Concussion Follow-up Must be Mandated for All
Concussion Follow-Up Must be “Next Day”
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Concussion follow-up protocols are not the same for non-athletes. If we could take the model of periodic c0ncussion follow-ups from the world of sport and apply that to the brain injuries that happen in accidents, we would then likely identify almost all concussions that are likely to be disabling. Even more important than asking better questions on the day of the accident, is to have a medical professional ask the injured person something about his or her memory the next day. That next day concussion follow-up must include focus on memory for events between the time of the accident and the moment of inquiry.
Amnesia is far easier to spot at 24 hours than at 2 hours. First, there is a lot more to have forgotten as more time has passed. Second, the intact immediate memory that fools so many inquiries on the day of the accident, will create no smoke screen the next day. How much the injured person remembers of the previous 24 hours events will show how severe this particular concussion is.
Despite all of the momentum for better concussion follow-up in the NFL, we must clearly recognize that the scrutiny the athlete gets the day after the concussion is far superior to what the rest of us get. The million plus other people a year who suffer a concussion in the U.S. don’t get the next day concussion follow-up. Even those at much higher risk of a bad outcome do not get the athletes concussion follow-up. Accidental (real world) concussions involve far more serious risk of persisting disability. (They do carry less risk of second impact syndrome.) Here is a partial list of the reasons for more disability from accidental injuries:
Sport Concussion is a Young Person Injury. First, sport concussions typically happen to those with the greatest chance of a good recovery from concussion, young and athletic people. If we were going to list the three or four most common risk factors for a bad result from concussion, age would be at the top of that list. The reason for age being an issues is multiple. One reason is that younger brains have a gene that stimulates neuronal re-growth that just does not exist when a person is over 40. The closer someone is to 40 at the time of the concussion, the more likely they will have persisting deficits from the brain injury.
Men Are at Less Risk. Most sport concussions happen to men. Yet, men are at less risk of poor outcomes from brain injury. This may be seem politically incorrect to say, but women are simply more vulnerable to brain injury. This is not just because they are not as strong, but also because concussive type forces are more likely to damage the white matter of the brain. Women are more white matter dependent in their thinking than men.
The Blow is Expected. Most sport concussions happen to people who are prepared to get hit. The sport concussions that are the most serious are usually to someone who is surprised or motionless at the time of the blow. In contrast, almost all accidental concussions are a surprise. When the body knows it is going to get hit, it protects itself, considerably reducing the extent of the acceleration/deceleration. It may be that the reason that quarterbacks, running backs, wide receivers fewer concussions despite severe forces is that they anticipate the blow. The concussive blow is the minority. Have you been puzzled how an athlete can receive the same blow 100 times, then have a concussion on the next? The explanation may be that the body wasn’t prepared for the concussive hit. To use a sports analogy – the brain was blindsided.
Athletes are Stronger. Sport concussions happen to people whose bodies have stronger muscles. Stronger neck muscles significantly reduce the speed and the length of the acceleration/deceleration arc. When I speak about arc, I am speaking about how far forward, backwards or sideways the head will move on the neck, after being hit. It is this motion that accounts for most of the force on the brain’s axons.
There are about another half of dozen things that could be added to this list. Don’t forget that when you hear about permanent brain damage to professional athletes, there is a far higher risk of permanent brain damage from a single concussion to a 40 year old person who is in a motor vehicle wreck. What makes the risk of long term brain damage in professional athletes so significant is the number of concussions they might suffer over a career. Also worth mentioning is that the concussions that happen to older players are more likely to be a problem than they were earlier in their careers. As most NFL football players retire well before age 40, this phenomenon is seen mostly in quarterbacks.
As we finish this treatment of amnesia after concussion, we want to highlight these three points:
- Confusion and amnesia are not the same thing;
- Amnesia, particularly Post Traumatic Amnesia (“PTA”) cannot be determined without asking questions that test the formation of memories from the period from five minutes post injury to the time of the evaluation; and
- The most significant thing that could be done to improve the concussion and treatment of non-sport concussion would be to institute some similar system as athletic trainers use to return athletes to play for all TBI.
While we have used younger men to illustrate the principles of amnesia, those are not the ones who were at real risk of disability. That Conan O’Brien and Troy Aikman survived with little apparent disability, does not mean that the same force applied to the brains of someone more vulnerable, might not resulted in disability.
The key to understanding so called “mild” brain injury is to accept the reality that this kind of trauma will not disable the vast majority of those suffering it. Yet in a vulnerable subject or if the forces impact the brain in some unique way, significant and lasting deficits and disability may result. For that reason:
- Women need more concussion follow-up;
- All people over 40 need more concussion follow-up;
- Anyone with a history of anxiety, treatable depression, migraine or other neurological disorders, need more concussion follow-up.
How the brain gets injured in a mild traumatic brain injury will be the subject matter of our part of Brain Injury Help.