Concussion

Concussion is a “Complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces”. Clinically it should be called “Traumatic Brain Injury (TBI)”. It is the most common form of head injury. WHO Task Force on Traumatic Brain Injury estimated that more than 6 out of 1000 people suffer from concussion and the most common causes are sports injuries, road traffic accidents, falls, forceful blow to the head or body and in extreme cases; IED on the battle field.

Symptoms of TBI are diverse and complex. It can also have a delayed onset hours and days later. Usual complaints are headache, neck pain with stiffness, dizziness, nausea, poor balance, fatigue, apathy, light and sound sensitivity, visual disturbances, amnesia, emotional labile (crying, talkative), cognitive impairment (slow reaction time, memory loss) and difficulty with mental focus and concentration.

Previous concussion sufferers are more susceptible to another one, particularly if the new injury occurs before symptoms from past concussion have completely resolved. Even a smaller impact can cause the same full blown symptoms. Repeated concussions increase a person's risk in later life for dementia, Parkinson’s disease, and depression.

Some facts of concussion:

  • One does not have to lose consciousness in order to be diagnosed as suffering from concussion.
  • A concussion is a concussion. All concussions are serious.
  • It rarely has ‘visible’ brain structural injury, CT and MRI are often normal while symptoms are not proportional to severity of TBI.
  • There is no definitive laboratory test to diagnose a concussion neither is there a universally accepted standard grading system.
  • Clinical diagnosis is based on physical signs such as impaired balance, behavioural changes (crying, irritability), cognitive impairment (slow reaction time, memory loss), amnesia, and sleep disturbance.
  • Post concussive symptoms can be subtle and prolonged for months and even years especially in children.

The Mechanics of Injury:

  • The brain is bathed within a thin layer of cerebral spinal fluid, it has the consistency similar to microwave cooked scramble egg.
  • At impact the brain smashes against the hard bony cranium with rotational force centred at the mid brain and thalamus.

The law of physics stated that ‘Action and reaction are equal and opposite.’ With that the brain then smashes to the opposite side of the cranium and this can take place more than once before it stops. At the same time the brain also compresses upon itself. It is therefore not hard to imagine why we call it Traumatic Brain Injury.

Today, no single definition of concussion or TBI is universally accepted. Adding to it, intracranial haemorrhages of various types make it more confusing. There are no less than 40 different systems that measure the severity or grade of head injury with little agreement between them.

If this sounds confusing, it is. Conventional medical approach dealing with concussion focuses mainly on the brain and the only treatment is rest. Then waits and see in the hope that the brain will heal itself. There is no pharmaceutical treatment for concussion. Frequently the effects of trauma to the cervical spine are also overlooked. The brain stem extends into the atlanto-occipital junction (base of the skull) and provides nerve connections between the motor and sensory systems from the main part of the brain to the rest of the body. It also regulates the central nervous system, and is pivotal in maintaining consciousness and regulating the sleep cycle, heart rate, breathing and metabolism. TBI and cervical dysfunction go hand in hand in every case without exception. If treatments are not focused on both areas, recovery will never be completed.

A series of biological malfunctions take place following concussion; brain neurotransmission impairment, ions regulation between cells’ membrane turned aberrant, cellular metabolism and energy use become deregulated and cerebral blood flow reduced. Concurrently with these processes, the activity of mitochondria is also compromised; that interfered with the re-synthesise of ATP and a whole chain of biochemical reactions in the body which governs numerous functions.

Case Study

A 20 years old young man presented at my clinic with right knee pain for 7 months and inability to bear weight on the right leg after landing on that leg fully extended while doing a bicycle trick that failed. He had been treated with physiotherapy but to no avail. Three weeks into the knee treatment with Low Intensity Laser Therapy, he was improving steadily and weight bearing ability also increased. However, he continued to appear depressed with the improvement. During a conversation with his mother, it was revealed that 4 years ago while doing a bicycle trick ride he fell on his head and was knocked unconscious and hospitalized for 4 days. This was not revealed during initial history and patient later admitted that he forgot about it. Since the concussion, he has been depressed with frequent headache, stiff neck, disturbed sleep pattern, poor concentration and attention span, irritable, disinterested in school work and dropped out of school, loss his part time job and has no incentive to look for another, started drinking, stayed up late and slept all day.

This patient has all the signs and symptoms of Post Traumatic Brain Injury Syndrome and was sliding down a slippery slope of self destruction for 4 years. Immediately we commenced Low Intensity Laser Therapy for the TBI.

The patient received treatments over a period of several months, averaging 1 or 2 sessions a week depending on the weekly assessment. At the end of the planned treatment programme, he had re-enrolled back to school and scored 94% in physics test and has an 88% in his year end final average. He also holds down a job and resumes his trick cycling. This patient's mother called on the day we were in the midst of moving to a new office and said “Thank you for giving my son back to me. Today, he is in his usual healthy, happy and cheerful self again.”