Concussion (Mild Traumatic Brain Injury)

WHAT IS A CONCUSSION?

A concussion is a brain injury that causes changes in how the brain functions.

A concussion is also called a mild traumatic brain injury (mTBI) and is the least severe category of traumatic brain injuries (TBI). The term concussion is more commonly used when the injury is sustained in a sport. Concussion is the most frequent type of TBI and the one that leads to the highest number of medical visits each year.

IN CONCRETE TERMS, A CONCUSSION IS A DISRUPTION OF BRAIN FUNCTIONS CAUSED BY AN EXTERNAL FORCE. This force causes a great acceleration of the brain inside the skull. This leads to stretching and twisting of the brain and neurons.

A concussion is a functional brain injury because it has consequences on the functioning of the brain and not on the structure of the brain. So the brain doesn't function as well, but it is not broken. 

"It can be compared to a computer infected by a virus; the computer does not function as well even if all its components are intact.
In contrast, a moderate or severe TBI causes structural damage to the brain in addition to having functional consequences."

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What are the symptoms of a concussion?

The most common symptoms of a concussion are:

• Headaches
• Dizziness (not to be confused with vertigo; see the vertigo and dizziness section)
• Fatigue and sleep problems
• Concentration difficulties
• Sensitivity to light and noise.

There are several other symptoms that can be experienced following a concussion:

• Vertigo and nausea (see the VERTIGO AND DIZZINESS section)
• Neck pain
• Irritability, sadness
• Feeling slowed down or confused
• Balance problems

NOTE THAT THE SYMPTOMS OF A CONCUSSION ARE NON-SPECIFIC, MEANING THAT THESE SYMPTOMS ARE ALSO FOUND IN SEVERAL OTHER CONDITIONS. For example, people with migraines may also have headaches, nausea, and be sensitive to light. This makes the diagnosis and treatment of concussion more difficult and requires a healthcare professional with expertise.

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What are the most serious symptoms to watch out for?

The following symptoms should be monitored:

IF YOU EXPERIENCE ANY OF THESE SIGNS OR SYMPTOMS, YOU SHOULD GO TO THE EMERGENCY ROOM OR SEE YOUR DOCTOR IMMEDIATELY. It should be noted that one should always be more cautious when the person has already suffered a concussion in the past.

• Headaches that worsen
• Incoherent speech or difficulty speaking
• Significant weakness or numbness in the legs or arms
• Loss of balance or marked incoordination
• Significant nausea or repeated vomiting
• Loss or decrease in level of consciousness
• Seizures
• Inability to wake up after a night's sleep or a nap
• Symptoms that worsen from day to day or persist for more than 14 days

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When do the symptoms of a concussion appear?

Symptoms may appear immediately after the injury, but also in the days that follow. It is therefore important to be vigilant in the hours and days following an injury in order to monitor the signs and symptoms of concussion. 

Just because you don't feel anything in the minutes following an impact doesn't mean you haven't had a concussion.

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What are the causes of a concussion?

A concussion occurs when there is a significant acceleration of the brain within the skull.

Here are several examples that can cause significant acceleration of the brain:

• A rapid head movement (after a car accident or sudden braking in a car)
• A fall (while downhill skiing, rock climbing, tumbling down stairs, cycling, etc.)
• A direct blow to the head (receiving a punch, getting hit on the head with a heavy object)
• A blow to the upper body (such as a body check in hockey)
• Any other situation that causes the head to accelerate (landing on your feet from a significant height, landing after a ski jump).

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How is a concussion diagnosed?

A concussion is diagnosed based only on the history of the injury and a physical examination.

A concussion may be suspected IF YOU HAVE EXPERIENCED A SIGNIFICANT HEAD ACCELERATION AND EXHIBIT A SINGLE SIGN OR SYMPTOM following this event. For example:

• Receiving a body check in hockey or a tackle in football and experiencing a headache or dizziness following the impact
• Being in a car accident and experiencing nausea afterward
• Getting hit on the head with an object and having difficulty concentrating afterward

THE PRESENCE OF JUST ONE SYMPTOM AFTER SUCH A SITUATION IS SUFFICIENT TO DIAGNOSE A CONCUSSION.

It is not normal to have headaches at the end of a sports practice. This may be a sign of an old, poorly healed concussion or poor management of a current concussion.

There is no test (X-ray, MRI, scan, blood test) that can detect a concussion since there is no visible damage to the brain.

However, when severe clinical signs and symptoms are present (see above), tests are necessary to rule out a more serious brain injury, such as a moderate or severe TBI, or a fracture to the skull or neck.

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When should you consult a physiotherapist for a concussion?

You should consult as soon as possible after an injury where a concussion is suspected.

If you have not consulted a physiotherapist quickly and have had symptoms for more than 14 days, you should consult a physiotherapist immediately.

The speed of concussion recovery is greatly determined by when you consult a healthcare professional. Indeed, the first few days after the concussion must be managed perfectly for the fastest possible recovery. It is therefore important to receive the right advice and know what is allowed and prohibited. THE SOONER YOU CONSULT, THE FASTER YOU RECOVER.

Note that the physiotherapist you consult should be trained to treat concussions. Not all physiotherapists treat these injuries. You must specify this request when making your physiotherapy appointment.

Note that you do not need to see a doctor before consulting a physiotherapist. If your physiotherapist believes that an evaluation with a doctor is necessary, they will tell you.

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What are the physiotherapy treatments to relieve a concussion?

Concussion treatment in physiotherapy is done in three parts:

• Assessment and treatment of the different body systems that may be responsible for the symptoms
• Planning the return to work or school (cognitive activities)
• Planning your return to sports and other leisure activities

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ASSESSMENT AND TREATMENT OF BODY SYSTEMS

Your physiotherapist is the only healthcare professional with the expertise to assess the three systems that may have been affected by the concussion, namely:

• The vestibular system (responsible for balance)
• The oculomotor system (responsible for eye coordination)
• The cervical spine (the vertebrae in the neck)

After the assessment, your physiotherapist will determine the appropriate exercises to do at home and the treatments to perform in the clinic to address any issues with one or more of these systems. Your physiotherapist can treat joints, muscles, and nerves to help reduce symptoms.

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PLANNING YOUR RETURN TO WORK OR SCHOOL

Often in collaboration with a physician, your physiotherapist will plan the progression of your return to work or school after an initial absence. They can also advise on necessary adjustments for this return, such as:

• Limiting the amount of homework and exams at school
• Managing the amount of time spent in front of screens
• Restricting the amount of physical exertion at work

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PLANNING YOUR RETURN TO SPORTS AND OTHER LEISURE ACTIVITIES

Your physiotherapist will also plan your return to sports training and, ultimately, your return to competition. This planning follows a specific protocol with steps to be followed. Your physiotherapist can also authorize a full return to competition with contact.

The physiotherapist can also make recommendations to sports team coaches.

The vast majority of concussions usually heal within 10 to 14 days if a proper protocol for the injury has been followed.

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What to do at home for a concussion?

Concussion treatment is done in three steps.

• 1-Relative rest
• 2-Consultation with your physiotherapist
• 3-Return to physical activity, school, and/or work

Treatment parameters vary from person to person because no two concussions are identical.

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STEP 1: RELATIVE REST

The first thing to do immediately when a concussion is suspected is to have relative rest for 24 to 72 hours.
During this period:

• Make sure you are accompanied and monitored by a loved one.
• Avoid any situation that could lead to an impact or acceleration to the head.
• Avoid any activity that significantly increases symptoms.
• Do not remain completely inactive, lying down in a dark room. You can do some reading, go for short walks, or do a little cooking as long as your symptoms do not increase significantly.
• If your symptoms increase while doing light activities, you should rest until they decrease before resuming those activities.
• If you have any serious signs or symptoms (see above), see a doctor or go to the emergency room immediately.

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STEP 2: CONSULTATION WITH A PHYSIOTHERAPIST

You will have a complete assessment and a specific plan to follow with good exercises tailored to your condition.

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STEP 3: GRADUALLY RETURN TO COGNITIVE ACTIVITIES AT HOME

After a 24-hour period with no symptoms, gradually begin light cognitive activity for periods of 45 minutes, such as:

• Reading
• Crosswords
• Simple homework
• Answering emails

During this step, make sure not to cause a significant increase in symptoms with these light activities.

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STEP 4: GRADUALLY RETURN TO WORK OR SCHOOL AND GRADUALLY RETURN TO PHYSICAL ACTIVITIES

After 24 hours without symptoms, a gradual return to school or work can be started. For physical activity, consider gradually starting four or five days after the injury.

The return to work or school must follow its own steps, and the same is true for the return to sports, but the two steps overlap. Therefore, it is not necessary to wait until you have made a full return to work or school to begin physical activity.

• For school or work:

Start with half days every other day, then gradually increase the number of hours when you have no symptoms for more than 24 hours.

The young person should not be put in stressful positions at school through exams or academic recovery until they are much better. The goal of this step is primarily to get used to resuming a schedule, seeing people, and being in our work or school environment.

For work, it is possible to start by prohibiting certain tasks, such as lifting heavy loads or working in front of a screen for long periods, for example.

• For the return to physical and sports activities:

Start with physical activity alone. Do not start training immediately with your team. Then, after 24 hours without symptoms, progress to training with the team without contact before adding contact. The last step is a return to games and competitions. Between each step of the return to sport, there must be a period of 24 hours without symptoms to move on to the next step.

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IMPORTANT: ALL STAGES OF RECOVERY SHOULD BE SUPERVISED BY A PHYSIOTHERAPIST AND IN COLLABORATION WITH OTHER HEALTH PROFESSIONALS AROUND YOU.

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Note that throughout this recovery phase, being positive and optimistic about your progress will lead to better development. Surround yourself with people who help you to be positive and avoid any situation of conflict or negative emotion with your loved ones, your employer or your coach.

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What if my symptoms do not disappear after 14 days?

At this point, it is essential to consult a physiotherapist who specializes in concussions to identify the cause of persistent symptoms.

When symptoms persist for more than 14 days in adults or more than 4 weeks in children, it is considered post-concussion syndrome. If you have not been properly guided, you may still experience symptoms after two weeks.

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This can be explained by one or more of the following:

• A neck injury that has not healed on its own
• A vestibular system injury that has not resolved
• An oculomotor problem that has not been corrected
• The cardiovascular system has not been sufficiently stimulated during recovery
• Psychological factors that limit recovery (fear, stress, anxiety, depression, post-traumatic stress, etc.)

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What are the risk factors for developing a concussion?

• Women are more at risk than men
• People who play contact sports are more at risk
• Athletes who have already had a concussion are more likely to have another one
• Young people under 24 and older adults 75 and over are the groups most at risk

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Some facts about concussions to debunk certain myths...

• Helmets do not reduce the risk of concussion. They reduce the risk of head injuries such as fractures. Therefore, they are very important for limiting serious head injuries, but the brain is not more protected from acceleration by wearing a helmet.
• Wearing a helmet even seems to be associated with a false sense of protection in contact sports and may cause athletes to use their helmets to make contact. For example, tackling in football with the helmet. This is a behavior to avoid since it leads to head contact, which is a risk for concussion.
• Mouthguards are not a way to reduce the risk of concussion. They are important and effective in reducing injuries to the mouth and teeth. This is true for all types of mouthguards, whether they are custom-molded or not.
• Loss of consciousness is NOT a diagnostic criterion for concussion. In fact, less than 10% of people will lose consciousness during the impact that led to the concussion.

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Some statistics on traumatic brain injuries

• In the United States, in 2014, approximately 2.87 million emergency room visits, hospitalizations, or deaths were related to TBIs.
• Each year, more than 800,000 children in the United States are treated in hospital emergency rooms for TBIs.
• In the United States, the age groups most at risk for TBI were 0-4 years, 15-24 years, and 75 years and older.
• In the United States, more than 300,000 concussions are reported in a sports context each year.
• A study conducted at McGill University in Montreal reports that 60% of university soccer players report concussion symptoms at least once each season. The study also reports that the frequency of concussion in soccer is similar to that in football.

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To learn more...

You can listen to the podcast "Parle-moi de santé" created by one of our physiotherapists, Alexis Gougeon. Episode #6 covers the topic of concussions. 

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Find the episode on YOUTUBE: 

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Click below to listen to episodes on podcast platforms:

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Sources

• National Research Council, Committee on Sports-Related Concussions in Youth. Sports-related concussions in youth: improving the science, changing the culture. National Academies Press; 2014 Feb 4.
• Daneshvar DH, Baugh CM, Nowinski CJ, McKee AC, Stern RA, Cantu RC. Helmets and mouthguards: the role of personal equipment in preventing sport-related concussions. Clinics in sports medicine. 2011 Jan 1;30(1):145-63.
• Abrahams S, Mc Fie S, Patricios J, Posthumus M, September AV. Risk factors for sports concussion: an evidence-based systematic review. British journal of sports medicine. 2014 Jan 1;48(2):91-7.
• Faul M, Wald MM, Xu L, Coronado VG. Traumatic brain injury in the United States; emergency department visits, hospitalizations, and deaths, 2002-2006.
• Dick RW. Is there a gender difference in concussion incidence and outcomes?. British journal of sports medicine. 2009 May 1;43(Suppl 1):i46-50.
• Moser RS, Olek L, Schatz P. Gender differences in symptom reporting on baseline sport concussion testing across the youth age span. Archives of Clinical Neuropsychology. 2019 Feb;34(1):50-9.
• McCrory P, Meeuwisse W, Dvorak J, Aubry M, Bailes J, Broglio S, Cantu RC, Cassidy D, Echemendia RJ, Castellani RJ, Davis GA. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. British journal of sports medicine. 2017 Jun 1;51(11):838-47.
• Institut national d’excellence en santé et en services sociaux, 2020, retrieved January 12, 2021, https://www.inesss.qc.ca/
• American Association of Neurological Surgeons, 2021, retrieved January 12, 2021, https://www.aans.org/

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