Reframing Our Understanding of Concussions
Defining the Complex Nature of a Complex Injury
Concussions have become an injury of great interest and concern in recent years, especially in the world of sports. However, there remains much we are still learning about the intricate nature of concussions. New light is being shed on reframing our understanding of what defines a concussion, the diverse symptom presentations, and how to properly evaluate, manage, and treat concussions for optimal recovery.
It’s All About the Energy
A concussion occurs when an acceleration, deceleration, or translational force causes the brain to shake and move within the skull. This motion causes the membranes around neurons to stretch, leading to an uncontrolled exchange of chemicals that disrupts the delicate balance of energy supply and demand in brain cells. It triggers an influx of calcium and release of potassium, while simultaneously reducing blood flow to neurons. This throws the cells into an energy crisis where they struggle to function efficiently. The result is a “metabolic mismatch” rather than any structural damage or cell death.
Heterogeneous and Individualized
Unlike a “one size fits all” diagnosis, concussions can vary dramatically in their presentation and symptoms between individuals. Some experts outline six distinct subtypes of concussion that may occur alone or in combination: (1) cognitive/fatigue, (2) vestibular, (3) ocular motor, (4) migraine, (5) anxiety, and (6) neck. Identifying the specific subtype(s) involved is key to guiding targeted and individualized treatment.
Pre-existing Vulnerabilities Matter
Certain pre-existing conditions like a history of car sickness, lazy eye, and anxiety can act as vulnerabilities that increase both susceptibility to concussion and the tendency to develop certain concussion subtypes when an injury does occur. Females also have a higher inherent risk than males across factors ranging from biomechanics to hormones.
Early Specialty Evaluation and Care Is Crucial
Given this understanding of the diverse symptomatology and risk profiles underlying concussions, early assessment and management is vital. Evaluation within one week by concussion specialists allows prompt initiation of tailored treatments best suited to target the dysfunction(s) present in each patient. This results in marked improvements in both speed and extent of recovery.
Treatments Should Be Active Rather Than Passive
In stark contrast to outdated notions of resting as treatment, properly targeted and supervised active retraining of dysfunctional systems offers the most benefit. This includes therapies like targeted vestibular retraining for dizziness, ocular therapy for vision changes, exertion exercise for concussion-induced fatigue, graded exposure therapy for light/noise sensitivity, and more. Complete rest often proves counterproductive by worsening secondary symptoms.
Outcome With Proper Care Is Encouraging
With accurate diagnosis of concussion subtypes and appropriate targeted treatments, the prognosis for full recovery is quite good in most patients. This allows successful return to activities and sports when properly managed by experts. The key is accurate evaluation and active rehabilitation to “retrain” dysfunctional systems early before secondary symptoms complicate recovery.
Elderly Concussions Demand Our Attention
While athletes capture much of the concussion spotlight, elderly patients represent an underappreciated population vulnerable to concussions from falls and accidents which can severely impact their function and independence. However, with expertise in assessment, targeted treatment, and graded reconditioning, significant improvements are very achievable in this group as well. Restoring activity levels and confidence reduces anxiety, improves recovery trajectories, and prevents complications.
The Bigger Picture
Broader relationships between concussion and conditions like chronic traumatic encephalopathy (CTE) or neurodegenerative diseases remain actively debated within ongoing research, with no definitive conclusions established yet. However, when individual concussions are properly managed acutely, cumulative or downstream effects seem far less likely.
Reframing the Paradigm
In all, this reframed understanding of concussion pathophysiology, heterogeneity in symptom presentation, critical importance of early targeted care, and largely optimistic prognosis with proper active rehabilitation offers renewed hope. Concussion need not be the nebulous, dead-end diagnosis many patients fear today. Instead, emerging science and clinical expertise paints a far brighter future for preventing long-term disability in those unfortunately affected by this complex injury.
