06/04/2025
Understanding Concussion
Traumatic brain injury and concussion are common, however mostly invisible, injuries.
First, there must be a clear mechanism of dysfunction and/or injury. For concussion, this includes a short loss of consciousness, alteration of consciousness, forgetfulness/amnesia, or any focal neurologic deficits affecting senses, speech, or movement. Following a concussion, patients often experience headache, dizziness, mental fogginess, and trouble concentrating.
There is no minimum impact threshold for traumatic brain injury (1).
At Natural Pain Solutions we assess concussion and traumatic brain injuries with a physical exam, and then we can validate symptoms using scales that have been established by the scientific community. We perform balance and vestibular screening and a general neurocognitive assessment. Things a doctor may observe include changes in the way a person walks, weakness, tingling in the arms and legs, severe or progressing headaches, vomiting, combative state, seizures, visual disturbances, and neck pain. Patients might have difficulty with exercise or even postural changes. There is often disruption of sleep and decreased emotional regulation.
Depression can result as a response to the experience as well as being a primary symptom and direct result of the concussion (2). The same applies to anxiety.
There are often changes in blood pressure, heart rate, glucose metabolism, sexual response, cerebral blood flow, and gastrointestinal function (3).
The vast majority of people who have sustained a concussion will recover within 3 to 4 weeks (4). This recovery timeline is supported by multiple sources showing that most children recover within 2-4 weeks, with 80% of patients recovering within 10 days on average.
We believe that patients should not rest more than a day or two before resuming activities and starting intensive concussion treatment with a qualified practitioner (5,6). This approach is based on current consensus guidelines that emphasize early, gradual return to activity rather than prolonged rest.
This does not mean that somebody with a traumatic brain injury or concussion should return 100% to normal activities. Anything that might put one at risk for repeated concussion must be avoided absolutely until the brain is healed. The return-to-activity process should follow established protocols, with symptom guidance determining the appropriate level of exertion (4).
Any medication, drugs, or use of alcohol must be ruled out while assessing symptoms.
It should be noted that a concussion is an injury that is identified as an acute disruption in brain function rather than any structural changes in the brain. This means we typically will not see anything on neuroimaging. Dr Grace orders CT scans to assess that there is no structural damage.
If the patient is not able to remember things after the accident (anterograde amnesia), that tends to be a more favorable prognosis than if they cannot remember things prior to the injury (retrograde amnesia), which indicates a worse prognosis (7).
Assessment tools such as the Glasgow Coma Scale help clinicians evaluate the severity of brain injury and guide treatment decisions (8).
After a concussion, cell membranes become more permeable in our brain, which triggers increased brain activity. The demand for energy is high in the brain, but it cannot get enough. The proteins that help the nerves survive are broken down, and that disrupts nerve function (9,10). Although it is rare, in some instances, there might ultimately be some cell death.
Axons that are not fully myelinated are more vulnerable to damage while being stretched. This is one reason that young people are more vulnerable to concussions (11,12).
References
1. Meaney DF, Smith DH. Biomechanics of concussion. Clin Sports Med. 2011;30(1):19-31.
2. Rosenbaum SB, Lipton ML. Embracing chaos: the scope and importance of clinical and pathological heterogeneity in mTBI. Brain Imaging Behav. 2012;6(2):255-282.
3. Leddy JJ, Kozlowski K, Donnelly JP, Pendergast DR, Epstein LH, Willer B. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med. 2010;20(1):21-27.
4. Centers for Disease Control and Prevention. (2024). Managing Return to Activities. HEADS UP. https://www.cdc.gov/heads-up/hcp/clinical-guidance/index.html
5. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838-847.
6. Leddy JJ, Haider MN, Ellis MJ, Willer BS. Exercise is medicine for concussion. Curr Sports Med Rep. 2018;17(8):262-270.
7. Cantu RC. Posttraumatic retrograde and anterograde amnesia: pathophysiology and implications in grading and safe return to play. J Athl Train. 2001;36(3):244-248.
8. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: A practical scale. Lancet. 1974;304(7872):81-84.
9. Giza CC, Hovda DA. The neurometabolic cascade of concussion. J Athl Train. 2001;36(3):228-235.
10. Barkhoudarian G, Hovda DA, Giza CC. The new neurometabolic cascade of concussion. Neurosurgery. 2014;75 Suppl 4:S24-33.
11. Lebel C, Beaulieu C. Longitudinal development of human brain wiring continues from childhood into adulthood. J Neurosci. 2011;31(30):10937-10947.
12. Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80(24):2250-2257.
