Some concussions produce permanent brain injury

Conway McLean, DPM

Like so many Americans, I enjoy playing and watching sports. Not all sports, of course. Although the Olympic coverage of curling was extensive, I couldn’t get excited. But the numbers don’t lie: in America, football is king.

Years ago, baseball was America’s game, but, no longer. Football is followed almost year-round, with the college player draft the most recent example. Fans are devoted to “their” team, and often will display such passion you would think they did own the team.

Many complain about the amount of down time in this particular sport, in which there is no action, and nothing is happening. Perhaps it is some call being reviewed or one of the multitude of commercials being shown, but the actual playing time is a fraction of the duration of a game. Still, we watch, anticipating the next amazing catch or big hit.

And some of the collisions that take place during a typical game are astounding. With the protective gear in place, the high-tech helmets and shoulder pads worn, players are able to launch their bodies into an opposing player with tremendous force. Understandably, injuries are suffered on a regular basis.

The physics of American football are a critical component, medically-speaking. (As a “soccer” player of many decades, I will continue to use the designation of “American” football.) When two bodies collide, the change in momentum is significant. The sudden deceleration is somewhat muted, to a degree, by the protective padding players wear. The impact is absorbed, sparing the bones and muscles from the force of the collision.

But what about the brain? A helmet-less head has its own protective mechanisms. Cerebral spinal fluid surrounds our brain, which is composed of delicate and squishy tissue, and this liquid layer is often enough to protect the organ from various bumps.

But a concussion occurs when the brain is accelerating extremely fast and then comes to a hard stop. At that point, the rapid change in momentum causes the brain to jostle inside the skull so much that the cerebrospinal fluid can’t protect it.

The analysis of concussions has many elements, an important one being what happens afterward. It’s this topic, the after-effects of a concussion, where even greater debate is found. More lasting symptoms are a hallmark of a condition called ‘post-concussion syndrome or, conveniently, PCS. The symptoms of PCS may continue for weeks, months, or a year or more after the traumatic brain injury, in contrast to a simple traumatic brain injury, in which the severity of the symptoms typically decreases rapidly.

We now have an idea how a concussion occurs, but unfortunately, there remains notable debate concerning when it is a concussion and when it becomes PCS. The experts can’t seem to agree. We still don’t know the exact physiological mechanisms in the brain that cause the latter condition. The question of the cause or causes of PCS has been heavily debated for many years and remains controversial. It is not known to exactly what degree the symptoms are due to physiological changes or to other factors, such as a pre-existing psychiatric disorder.

Many have raised concerns regarding financial motivation in some of these cases, or that it is related to an application for disability compensation. The subjectivity of the complaints complicates assessment and makes it difficult to determine whether symptoms are being exaggerated or feigned. Still, the majority of experts believe that PCS results from a mix of factors, including preexisting psychological factors and those directly relating to the physical injury.

It is well-recognized that PCS is associated with a tremendously wide range of symptoms. Many of them can be worsened by other disorders, so there is considerable risk of misdiagnosis. Or, psychological factors may worsen the original symptoms. Some have become preoccupied with their injury, assuming a “sick role”. Headaches that occur after a concussion may feel like migraine headaches or tension-type headaches.

This discussion is ignoring, by necessity, the controversy surrounding Chronic Traumatic Encephalopathy, aka CTE, the disabling condition suffered by individuals who have had repeated blows to the head such as might occur to someone playing years of a traumatic contact sport. These individuals do show physical changes in their brain anatomy, but these are discernible only by autopsy. The behavioral changes are extensive, and have led some to commit violence, on others or themselves.

The symptoms of post-concussion syndrome generally do not occur immediately after the injury but in the days and weeks following. These can include some purely physical ones, like nausea and dizziness, but typically are of a more psychological nature such as problems with concentration, depression, irritability and anxiety. Individuals who once were high functioning, balancing a variety of undertakings, find themselves struggling to perform two simple tasks together.

Adding to the difficulty in diagnosing this disorder is the lack of definitive studies. Conventional imaging studies of the brain following a concussion are typically normal, although some novel imaging techniques have found some subtle clues. Changes in cerebral blood flow have also been observed as long as three years after a concussion in studies using a special type of computerized X-ray imaging (SPECT).

The prognosis for PCS is generally considered positive, with about half experiencing total resolution of symptoms in a few days to several weeks. In others, symptoms may remain for three to six months. In approximately 15 percent of people, symptoms may persist for years or be permanent. If symptoms are not resolved by one year, they are likely to be permanent, although, in some cases, improvements have occurred after several years. Older people and those who have suffered a prior head injury are likely to take longer to recover.

A brain injury is hard for a spouse or friend to understand. Everyone gets headaches and gets tired. Lots of people forget where they parked the car. The difference in PCS is qualitative; these people are constantly aware their “head isn’t right”. Many describe a fog that prevents clear thought. The physical fatigue can be crushing, and the sensitivity to loud noises debilitating, eliciting a piercing headache.

As a society, we have some very tough questions to answer concerning brain trauma and concussions in sports participants. Many of us are practicing avoidance behavior when it comes to the distinct possibility our son or daughter could be permanently altered, mentally and intellectually, while playing a contact sport. It is frightening to think about what can happen when a person’s brain is traumatized by a blow to the head.

Post-concussion syndrome is profoundly disruptive no matter what stage in life you are at. Symptoms can be so life-altering that depression and anxiety are simple “a part of life”. The mental health issues of PCS are quite severe for many of those afflicted. If you’ve had a brain injury, but symptoms have continued, seek care from an expert. Although there is no definitive cure, various therapies and techniques can help considerably. As is often stated, don’t suffer in silence: help is out there. Sometimes you just have to look for it.

Editor’s note: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.