Vol. 105 January 15, 2014 Concussion’s Clinical Controversies

hubConcussion” is derived from the Latin concutere meaning “to shake violently” which describes very well what actually happens to the brain. The brain “floats” in a pool of fluid and is tethered to the skull in a number of places. When the head is impacted the brain can bounce against the skull, get yanked by its tethers, and be disrupted. A concussion can occur without an actual impact or blow to the head. A strong rotational motion or a whiplash movement can do it. None of the bounced or yanked areas show up on CT scan or MRI, so the diagnosis of concussion is a clinical judgement. Clinical judgements can obviously differ. Much of the current buzz about concussion and its treatment is fed by current variations of the clinical “truth”.  That is neither alarming nor surprising.. It merely illustrates medical science’s constant striving toward uniform standards and the holy grail of  “evidence-based medicine”.  Here are some of the current concussion controversies.

1. Point: Sports’ concussions are increasing at an alarming rate.
Number of people 19 yo. or younger seen in ERs for concussion in 2009: 250,000       Number seen in 2001: 150,000
70% of ER sports injury patients were males.  Concussions were most frequently associated with bicycling or football.

Counterpoint: Concussions may be like autism and ADHD. They’re not increasing. We are are just better at counting them and/or are more aware and more worried about them.
Female soccer players have 40% more concussions than male soccer players. Frequency of concussions in female soccer players is #2 after male football players.
No single definition of concussion, minor head injury, or mild traumatic brain injury (MTBI) is universally accepted so how do we know everyone is measuring the same thing? Although the number of ED patients diagnosed with concussion at Children’s Medical Center, Boston, has increased from about 2,000 a year to 5,000 a year since 2001, the number actually admitted to the hospital has remained the same (ie; presumably no increase in the severity of concussions).

2. Point: The treatment for a concussion is complete brain rest (“cocoon therapy”).(1)
Recommended actions include staying home from school in a darkened room without TV, smart phone, or other electronic devices until all symptoms clear. “No video games. Do not have conversations for more than 10 minutes. Don’t watch sports where you have to track a ball with your eyes. Decrease or remove flourescent lights from your house. Listen to speakers only on low volume, no headphones”.

Counterpoint: “Thinking does NOT cause brain damage.” Sensory deprivation for the active, adolescent athlete is a punishment, not a treatment. (2)
A few days out of school, no academic tests, and of course, no sports, is a reasonable approach as long as symptoms are resolving, as they do in most cases. Returning to the usual academic and social school routine in 2-3 days actually reduces stress and avoids “obsessive thinking while staring at a blank wall”. “Be aggressive about getting back to life and conservative about getting back to sports.”  Interestingly, from another source, some psychiatrists strongly recommend a “return to school routine” within 3 days of a school crisis associated with a student’s accidental death or suicide as a means to reduce obsessive pre-occupation with the event.(3)

3. Point: Post-concussive syndrome is a dreaded complication of concussion. Prolonged symptoms of headache, slow thinking, and light-headedness is an omnious sign.
One of the working definitions of post-concussive syndrome is the presence of at least three of these symptoms: headache, dizziness, fatigue, irritability, impaired memory and concentration, or insomnia for 3 to 6 months. Depending on the study the incidence of post-concussive syndrome ranges all the way from 29% to 90%.

Counterpoint: 90% of concussion suffers are symptom-free in 28 days; half within a week.
Concussion clinics that have sprung up are mostly dealing with the “worried-well” parents whose genuine concern about their children has been whipped up by media hype and real individual variability in the mount of time needed for symptoms to resolve.  Constant reassurance by a multi-disciplinary team, support groups, and the very rare, reluctantly administered “therapeutic MRI” are used to reassure anxious parents while time heals the insult.  “Any post-concussion symptoms that last for more than a month should cause a referral to a behavioral therapist because the concussion has most likely unmasked an underlying depression, anxiety, learning disability, ADHD, or a school/family stress issue”.(2)

4. Point: Specially constructed helmets for football, hockey, and lacrosse players will protect them from concussion.
“Concussion-proof” helmets for all ages are on sale for $40 to $400 for football, hockey, and lacrosse.

Counterpoint: Special helmets do not provide concussion protection because the cause of injury is the rapid movement of the brain within the skull and only an unwearable cinder block-like structure can prevent that head motion.
Dr. Robert Cantu, Boston neurosurgeon, leading researcher of brain injuries and chronic traumatic encephalopathy, and the vice president of the National Organizing Committee on Standards for Athletic Equipment, admits that the NFL would probably have fewer concussions if the helmet were removed from the game. “Yes it’s true — you wouldn’t be tackling with your head,” he said. “The yin and the yang is that helmets are made so well today that it doesn’t hurt to hit with your head, and it’s a pretty effective maneuver.” Some have suggested a return to the old leather helmets like the one Jim Thorpe wore.

5. Point: Measurement of the blood level of a protein will allow us to pinpoint the diagnosis of concussion.
“A blood test measuring levels of SNTF protein will be able to diagnose concussion severity and predict risk of long-term consequences of concussion.”

Counterpoint: Maybe, sometime in the distant future.
Many other proteins have been found to be elevated in concussion patients. These include tau proteins, S-100B, beta-amyloid, NSE proteins, and alpha-beta peptides, and some of these have also been found to be elevated in students kept up all night.

6. Point: Functional MRI (fMRI) and PET scans measure brain function and can reveal brain injury that does not show up as structural damage on regular MRI or CT scans.
fMRI and PET scans measure the metabolic activity of the brain, obviously a much more sensitive measure than structural damage.  Areas of the brain associated with vision, reading, and balance may show decreased activity by fMRI after a concussion.

Counterpoint: fMRI is on a par with phrenology, the determination of a person’s personality by feeling the lumps and bumps of the skull.
Attributing a specific function to just one area of the brain, a complex interconnected neural network,  is like attributing a person’s generosity to just one bony bump on the back of the skull. The science of fMRI is so new that generalizing its findings should be classified as pseudo-science.

7. Point: The increased NFL penalties, both in yardage and in dollars, for head tackles have resulted in an increase of ACL injuries.
NFL Reddit blog keeps an ongoing list, by name, of NFL football players who have had torn ACLs this year. The list currently stands at 55. CBS reported 45 ACL injures earlier in 2013.

Counterpoint: The NFL Health and Safety Advisory Committee recently reported that ACL injuries are down this year.
2013:  30        2012:  39        2011:  35      2010:  37
These figures may just include those injured in games while the Reddit blog includes those injured in practice and “off-season”.

Editorial notes:
You may have recognized in the list of post-concussive symptoms some adjectives commonly applied to many normal adolescents. In practice it can be difficult to separate a true concussion sufferer from a malingerer or one seeking secondary gain. I suspect that some adolescents have learned via school educational efforts (a sought-for result) and the web which symptoms “to have” to be excused for a while from activities they don’t like. I have found that describing cocoon therapy as an option for their symptoms readily separates the truly suffering from the others when the adolescent considers the “relative risk-benefit balance” of diagnosis vs. treatment.

A  Smithsonium Channel video demonstrating the etherizing of a mimosa plant as proof that plants feel pain,  and a recent New Yorker article describing decades of research on how plants “think” using the complex, interconnected network of their root tips makes me wonder if the next chapter of the concussion saga might be, “Can Plants Get Concussions?” (written by Malcolm Gladwell, of course).

 

References:
1.Connecticut Medicine 74:3, March 2010, pg 149-156
2.Richard Ginsburg, PhD, Director of Sports Concussion Clinic, MGH, Harvard Pediatric CME course, December 2013
3. Michael Jellinik, MD, MGH Dpeartment of Psychiatry, Peds Clinic of North America, “20 steps for schools dealing with the death of a child”

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One Response to Vol. 105 January 15, 2014 Concussion’s Clinical Controversies

  1. Seppo Rapo says:

    Well done. Seppo

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