Complex Consussion

Concussion is usually thought of as a strong blow to the head.

In reality, concussion is a much more complex neurological event.

Normally recovery occurs within 3 to 10 days.

Sometimes concussion recovery is much longer and this is called complex concussion.

Concussion as a Head Impact

The brain is housed in the skull and surrounded by fluid. The skull is connected to the neck by muscles that are monitored by nerves that go to the brain.

When an impact to the head occurs the impact/forces are absorbed by the neck.

This absorption of force causes extreme stretching of the neck that sends signals from the nerves to the brain. When the load to the neck is large this can create an overload in the brain.

The overload results in nerves firing too much that causes inflammation and general brain overload. This usually shows up as difficulty thinking, sensitivity to light, nausea, and headache.

Sometimes the neck is not able to completely absorb the forces and the brain can move in the fluid in the skull. The fluid around the brain absorbs and prevents forces from affecting the very sensitive tissues of the brain.

However, it only takes a small amount of force to irritate the brain and create inflammation and irritation. This inflammation and irritation add to the nerve signals sent from the neck muscles resulting in multiplied irritation and further adding to the brain overload.

Concussion as a Whiplash Mechanism

Some concussions can result from impacts to the body that can occur to the shoulder, torso or even the lower body.

Decelerations of the torso or lower body can result in the neck trying to control momentum generated from the weight of the head. This can result in stretching of the neck muscles with the same overload to the nervous system as described above.

Head impact and whiplash can occur in varying combinations in a multitude of situations.

The truth is, multiple activities can result in a concussion, whether on the soccer field, driving a car, or going down a staircase.

New Attention to Concussion

Concussions have received increased attention over the last decade.

This is largely due to an increased understanding of the brain’s vulnerability after an initial concussion. We now know that until a brain is fully healed it is highly susceptible to injury so much so that deaths have occurred. This concept has been described as double concussion or second impact syndrome.

There is some evidence, most notably identified in professional football players, that repeated trauma can have long-term cognitive effects.

Because concussions are extremely common, extensive protocols have been developed to prevent the consequences of unhealed concussion.

These protocols are anchored in the resolution of concussion symptoms.

Symptoms of Concussion

The neurological irritation of the brain causes several well-established symptoms, these include:

• Headache
• Nausea
• Confusion
• Light or sound sensitivity
• Memory difficulties

The vast majority of concussions are considered mild. In mild concussions, the symptoms improve quickly – sometimes in just a couple of hours.

However, because of the concerns of double concussion syndrome sports medicine professionals are required to be very cautious in returning people to concussion prone activities. This is largely controlled through concussion protocols where we limit activity while concussion is healing.

Additionally, we recommend reducing brain stimulation for a period of time:

• Rest in a quiet, dark environment
• Reduce your physical activity
• Reduce mental demands at work or school

Some people fail to have diminished symptoms as we progressively increase their activity, their return to play, and get stuck within the protocols. In some cases, we are able to simply extend recovery times that result in recovery.

However, some people are unable to return to activities within normal timelines, this is commonly referred to as complex concussion.

The patient’s tendency to evolve from acute to complex concussion is a combination of concussion severity, genetic predisposition, gender, associated medical conditions, cumulative neurological, physical or psychological trauma.

Signs of a Complex Concussion

The symptoms of a complex concussion are representative of sustained neurological irritation that interferes with healing.

The symptoms of a concussion can evolve or simply persist and include:

• Head/Neck or face pain
• Persistent nausea or vomiting
• Severe sluggishness, fatigue, and loss of energy
• Difficulty speaking
• Difficulty with balance and/or walking
• Confusion or loss of memory
• Difficulty with concentration or attention to detail
• Irritability and low frustration tolerance
• Personality changes
• Dizziness or vision changes
• Loss of hearing

It is important to identify symptoms of complex concussion as early as possible because of the tendency for the symptoms to progress or evolve. This indicates that the nervous system is becoming more irritable. If this is allowed to progress it is more difficult to treat.

Treatment plans are typically multidisciplinary including combinations of physical therapy, massage, medication and controlled return to aerobic exercise.

Complex Concussion vs Chronic Migraine

The symptoms of complex concussion and chronic migraines are very very similar.

This is due to the fact that both conditions affect the same parts of the brain. Where complex concussion is due to trauma, chronic migraine is typically genetic without a primary traumatic component.

However, it is reasonable to think of these on a continuum from traumatic to atraumatic and the treatments are virtually identical.

Consequently, there are a lot of treatment options that give us the opportunity to return athletes to activity whereas historically complex concussion has had a high percentage of retirements from athletics.

Final Thoughts

Our understanding of head and neck trauma as well as the nervous system has advanced dramatically in the last two decades.

This has given us tools to treat the simplest to the most complex neurological problems.

We are more successful in treating concussion than we ever have been and this enables our most active people to live full productive lives.