Concussion:
Understanding
Mild Traumatic Brain Injury
Moderated by
Doris McMillon
Featuring
James Kelly, M.D.
Professor of Neurosurgery and Physical Medicine and Rehabilitation at the University
of Colorado Denver School of Medicine
Aditya Bhagwat, M.D.
Clinical Neuropsychologist from Walter Reed Army Medical Center
Lesley LeMasurier
a college senior at the University of Colorado; trained with the United States Ski Team
until the toll of cumulative mild TBIs ended her ski career
Mild TBIs are concussions
• Each year, more than 1.5 million people experience some
form of traumatic brain injury (TBI)
• 85% of people with mild TBI have no long-term symptoms
• 15% of people with mild TBI have lingering or long-term
symptoms
• Many people don’t realize they have sustained a mild TBI
What is a concussion?
• It is at the mild end of the spectrum of traumatic brain injury
• May be confused or have a lapse in memory
– Reflecting brain dysfunction
• You don’t have to lose consciousness in order to sustain a
concussion
What happens to the brain?
• Impact shakes the brain inside the skull
• A wave through brain tissue causes discharge of damaging
chemicals
• Nerve cells can shear
• Microscopic damage can affect the anatomy and function of
brain cells
How can I tell if I’d had a concussion?
• You don’t have to lose consciousness
• The person may think they were unconscious because they
can’t account for some span of time (memory gap)
Common signs of mild TBI
•
•
•
•
•
•
•
Headaches
Nausea
Confusion
Slow thinking
Sleep changes
Mood changes
Dizziness
Common signs of mild TBI (cont.)
• State of confusion
– Length of time can vary, depending on the severity of the injury
– Could last a few seconds, minutes, or even hours
Common signs of mild TBI (cont.)
• Nausea
– Due to the swelling of the brain and the release of neurochemicals
• Headaches
– Most common sign of a concussion
Common signs of mild TBI (cont.)
• Mood changes
– May result in depression due to the dysfunction of the brain
– Depression may go away, but some need help in counseling or
medications
Common causes of mild TBI
• Motor vehicle collisions
• Falls
– Toddlers learning to walk
– Elderly who are beginning to experience coordination
problems
• Contact sports
– More common amongst 15 – 25 year old males
TBI in the military
• 20% of soldiers in Iraq and Afghanistan have suffered some
type of TBI
• Most are mild TBIs, but some are moderate to severe
• Increased awareness is leading to better tracking and
screening
TBI in the military (cont.)
• Concussions
– The majority of military injuries are mild concussions
• Moderate to severe TBI
–
–
–
–
More severe loss of consciousness
Contusions or bleeds, such as a brain hemorrhage
More symptomatic
Longer recovery
Causes of TBI in service members
• Falls
– Being thrown against the ground or a wall during an explosion
– Falling out of a motor vehicle
• Penetrating injuries (the more moderate to severe TBI)
– gunshot wounds
– shrapnel from improvised explosive devices (IEDs)
• Blast injuries
• Other combat-related injuries
Similar symptoms in civilian and military populations
•
•
•
•
•
Headache
Confusion
Nausea
Mood and behavior changes
Sensitivity to light and noise
Identifying TBI in service members
• Screenings
– Wounded are screened at the hospital
– Returning soldiers are screened by a physician – usually a
questionnaire that asks about symptoms
• Diagnosis
–
–
–
–
Cognitive
Neuro-testing
Interview
Medical records
Short video on mild TBI
• Featuring
–
–
–
–
Dr. James Kelly
Dr. Randall Chestnut, neurosurgeon
Pat LaFontaine, retired NHL ice hockey player
Garrick Utley, reporter
Alpine ski racer Lesley LaMasurier
• Started skiing at age six
• Attracted by challenge and speed
Crashing and TBI – part and parcel of skiing?
• For many years, Lesley rarely questioned her crashing
– It was just something that came with the sport
• She became more fearful when she was a teenager and
started crashing more and more frequently
Lesley’s history of concussions
• First mild concussion occurred playing soccer
– did not lose consciousness
– confused state of mind
– headache
• Experienced two more concussion while skiing
• Doctors and coaches told her simply to be careful
Lesley’s major crash
• Was training with the United States Ski Team while dealing
with TBI symptoms for two years
– Migraines
– Trouble sleeping
– Difficulty staying focused
• Entered a race with a broken leg and torn ligaments
– Crashed and found her helmet in two pieces at her side
Pressure to continue
• Pressure from coaches, teammates, and family members
• Pressure to tough it out; get back on the slopes
• Kept her symptoms from others so she wouldn’t come
across as complaining
No more faking it
• Lesley’s symptoms started to get worse:
–
–
–
–
Migraines
Increased heart rate
Vision difficulties
Didn’t feel like herself, wondered what was wrong
• “No blood, no break…keep going”
• Ended up in the hospital for MRI scans and other tests
What can parents and coaches do to help their young
athletes?
• Take even seemingly minor injuries to the head seriously
• Seek closer monitoring to protect athletes from additional
concussions
• Identify healthcare professionals to diagnose the nature of
the injury
• Seek additional, more specialized care if necessary
Changing the “no pain, no gain” mindset
• There is often pressure from coaches, teammates, parents,
and the athletes themselves to continue to play even when
injured
• Education and awareness about the short- and long-term
effects of TBI are crucial
• Athletes often tend to listen more to their teammates than to
doctors when it comes to being careful and seeking
treatment after a TBI
Military TBI assessment tool: MACE
• Military Acute Concussion Evaluation (MACE)
– Developed by Defense and Veterans Brain Injury Center
• Anytime there is an incident – whether an explosion or car
crash – this instrument can be brought out and the solider
can be quickly assessed for signs of a TBI
• Includes history of incident and questions that assess
neurological state of person
Do multiple concussions make a person like Lesley
more vulnerable?
• The persistence of symptoms and some subtle findings on
examinations suggest that it would be unwise for Lesley to
return to her previous level of competitive skiing
• Lesley has retired
– The risks are too high, but continued improvement is definitely
part of the picture
How long do cumulative effects last?
• If there is another risk or exposure soon after a concussion,
the likelihood of experiencing a repeated concussion is great
• With athletes who have had at least two or three concussions,
a decade, two, or even a lifetime of increased risk of
concussion is possible
• Statistically the risk is greater if people have a history of
concussions
Lesley’s most serious symptoms
• Increased heart rate
– So high for so long that it would lead to exhaustion
– Elevated even when she was just standing
•
•
•
•
Shortness of breath
Trouble sleeping
Ongoing migraines and exhaustion
Sweating
What is postural orthostatic tachycardia syndrome?
• The heart rate goes up dramatically and abnormally when
you stand
– This is something physicians haven’t paid enough attention to
• It can be one of the residual effects of concussion or mild
TBI
Invisible TBI-related symptoms in soldiers
• The military’s goal is to make sure no TBI is invisible
– Every hospital service will know about the possibility of a TBI
• Every patient with a possible TBI or any injury above the
neck is thoroughly evaluated
Treatment for concussion
• Common effective treatment
– Eliminate or reduce their pain for better sleep
• Sleep is crucial
– If physicians can help patients sleep better in a predictable,
every-night pattern and get deep, restful, rejuvenating sleep,
concussion symptoms often resolve
Treatment for concussion (cont.)
• Treatment has to be individualized
• The main treatments are for:
– Pain relief
– Sleep issues
– Mood and behavioral issues
Quality of treatment
• The nation is improving in all areas little by little, but we’ve
still got a long way to go
– Still struggling with emergency departments dismissing a
concussion rather than identifying and dealing with it
Treatment of TBI in the military population
• Treatment is symptom-driven
– Soldiers often have other traumatic injuries as well as
psychological trauma from post-traumatic stress disorder
(PTSD)
• Physicians first work to control pain
• The military also works to educate service members about
prevention and early intervention
Unique challenges dealing with mild TBI in the military
• Patients often have multiple traumas that may perpetuate
the symptoms that might have started with a concussion
– Multiple injuries that can lead to multiple surgeries and
ongoing rehabilitation
• The overlay of pain and other injuries along with the
psychological issues can complicate the medical picture
Rehabilitation protocols in the military
• A multidisciplinary team tracks every TBI patient
• This team includes:
–
–
–
–
–
–
Neurologists
Physical therapists
Occupational therapists
Speech therapists
Psychologists
Neuropsychologists
Rehabilitation protocols in the military (cont.)
• Rehabilitation and treatment starts at Walter Reed Army
Medical Center (WRAMC)
• Then the team works with the Veterans Administration (VA)
and community-based organizations to help each TBI
patient get the help he or she needs
Determining the best treatment for a mild TBI
• Doctors actions for treatment
– Will look at what happened to the person at the time of injury
– Might speak with paramedics to get more information about
the event
– Might interview the person’s family, friends, or co-workers to
look at the whole spectrum of change in that person post-TBI,
to determine whether a concussion actually occurred, how bad
it was, and what kind of treatment would be best
Researchers’ contributions to mild TBI
• Discovering what are ideal treatments for mild TBI
• Information dissemination
– What are the effects?
– What the recovery expectations?
– What treatments work best with certain types of symptoms?
How are psychological effects of TBI addressed?
• Early intervention with psychotherapy
• Cognitive behavioral therapies
• Empowering the individual with related knowledge and
education
Finally finding out why
• TBI can alter a person’s moods and behavior – his or her
whole sense of self
• For Lesley, it was an enormous relief to her as well as to her
family and friends to understand that her behavioral
changes were a result of her repeat concussions, not
something else
Short video on preventing TBI
• Featuring
–
–
–
–
Dr. James Kelly
Dr. Randall Chestnut, neurosurgeon
Pat LaFontaine, retired NHL ice hockey player
Garrick Utley, reporter
Should kids be allowed to play certain sports?
• That is an individual family’s choice
• The most important thing that parents can do to keep their
children safe is to make sure they wear helmets and other
proper safety equipment
Ways to make sports safer
• Wear the proper helmet for each sport
• Reduce risk of injury by changing some of the rules in
certain sports
– banning intentional hitting from football and ice hockey
• Ban boxing entirely
• Stop players from taking unnecessary risks in sports when it
comes to repeat concussions
Baseline testing for TBI
• To date, there is no baseline testing for the general
population
– Pro sports teams and big colleges mostly perform baseline
testing on their players
Baseline testing for TBI (cont.)
• Baseline testing includes a battery of cognitive and other
tests that can be done before the individual is at risk of
some kind of concussion
• After an injury, the same test would be repeated to show
any differences or deficits and then to track the recovery
from there
The challenges of baseline testing for TBI
• Getting an individual at his or her optimal level both for the
baseline test and the test(s) post-injury would be
challenging
– People get the flu, they might have a bad sleep, or a fight with
their spouse causing their test to run lower than it might
• For the military: the sheer volume of testing necessary for
the number of service members alone would make
efficiency difficult
Getting people to take prevention seriously
• Getting the average person to wear a seatbelt, or a helmet
when riding a motorcycle or bicycle is often challenging
• Some people simply don’t want to be told what to do
– They don’t like restrictions
• Some people may minimize what the effects of a
concussion can be
– They may not think “getting their bell rung” is a big deal
because they have not been properly educated about the
effects of a concussion
How can you encourage adults to wear helmets?
• Injury can still occur while wearing a helmet
• Everyone should take that extra precaution to avoid more
severe injuries
• Put your pride aside
Can heading a soccer ball lead to a concussion?
• The Institute of Medicine claims that if it’s done correctly in
the usual manner of propelling the ball in the other direction,
a concussion will not occur
• There is no current evidence that children’s brains are being
injured by heading a ball
Can concussions lead to Alzheimer’s?
• Repeated concussions can increase your risk
• The issue is a combination of genetic predisposition and the
exposure to concussion
What are some long-term effects of concussions?
• The statistical risk of a future concussion is increased, but
long-term risks are unknown
– No data at this time
Aging issues versus concussion symptoms?
• Has the senior citizen experienced a head injury from a fall
or has been struck in the head
– Look at the effects of a concussion
• Memory loss
• Headaches
• Nausea
• Dizziness
• Light sensitivity
• If no injury has occurred and the senior citizen is only
experiencing memory loss, it is possible dementia
Any recommendations for those who are forced to give
up sports?
• Having to give up a sport is often difficult to accept
– Focus attention on other activities
• Academics
• Working out
• Mild activities, such as tennis or golf
• Probably never experience their thrill, but they can find other
avenues
Can brain exercises help a concussion?
• Brain exercises are part of the rehabilitation process
– Used by speech language pathologists and occupational
therapists
• Beneficial for the general population
– with or without an injury
Dr. Bhagwat’s final thoughts
• Educating the public and raising awareness about
concussion and its short- and long-term effects is crucial
Lesley’s final thoughts
• If people are feeling the symptoms related to TBI – athletes,
anybody – they need to seek the proper help
• These symptoms aren’t a result of a poor attitude
– There may have something wrong with the brain
Dr. Kelly’s final thoughts
• One of the best treatments for brain injury is preventing it
Learn more
• To learn more about traumatic brain injury, signs and
symptoms, treatment options, and ways to prevent it, please
visit
BrainLine is funded by the Defense and Veterans Brain Injury
Center, the primary operational TBI component of the Defense
Centers of Excellence for Psychological Health and Traumatic
Brain Injury, through a subcontract award with the Henry M.
Jackson Foundation for the Advancement of Military Medicine.
Acknowledgment of Support and Disclaimer
This material is based upon work supported by the USAMRAA under
Contract Number W81XWH-07-C-0089.
Any opinions, findings and conclusions or recommendations expressed
in this material are those of the author(s) and do not necessarily reflect
the views of the USAMRAA.
© Greater Washington Educational Telecommunications Association, Inc., 2008