Optimum resolution of concussions requires rest and time 

Healing of the cellular processes in concussions has been likened to brain cell recovery after stroke. 

Issue: October 2012

There has been a great progress during the past 10 years in our understanding, evaluation, diagnosis and treatment of concussions. I remember a time when a sideline diagnosis was getting your “bell rung” and the athlete often returned to the game after a short period of observation. We did not realize the full extent of the injury or possible future consequences. In light of recent literature and as a stimulus for Orthopedics Today readers to pursue this topic further, I have asked David A. Wong, MD, MSc, FRCS(C), to share his insights on concussion research and treatments. 

Douglas W. Jackson, MD 
Chief Medical Editor 

David A. Wong, MD, MSc, FRCS(C): Recent research has led to concussion being defined as an actual injury to the brain. The Centers for Disease Control and Prevention places concussion in the category of “traumatic brain injury.” In sports, the brain is generally subjected to a direct blow/impact, but indirect acceleration/deceleration G-forces (such as hard shaking or shear) may give rise to a concussive syndrome as well. 

Jackson: What occurs to the brain cells during a concussion? What do we know about recovery times?  

Wong: The pathophysiology of concussion at the cellular level appears to vary considerably. Mild concussions are more irritative or inflammatory-based processes that result in a temporary disruption of brain cell function. Rarely, more serious injury can cause cell death and permanent functional changes. Fortunately, the most concussions reside on the less extreme side.  

Knowledge of the physiology of healing/recovery for concussions is the key take-home point in this discussion. Healing of the disrupted cellular processes in concussions has been likened to the recovery that brain cells go through after a stroke. Optimum resolution requires rest and time. The cells have an increased requirement for oxygen and glucose during healing. While this process is in motion, the brain may be in a somewhat vulnerable state resulting in more susceptibility to recurrent injury or “second impact syndrome.” 

Recovery times are inconsistent. Most concussions are mild, and symptoms and will resolve in a time frame of days to a few weeks. However, a repeat injury before the brain has completely recovered may result in prolonged recovery times and a more serious level of symptomatology. 

Jackson: What signs and symptoms on the sidelines should preclude a high school athlete from returning to the game? 

David A. Wong

Wong: A team physician should definitely consider pulling athletes with any seizures, post-traumatic amnesia, disorientation/confusion, blurred/double vision, slurred speech or loss of consciousness. Also of concern are the signs and symptoms, such as headache, nausea and balance or coordination difficulties. 

For the decision-making process in the less obvious situation, the Zurich consensus meeting on concussion has suggested that sideline evaluation be performed using the SCAT2 instrument or the Pocket SCAT. The Pocket SCAT is quickly and easily administered on the sideline and includes a rapid evaluation of three of the areas included in the more comprehensive SCAT2. The three areas are: 

Symptoms (loss of consciousness, amnesia, headaches, blurred vision, etc.); 
Memory (questions include what is the venue for the game, who scored last); and 
Balance/coordination (five errors in 20 seconds walking heel-toe or eyes closed).

Jackson: What are we learning about the significance of concussions in high school football players? 

Wong: There has been research suggesting that the immature brain is more susceptible to injury and takes longer to recover. Concussion also has been implicated in other problems, such as poor concentration, moodiness and cognitive difficulties (e.g., impaired comprehension and computation abilities). Such issues in the high school athlete may manifest as problems with interpersonal relationships, disruptive behavior and reduced academic accomplishment. 

Instruction in proper tackling and blocking techniques will help prevent direct head trauma. High school is the optimum time to emphasize concussion prevention and awareness for both athletes and coaches. 

For more information:

David A. Wong, MD, MSc, FRCS(C), is past president of the North American Spine Society, and director at the Advanced Center for Spinal Microsurgery, Presbyterian St. Luke’s Medical Center. Wong is also an Editorial Board member for Orthopedics Today. He can be reached at 7800 East Orchard Rd., Greenwood Village, CO 80111; email: ddaw@denverspine.com. 

Disclosure: Wong has no relevant financial disclosures. 