the best interests of the athlete.
Concussions are common injuries in athletics
The Centers for Disease Control and Prevention (CDCP) reported that at least 300,000 athletes per year suffer concussions within the context of sports in the United States alone. This incidence rate is conservative and likely seriously under-estimates the true incidence because: (a) the CDCP based its statistics only on those athletes who lost consciousness, and (b) players and coaches tend to lack awareness or minimize symptoms of concussion. Typically, concussions do not cause a loss of consciousness (LOC). In fact, approximately 90% of concussions in sports occur without LOC. A recent study found that 70% and 63% of football and soccer players, respectively, reported symptoms consistent with concussion, although only 23% and 20% realized they had, in fact, sustained a concussion. This partially explains why some injuries appear to go unrecognized or unreported by the athlete. However, on a confidential survey regarding their concussion histories 40% of high school football players believed that they were concussed but deliberately did not reveal this information for fear of losing playing time.
Concussion rates in high school and college football have ranged from approximately 3–4% to 7–9%. A systematic review of published literature revealed that hockey had the highest incidence of concussion compared to football, soccer, and taekwondo/boxing for high school, college, and amateur adult males. However, out of all high school sports, football has been found to have the highest inherent risk among males, and soccer the highest inherent risk among females.
Concussions result in physical, psychological, and cognitive symptoms
A concussive injury to the brain follows a blow to the skull or an action that generates abrupt acceleration and deceleration of the brain within the skull. The acceleration/deceleration forces may lead to linear and/or rotational movement of the brain whereby brain tissue moves against itself inside the skull, increasing the risk for neurocognitive and neurobehavioral deficits. Under the vast majority of circumstances, concussions in sports do not result in damage to the brain that is visible with static neuroimaging techniques, such as CT or MRI. However, structural damage can occur, especially in sports such as equestrian and auto racing.
The vast majority of concussions in athletes fall at the mild end of the mild traumatic brain injury severity continuum. Loss of consciousness typically is not present, and post-traumatic amnesia is typically brief. This injury is likely associated with low levels of axonal stretch resulting in temporary changes in neurophysiology.
The most common symptoms of sports-related concussion include headaches, dizziness, confusion, nausea, memory difficulties, “mental fogginess,” fatigue, balance problems, attention and concentration difficulties, sleep disturbances, and “nervousness”. Many athletes with concussions have neurocognitive decrements detectable using traditional paper–pencil or computerized neuropsychological tests in the initial hours, days, and potentially weeks post-injury. Athletes tend to recover in terms of perceived symptoms and neuropsychological test performance within 2–14 days. It is important to note, however, that a very small minority of athletes can remain symptomatic at more than one or two weeks post-injury. The majority of athletes appear to recover fully within one-month post-injury, but some athletes can have lingering problems, especially if they have a history of numerous concussions or sub-concussive blows to the head (e.g., football, hockey, rugby, and soccer players but also mixed martial artists -MMA- and boxers).
Baseline and post-injury neuropsychological testing is preferred
Neuropsychological testing provides unique information that can be invaluable not only in diagnosing the injury but also in tracking recovery over time. Neuropsychological testing of athletes is standard practice in the management of concussions in U.S. college and professional sports (e.g., NFL and NHL). The standard use of neuropsychological testing in high school athletes is being debated within high levels of government in the U.S.
The model of neuropsychological assessment utilized in sports is distinctly different from more traditional models of neuropsychological evaluation that utilize extensive, time-consuming test batteries. Sports concussion assessment and management models are designed to promote the screening of large numbers of athletes in order to establish an individual standard for each athlete. The baseline evaluation is not meant to represent a comprehensive assessment but is targeted to assess cognitive domains that are most often affected by concussion, such as memory, attention, speed of mental processing, and reaction time. Baseline neuropsychological testing is usually conducted prior to the sports season. If an athlete is concussed, serial evaluations are conducted post-injury to determine the point at which neurocognitive deficits and clinical symptoms are no longer present. It is considered standard practice that an athlete’s neurocognitive performance must return to baseline or better before returning to play, in order to avoid the possibility of more serious, cumulative injury during the vulnerable recovery period. Although there is variability across sports concussion management programs regarding the administration of neuropsychological tests, the interpretation of neuropsychological test data should only be conducted by a clinical neuropsychologist who is the only healthcare professional that is uniquely qualified to translate the test data into recommendations for clinical management.
Most athletes recover from a concussion within one month
There is accumulating and converging evidence that isolated concussions in sports are almost always self-limiting injuries that are not associated with long-term cognitive or neurobehavioral problems. The pathophysiology of concussion appears to be predominately neurometabolic and reversible, although under certain circumstances a small number of cells might degenerate and die. It is reasonable, however, to assume that the vast majority of neurometabolic pathophysiology will undergo dynamic restoration in the hours and days following the injury. This dynamic restoration proposed in animal models seems to fit the recovery curves that have been reported repeatedly in studies with athletes.
There is some research that suggests that professional football players recover more quickly than younger athletes. In a large-scale prospective study, the vast majority of college football players recovered within seven days. There is evidence suggesting that high school football players take longer to recover than university and professional athletes. The majority of high school football players appear to recover within one month post-injury. Although the recovery rate for most athletes is reasonably well understood, much additional research is needed to identify reliable predictors of rapid versus slow recovery and to better appreciate the effects of multiple injuries.
Concussions should be managed conservatively and individually
Consensus guidelines for general management and return to play have been available for several years. First, the athlete should be asymptomatic at rest. Then, the athlete is progressed through increasing non-contact physical exertion, until he or she has demonstrated asymptomatic status with non-contact physical exertion and non-contact sport-specific training. The athlete should demonstrate full recovery of neurocognitive function as measured by neuropsychological testing prior to returning to play. Neurocognitive recovery is inferred when the athlete’s performance either returns to baseline levels or, in the absence of a baseline, is consistent with pre-injury estimates of functioning when the test data are compared to normative values. Although the preferred interpretation of post-injury test scores involves a comparison to baseline test scores, it is important to underscore that neuropsychological testing may be quite useful in the absence of baseline test data, particularly in the case of protracted or unusually severe symptoms.
Prolonged symptoms beyond 30 days post-concussion, especially if it is an athlete’s first concussion in a while, are often due to non-brain injury-related factors. These can include injuries to the inner ear (aka a vestibular concussion), eyes, or neck. Getting a proper evaluation by an Ear, Nose & Throat specialist (ENT) for symptoms of dizziness/imbalance/vertigo, a neuro-ophthalmologist or ophthalmologist (not an optometrist) for visual symptoms, and/or a good evidence-based physical therapist/chiropractor for neck pain/stiffness and headaches is essential.
Often, sleep difficulties can occur and are typically due to related neck pain or headaches beyond a month or so post-concussion. However, there is preliminary research suggesting a hyperactivation of the sympathetic nervous system (stress response) can occur after a concussion or multiple concussions. If this hyperactivation is supported by future research, it likely only occurs for the first few days to weeks post single concussion and possibly longer in a minority of individuals with a history of numerous concussions. Although not an established treatment for concussion specifically, neurofeedback and biofeedback are quite effective treatment modalities when it comes to treating hyperactivation of the nervous system. There are also a number of lifestyle and nutritional factors that may hamper or aid in recovery. We at Niagara Neuropsycholoy provide such treatments with the caveat that it has not been empirically validated for the treatment of concussion specifically.
Associated stress, tension, anxiety, irritability, and/or low mood/depression can also occur as a result of the functional impairment after a concussion. A licensed psychologist would be the treatment provider of choice for such difficulties.
It should be noted that well-meaning but misinformed health-care professionals (including many family physicians, neurologists, physiatrists, psychiatrists, psychologists, chiropractors, physiotherapists, occupational therapists, speech-language pathologists, and athletic therapists) often “prescribe” excessive rest and avoidance of stimulation (e.g., from screens, music, social interaction, work, schooling,etc) post-concussion. Current research suggests that such excessive rest beyond a few days to a maximum of one week is typically not helpful and may, in fact, prolong or worsen symptoms.
Concussions may carry some risk for cumulative effects
Once concussed, an athlete is at a statistically increased risk for a future concussion. The reasons for the increased risk are unclear. Part of this risk may simply involve personality characteristics of the athlete. For example, athletes who have personality style to be risk-takers, excitement seekers, aggressive, or impulsive may be more likely to put themselves in positions where they are more likely to get concussed (e.g., a hockey player who likes to play rough or finish their checks). Regardless, previously concussed athletes are four to six times more likely to experience a second concussion, even if the second blow is relatively mild. In mixed martial arts this is often referred to as having a “glass jaw”. In a more recent two-year prospective study of high school and collegiate football players, there was a six times greater relative risk for individuals with a history of concussion than for individuals with no history. Results of research on professional football players reveal mixed results, although Canadian Football League (CFL) players with a history of concussion were found to have increased risk of future concussion.
Athletes, their families, coaches, athletic trainers, and sports medicine professionals are concerned about possible lingering effects, or permanent brain damage, resulting from multiple concussions. The literature regarding the persistent effects of two previous concussions is mixed. With regard to possible long-term effects, some researchers have reported statistically significant adverse effects, and others have not. In a large-scale study, athletes with one or two previous concussions did not differ on neuropsychological testing or symptom reporting from athletes with no previous concussion on baseline, preseason testing. Research on the effects of prior concussion on recovery time from an athlete’s next concussion also has revealed mixed results. Some studies have found that some athletes with two previous concussions have slower recovery times whereas other studies found that concussion history was unrelated to recovery time in high school athletes.
There is accumulating evidence that a history of three or more concussions is associated with changes in neurophysiology, subjective symptoms, and neuropsychological test performance in some athletes. Furthermore, some athletes with three or more concussions are likely at increased risk of sustaining future concussions, experiencing worse on-field presentations of their next concussion, having a greater likelihood of slowed recovery, and experiencing more severe, acute changes in memory performance on neuropsychological testing. More research is needed to examine recovery rate in relation to concussion history. One thing to keep in mind is that when athletes report a history of two or three previous concussions in these research studies, they may be underreporting the true number of concussions experienced as many concussions go unnoticed when they don’t result in a loss of consciousness. Also, these same athletes are often participating in sports that involved large numbers of sub-concussive blows to the head (e.g., hockey, rugby, football, soccer, mixed martial arts, and boxing) and so they have likely experienced more blows to the head than the average non-competitive athlete or athletes in sports with low risk for head impacts (e.g., tennis, track and field, figure skating, gymnastics, etc).
An extraordinarily rare and tragic outcome of concussion may be catastrophic brain swelling leading to severe disability or death. This has been described as second impact syndrome, and over the past 20 years a number of cases have been reported. In theory, sustaining a second brain injury during a period of increased vulnerability, while the athlete is recovering from the first injury, has been potentially linked to second impact syndrome. The pathophysiology of second impact syndrome is thought to be cerebrovascular congestion or a loss of cerebrovascular autoregulation leading to considerable brain swelling. Most cases of second impact syndrome have been reported in children or adolescents. However, this is assumed to occur when two concussions occur very close in time (e.g., within minutes, hours, or a few days). Also, the whole concept of second impact syndrome is highly debatable and not empirically supported. Many of the cases only involved a single concussion and direct links between two concussions have not been reliably made.
Adapted from the National Academy of Neuropsychology Position Paper “Neuropsychological evaluation in the diagnosis and management of sports-related concussion”, Archives of Clinical Neuropsychology 22 (2007) 909–916
MORE SEVERE TRAUMATIC BRAIN INJURIES (TBI)
Each year, TBIs contribute to a substantial number of deaths and cases of permanent disability. In fact, TBI is a contributing factor to a third (30%) of all injury-related deaths in the United States.1 In 2010, approximately 2.5 million people sustained a traumatic brain injury.2 Individuals with more severe injuries are more likely to require hospitalization.
Changes in the rates of TBI-related hospitalizations vary depending on age. For persons 44 years of age and younger, TBI-related hospitalizations decreased between the periods of 2001–2002 and 2009–2010. However, rates for age groups 45–64 years of age and 65 years and older increased between these time periods. Rates in persons 45–64 years of age increased almost 25% from 60.1 to 79.4 per 100,000. Rates of TBI-related hospitalizations in persons 65 years of age and older increased more than 50%, from 191.5 to 294.0 per 100,000 during the same period, largely due to a substantial increase (39%) between 2007–2008 and 2009–2010. In contrast, rates of TBI-related hospitalizations in youth 5–14 years of age fell from 54.5 to 23.1 per 100,000, decreasing by more than 50% during this period.1,2
A severe TBI not only impacts the life of an individual and their family, but it also has a large societal and economic toll. The estimated economic cost of TBI in 2010, including direct and indirect medical costs, is estimated to be approximately $76.5 billion. Additionally, the cost of fatal TBIs and TBIs requiring hospitalization, many of which are severe, account for approximately 90% of the total TBI medical costs.3,4
TBI Classification Systems
TBI injury severity can be described using several different tools.
The Glasgow Coma Scale (GCS),5 a clinical tool designed to assess coma and impaired consciousness, is one of the most commonly used severity scoring systems. Persons with GCS scores of 3 to 8 are classified with a severe TBI, those with scores of 9 to 12 are classified with a moderate TBI, and those with scores of 13 to 15 are classified with a mild TBI.
Other classification systems include the Abbreviated Injury Scale (AIS), the Trauma Score, and the Abbreviated Trauma Score. Despite their limitations,6 these systems are crucial to understanding the clinical management and the likely outcomes of this injury as the prognosis for milder forms of TBIs is better than for moderate or severe TBIs.7-9
Potential Affects of Severe TBI
A non-fatal severe TBI may result in an extended period of unconsciousness (coma) or amnesia after the injury. For individuals hospitalized after a TBI, almost half (43%) have a related disability one year after the injury.10 A TBI may lead to a wide range of short- or long-term issues affecting:
- Cognitive Function (e.g., attention and memory)
- Motor function (e.g., extremity weakness, impaired coordination and balance)
- Sensation (e.g., hearing, vision, impaired perception and touch)
- Emotion (e.g., depression, anxiety, aggression, impulse control, personality changes)
Approximately 5.3 million Americans are living with a TBI-related disability and the consequences of severe TBI can affect all aspects of an individual’s life.11 This can include relationships with family and friends, as well as their ability to work or be employed, do household tasks, drive, and/or participate in other activities of daily living.
- Falls are the leading cause of TBI and recent data shows that the number of fall-related TBIs among children aged 0-4 years and in older adults aged 75 years or older is increasing.
- Among all age groups, motor vehicle crashes and traffic-related incidents result in the largest percentage of TBI-related deaths (31.8%).12
- People aged 65 years old and older have the highest rates of TBI-related hospitalizations and death.13
- Shaken Baby Syndrome (SBS), a form of abusive head trauma (AHT) and inflicted traumatic brain injury (ITBI), is a leading cause of child maltreatment deaths in the United States.
Adapted from the CDC.