Concussion

What is a concussion?

A concussion is a mild traumatic brain injury that results from a bump, violent jolt or blow to your head that disrupts normal brain function. A concussion can also be caused by a hit to your body that is strong enough to cause your head to forcefully jerk backwards, forwards or to the side.

Concussions stretch and bruise nerves and blood vessels and cause chemical changes in your brain that result in a temporary loss of normal brain function. A single concussion usually doesn’t cause permanent damage to your brain. Multiple concussions over a lifetime may result in structural changes in your brain.

Concussions are not usually life-threatening. However, the effects from a concussion can be serious and last for days, weeks or even longer.

Do you have to be knocked out to have a concussion?

No, you don’t have to lose consciousness to have a concussion. In fact, most people who have a concussion never lose consciousness.

Can you get a concussion from a hit to the chin or jaw?

Yes, sure. Although the jaw or chin can absorb some of the blow, if you are hit in the right place, it can definitely cause a concussion.

What’s the difference between a concussion and a traumatic brain injury?

Really there is no difference. Both are considered injuries to the brain. These are virtually the same terms.

Who is most at risk for a concussion?

People at greater risk for concussion include:

• Older people and children ages 4 and under due to their risk of falls.
• Adolescents due to bike accidents and sports-related head injuries.
• Military personnel due to exposure to explosive devices.
• Anyone involved in a car accident.
• Victims of physical abuse.
• Anyone who has had a previous concussion.

Adolescents are at higher risk of concussion than any other age group. Researchers think this is because their brains are still developing. The brain is still laying down its neural pathways and adolescents’ necks are typically weaker at this age than in young adults and older people.

What causes a concussion?

Brain tissue is soft and squishy. It’s surrounded by cerebrospinal fluid, which acts as a cushion between it and the hard protective exterior, the skull. A concussion occurs when your brain bounces or twists inside your skull or experiences rapid, whiplash-type back and forth movement that causes it to collide with the inside of your skull. This brain movement stretches and damages brain cells and leads to chemical changes in the brain.

These injuries cause your brain not to function normally for a brief period of time and result in the signs and symptoms of concussion.

Motor vehicle accidents, falls, and sports injuries are common causes of concussions. Any sport that involves contact can result in a concussion.

Among children, most concussions happen on the playground, while bike riding, or when playing sports such as football, basketball, ice hockey, wrestling, or soccer.

What are the symptoms of a concussion?

The most common symptoms of concussion include:

• Headache. (This is the most common symptom.)
• Nausea or vomiting.
• Confusion.
• Temporary loss of consciousness.
• Balance problems/dizziness/lightheadedness.
• Double or blurry vision.
• Ringing in the ears.
• Sensitivity to light and noise.
• Feeling tired or drowsy.
• Changes in sleep patterns (sleeping much more or less than usual or can’t sleep).
• Trouble understanding and/or concentrating.
• Depression or sadness.
• Being irritable, nervous, and anxious.
• Feelings of being “just not right” or in a "fog."
• Difficulty paying attention, forgetful, memory loss.

It’s very common for infants and toddlers to hit their head. Concussions in these little ones can be difficult to diagnose because they can’t say how they feel. Look for these signs of concussion in children:

• Bumps on the head.
• Vomiting.
• Being irritable, cranky.
• Will not eat or nurse.
• Change in sleep pattern, sleepy at unusual times.
• More fussy than usual, won’t stop crying despite being comforted.
• Blank stare.

It’s always best to call your pediatrician if your child experiences a bump to their head. In fact, the American Academy of Pediatrics recommends you call your doctor for anything more than a mild head bump.

How soon do concussion symptoms appear?

Concussion symptoms usually appear within minutes of the head injury. However, some symptoms may take several hours to appear. Symptoms can change days later; others can develop when the brain is stressed with use.

What signs and symptoms of a concussion are of greatest concern? When should a person go to an emergency room?

If a child or adult experiences any of the following symptoms in the hours or days after the head injury, get them to the hospital or call 911:

• Severe headache or a headache that continues to get worse over time.
• Seizures or convulsions.
• Loss of consciousness (greater than 1 minute).
• Severe dizziness, loss of balance or problems with walking.
• Repeated vomiting (more than once).
• Increasing confusion, such as difficulty recognizing people or places.
• Clear, watery discharge from the nose or ears
• Bloody discharge from the ears.
• Numbness, weakness or tingling in arms or legs.
• Unusual, bizarre or irritable behavior.
• Slurred speech.
• Pupils that are bigger than normal or unequal in size.
• Extreme drowsiness, difficulty waking from sleep, or fainting.

Seek emergency care if your infant has any of these symptoms:

• Loss of consciousness.
• Vomiting.
• Seizures.
• Discharge or blood coming out of the nose or ears.
• Unable to open eyes on their own.
• Difficulty waking from sleep.
• Swelling of the soft spot; bruising, especially around the eyes or behind the ears; swelling of the head; skull fracture.

Does a concussion occur exactly where the blow to the head occurs? Are there worse areas of the brain to have a concussion?

The force of a hit can cause a concussion on the part of the brain that was directly hit or on the opposite side of the brain (as the brain tissue itself moves from the force of the blow and hits the opposite side of the skull).

Different areas of the brain control different functions, so blows to your head can predict your symptoms. A concussion to the back of the brain causes balance issues, fogginess, neck pain and difficulty concentrating. These symptoms usually predict a longer recovery from a concussion.

Are there certain criteria that I could see in my child, adolescent athlete or my elderly parent that would indicate that immediate medical care is needed?

Yes. Call an ambulance if your child or elderly loved one has lost consciousness for longer than one minute, is not arousable, has a possible neck injury, shows a worsening of symptoms, has numbness that lasts or has weakness on one side of their body (can’t raise arm or leg or has unequal smile). If you have any doubt, it’s always safest to not move your loved one, call your local emergency department and closely monitor your loved one until help arrives.

How is a concussion diagnosed?

Your healthcare provider will ask about the event leading to your head injury, your symptoms and perform a neurological exam. The neurological exam will check your:

• Neurological function and reflexes.
• Vision, eye movement, reaction to light.
• Balance and coordination.
• Hearing.
• Strength.
• Neck muscles for their motion and for tenderness

Verbal, written or computerized tests may be used to check your:

• Thinking ability.
• Problem-solving skills.
• Memory and concentration.

You will also be asked if you’ve experienced mood changes, sleeping changes or any changes in behavior.

Imaging with CT scan or MRI isn’t always needed in the early evaluation of concussion. This is because most of the effects of a concussion aren’t seen on imaging. However, these imaging tests might be ordered if more serious effects of a concussion are suspected – like bleeding inside the skull, brain swelling or spinal cord or cervical spine injury – or if symptoms are worsening.

What tests can be used to assess my athlete’s brain to see if they are ready to go back to school or sport?

After the hands on neurological examination is complete, other neuropsychological tests can be used to assess a student-athlete’s ability to go back to school and sport.

ImPACT neuropsychological test

The immediate post-concussion assessment and cognitive test (ImPACT) is a concussion management tool used to help diagnose and evaluate student athletes. This computerized test measures a student athlete’s visual and verbal memory, reaction time, and processing speed.

The 30-minute test is ideally performed before the start of a sport season (a baseline test) and after a head injury (at various time points). Evaluating the test results and comparing with the baseline test helps care providers (healthcare, educational or sports organizations) document brain function and see if it has returned back to a student athlete’s healthy normal. It can assist with treatment decisions and help determine when it’s safe for a student athlete to return to their activity.

Hospital or Organization Concussion App

Some sports health centers within hospital systems have developed their own concussion app. These tablet-based, mobile tools are used to report and assess concussion and symptoms.

After baseline data are collected, the app can be used to document the athlete’s description of injury, track symptoms over time, detect loss of brain and memory function, and to help guide the athlete to a return to physical activity in order to get back to sport. The app compares assessments of balance, reaction time, information processing, coordination, memory, and vision after an injury to the athlete’s baseline and normative data. The app-based assessment can show the areas of most concern and help guide treatment and therapies over time.

How is a concussion treated?

You need physical and mental rest to recover from a concussion. Although you’ll need more rest and sleep than normal, you don’t need 100% complete rest. In fact, research has shown that too much mental rest can actually lengthen the recovery period and make you more sensitive to activities when you return to them.

Instead of stopping activities entirely, learn to recognize the triggers that bring on concussion symptoms. Start back slowly, in small amounts. When symptoms occur, back off and rest. It’s okay to do some of the activities that don’t make you feel worse. Limit any activities that worsen your symptoms.

For example, activities that may bring on symptoms include:

• Texting/spending time looking at your smartphone screen.
• Reading.
• Watching television.
• Playing video games.
• Listening to loud music.
• Doing any physical activity.

As your symptoms improve, you can continue to add more of your activities back into your day.

Can pain medications be taken for the headache symptom of concussion?

Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDS), such as naproxen (Aleve®) and ibuprofen (Advil®, Motrin®) should not be taken soon after a suspected concussion has occurred. These medications mask symptoms and thin the blood, which may increase the risk of bleeding. This is of special concern in elderly who fall and hit their head, as it’s not uncommon for these people to already be taking these drugs. After a concussion is diagnosed, if pain medication is needed, acetaminophen (Tylenol®) is a safer option. Symptoms need to be monitored closely.

Does diet play any role in recovery from a concussion?

There’s not much information about concussion and diet in the medical literature. There is some on nutrition and general brain health and well-being in the elderly. Some of the more researched supplements on diet include fish oils, turmeric, green tea extract and resveratrol. Any supplements taken should be in addition to a well-balanced diet high in fruits and vegetables and low in saturated fat and processed foods.

One thing to consider is that a concussed person may not feel as hungry or thirsty as before. Make sure to encourage eating throughout the day to keep blood sugar up and to try and drink six 8 oz. glasses of fluid (water, juice, Gatorade®) throughout the day. The brain is sensitive to low blood sugar and dehydration and these conditions can mimic or worsen concussion symptoms like headache, dizziness, fogginess, stomachache and irritability.

What’s a typical recovery plan for students who have experienced a concussion?

It’s important to know that recovery plans need to be individualized for each person. Your concussion specialist or family doctor can assist in creating this individualized plan and providing it to the student so they can share with the school.

At first students may need to miss several days of school for symptoms to calm down. Once the student can manage their symptoms at home in a controlled environment, they should gradually add some mental work like reading or writing in journal. If they can perform an hour of mental activity at home without worsening symptoms, they can try to return to school.

Students should not return to school for half days. Rather, they should try to complete as many classes as concussion symptoms allow each day. This may require getting more rest each day. Students should not set an alarm clock but wake when their body and brain are ready and then, if symptoms allow it, go to school. If the student gets symptoms during the school day, they should go to an agreed upon location, such as the nurse’s office or counselor’s office, and rest before returning to class. Should the student's symptoms result in them spending more time in the space designated for rest and recovery than in class, the student should consider going home.

Parents should work with teachers, school nurses, counselors or psychologists to make other adjustments in their school day. For example, students may:

• Need more time to do assignments or take a test.
• Need to have a reduced amount of schoolwork.
• Need to take extra breaks in and out of class.
• Need to have another student take notes for them.
• Need to use an electronic device to record lectures for review later.
• Need to leave the classroom early to avoid crowded hallways if they have a balance problems.

If symptoms get worse or problems that had resolved come back, cut back again and rest. Let concussion symptoms be your guide to your own recovery timeline.

How long does it take for a person to recover from a concussion?

Each concussion in each person is somewhat unique and so is their recovery timetable. In general though, most concussion symptoms resolve within 14 to 21 days. However, undiagnosed, unrecognized or poorly treated concussions can delay your recovery – increasing it from the typical two weeks to months or even longer.

If you’ve been diagnosed with a concussion and concussion symptoms are still present after 14 days or symptoms worsen, see a healthcare professional who specializes in concussion management.

What is concussion protocol?

Concussion protocol is an organization’s set of policies and procedures for caring for someone who has had a head injury. Even though concussions aren’t limited to sports, concussion protocol is most often associated with sports-related head injury.

The people involved in making sure the concussion protocol is followed include trained healthcare providers with knowledge of concussion care, athletic trainers, school nurse/counselor/teachers, rehabilitation specialists and parents.

A concussion protocol includes such information as:

• Education on concussion definition, signs and symptoms, and management.
• Pre-season baseline brain function test (ImPACT test or equivalent) of reaction time, memory, speed of mental processing and other factors per individual player.
• State law criteria for removing a player from activity.
• Sideline assessment of the head injury (includes comparison to pre-season ImPACT test or equivalent baseline results).
• School adjustments (shorter days, more breaks, extra time to finish assignments, etc.) during recovery.
• Gradual return to activity via a gradual process of small increases in activity.

How can I prevent concussion?

To reduce the risk of concussions:

• Always wear seatbelts in the car and buckle children in safety seats.
• Wear a helmet that fits when biking, riding a motorcycle, skating, skiing, horseback riding, or playing contact sports. A helmet should be secure and not move when you shake your head, but not be uncomfortably tight.
• Prevent falls on stairs by putting up handrails.
• Install safety gates on stairs to protect young children.
• Put grab bars in the bathroom, with nonslip mats in the tub and on floors.
• Improve lighting and remove trip hazards.
• Install safety guards by windows to keep children from falling out.
• Strengthen your neck muscles. Strong neck muscles may be able to help absorb some of the impact of blows to the head and decrease the risk of concussion.

When can a student athlete return to play after a concussion?

Student athletes are ready to return to play when they are:

• 100% symptom free at rest.
• 100% symptom free with normal mental activity.
• 100% symptom free with exercise.
• No longer taking any medications for concussion symptoms.
• Fully back to school and able to tolerate school work.

And

• Have a post-concussion neurocognitive test (ImPACT or other symptom and assessment tool) score that is at least as good as the pre-concussion score or pass certain criteria set by the school or athletic board.
• Have a physical exam and balance test that are within normal limits.
• Have been cleared for play by a healthcare provider trained in evaluating and managing concussions.

The thinking used to be that the student athlete needed to be symptom free for 24 hours before starting the multiphase process of physical activity toward the goal of returning to play. However, research has now shown that if the patient’s concussion symptoms are improving each day and they are able to attend a full school day with a few breaks for symptoms, they can begin to add very low level cardiovascular activities. These activities should consist of walking or biking on a stationary bike at an intensity that doesn’t make symptoms worse.

With the help of an athletic trainer or physical therapist, athletes can begin to increase their activity level each day, making sure they can tolerate increasing how hard they exercise over time without triggering symptoms before moving on. For example, start out slow with aerobic exercise, then move on to sport-specific drills, then contact activities and finally full participation. This step up in activity can take up to 10 days or longer, as each increase in activity may bring on symptoms and require rest and return to the previous step.

Following this approach, most student athletes are able to return to play within about three weeks after their symptoms began.

What can happen if an athlete who had a concussion returns to competition too soon?

Returning to competition too soon could put you at risk for a second concussion. A repeat concussion that occurs before your brain has recovered from a first one is called second impact syndrome.

Second impact syndrome can:

• Make your symptoms last longer than they would have if you rested and fully recovered.
• Slow your overall recovery.
• Increase the chances for long-lasting or permanent problems.

Long-lasting problems include difficulties with concentration and memory, headaches, and sometimes physical skills like maintaining your balance. Although this is rare, returning to competition without being fully recovered and getting hit again could result in a brain hemorrhage or even death. Never return to competition until ALL your symptoms are gone and you feel you are 100% back to your normal self.

If an athlete has a concussion, how likely are they to have another one?

Once you’ve had a concussion, you are three to five times more likely to have another concussion. The highest risk is for those who return to competition before their symptoms have completely gone away. No one should return to active play if they are still having symptoms from a concussion.

What are the long-term complications of concussion?

Long term complications of concussion include:

• Post-concussion syndrome. This is a condition in which you experience concussion symptoms for weeks or even months (instead of days) after experiencing a concussion. Such symptoms may include ongoing dizziness/spinning, headache, memory and concentration problems, mood swings, depression, anxiety, irritability, personality changes, insomnia (can’t sleep) and excessive drowsiness.
• Higher risk of anxiety and depression (especially if there’s been multiple concussions).
• Structural brain injuries from multiple concussions. People who have had several head injuries in their life are at higher risk of long-lasting impairment. Chronic traumatic encephalopathy is one example of a brain condition linked to repeated blows to the head.
• Problems with memory, naming and word-finding.
• Dementia.

Anyone who has symptoms that won’t go away or that are worsening seen be seen by their healthcare provider.

Are mild concussions serious?

Even if you’ve been told that you’ve only experienced a “mild concussion,” all concussions should be considered serious events. In most cases it’s true that a single concussion is unlikely to cause permanent brain damage. However, even having a mild concussion puts you at an increased risk of another concussion. In addition, if you were to experience another concussion before your concussion symptoms have fully gone away, you could be at greater risk of permanent damage or even death if you have another concussion.

Are concussions fatal?

It’s rare, but a concussion can lead to bleeding in the brain or brain swelling that can be fatal. This is one of the reasons why it’s so important to carefully watch a concussed person in the first 24 to 48 hours after the concussion and to seek immediate care if symptoms worsen.

Are there any cures for concussion besides rest?

There is no doubt that rest helps a brain recover from a concussion. There is research going on to determine how much rest is needed, but each concussion is treated individually. Typically, mental and physical rest is advocated. There is also research going on looking at medications that may be useful to prevent the progression of concussion, based on the physiology of what happens when the brain is initially concussed, and to help the brain "heal" more quickly.

Can a concussion cause jaw pain?

Yes. Head injuries and concussion can cause pain in your jaw as well as in the bones and muscles of your head, neck and shoulders. Temporomandibular joint disorder (injury to the jaw joint and jaw muscles) is a specific condition that can sometimes happen after hitting your head. Also, the main symptom of concussion – headache – can be the result of spasms and inflammation in your jaw muscles following a blow to the jaw.

What is a “sub-concussive” blow? How many times does a person have to be hit before showing signs of an injury?

First, every person is different. Many people can take a blow to the head without feeling or showing signs of sustaining a concussion. This is called a sub-concussive blow. In theory, one would think that taking several blows to the head would potentially “add up” to the point that the blows would cause concussion or brain injury. However, this has not been shown to be true.

There is no set number of blows and no exact or collected degree of force from blows over time that has been shown to result in a concussive injury. However we do know if you experience a blow and have shown or felt symptoms of concussion or have been diagnosed with a concussion and you continue to participate, you are at increased risk of permanent brain injury if you were to experience another concussion before you have fully healed and are 100% symptom-free.

How is whiplash, which sometimes happens along with concussion, treated?

Ongoing neck pain is a common complaint in both auto accidents and concussions. The head is bent back and forth on the cervical spine, which results in neck muscle injury and irritation. Useful treatments for whiplash include:

• Taking anti-inflammatory drugs, such as ibuprofen (Advil®, Motrin®), aspirin, or naproxen (Aleve®).
• Learning proper head/neck posture, especially when working on the computer or watching television.
• Physical therapy with a PT trained in either concussion or cervical spine.
• Massage.
• Temporarily keeping the neck still by using a soft foam neck brace (“immobilization”).
• Applying ice and/or heat (sessions of 20 minutes on, 20 minutes off).
• Injections of steroids and lidocaine into the nerve at the base of the skull to relieve pain.

Your healthcare provider can give you more specific information on these treatments or where to turn for more help.

Should someone with a concussion be woken from sleep at regular intervals?

This is a myth. This is outdated information that may even slow the recovery process. Rest helps the brain recover from a concussion. However, it’s reasonable to check on the concussed person while they sleep to make sure their breathing pattern hasn’t changed or to briefly wake them up to make sure their symptoms are not getting worse. The concussed person should be immediately seen by doctors if they fall asleep shortly after receiving a concussion or can’t be woken up.

How many concussions are too many? When should an athlete retire from their sport?

There is no general agreement on when to retire from sports due to head injuries. There are many factors to consider including:

• Number of head injuries/concussions.
• How long it took to fully recover from each concussion.
• How close together, in time, each concussion occurred.

Each concussion ups the odds of having another concussion. Each concussion is different. Each person’s reaction and ability to recover is different. You and your healthcare provider should discuss your history of concussions and be able to decide what is in you or your loved one’s best interest.

What type of healthcare provider treats concussion?

If you, your son or daughter or your older parent has experienced a mild blow to the head, you can see your family medical doctor or your pediatrician first for an initial exam. If a concussion is suspected, you may be referred to other doctors and healthcare providers who specialize in the evaluation and management of concussions. These clinicians include:

• Neurologists, neurosurgeons and neuropsychologists.
• Sports medicine specialists, exercise medicine physicians, athletic trainers.
• Neuro-ophthalmologists, vestibular therapists (therapists who specialize in dizziness symptoms ad cervical pain).

A Note from Cleveland Clinic

• Consider all head injuries as a potentially serious event. If you have a “gut instinct” that something more might be wrong or worry that a fall on the head or blow to the head needs to be checked out, do it. Call your doctor or go to the emergency room.
• Rest. Rest is one of the most important treatments for a concussion because it helps the brain to heal. Rest nearly completely for the first few days after a head injury, then slowly begin to “exercise your brain.” The unused, “stagnant” brain remains stagnant if not used and lengthens recovery. But too much use overstimulates the brain and can cause symptoms to return or worsen. Take a slow approach. Identify and avoid or limit your time doing things that cause symptoms. For example, if symptoms increase with the bright light of a computer or smartphone, adjust the brightness setting, wear sunglasses or strictly limit your time on these devices. Ease into normal activities slowly, not all at once.
• Don’t drink alcohol without your doctor's okay. Alcohol and other drugs may slow recovery and increase the chance for further injury.
• Don’t drive until cleared by your doctor. Your reaction time could be slower until you fully recover.