For every concussion reported, experts estimate 26 are ignored or treated at home. Medical providers across the region are working to change that by increasing awareness about concussions and making it easier for people to get the care they need fast.
By Sarah Markel
As head athletic trainer for T.C. Williams High School, Marjorie Franke stands on the sidelines of every football practice and every game watching for signs of injury—particularly concussion.
Normally, when a player gets hit, she notifies the coach so he or she can pull the player for a series of state-mandated sideline concussion screenings. This past season, during one particular game, something about a player’s behavior on the field caught her attention. “For a few plays in a row, he struggled to get up,” says Franke, who leads concussion training for parents and athletes at the school. “When he stood up, he appeared to be stumbling, and his teammates were patting him on the back.”
Even though she hadn’t seen the player take a hit, Franke didn’t wait to call a medical timeout. She just started running onto the field.
An Emerging Crisis
A decade ago, there wasn’t much talk about concussions, even in the medical profession. “As we went through medical school and residency, we barely saw any concussions,” says Ejaz Shamim, a neurologist with Kaiser Permanente. Dr. Shamim completed his medical residency in 2005. “Nobody ever talked about it. Now we are seeing it a lot more.”
Increased media attention has heightened awareness of the risks of concussion. Football has been the focus of much of this attention, as with Sony Pictures’ Christmas Day release of the movie Concussion. The issue had surfaced well before, however. For example, T.C. Williams’ Marjorie Franke credits the 2013 Frontline documentary League of Denial with increasing her vigilance about concussions, even though she had learned about concussions in college and graduate school. A class action lawsuit brought by more than 5,000 players against the NFL has also spurred awareness of the long-term risks of the degenerative disease known as chronic traumatic encephalopathy. CTE, as it is called, has been found in the brains of football players with a history of repetitive brain trauma.
In response to the growing awareness of the risks of concussions, local, state and federal governments are increasing funding for concussion research. Between 2009 and 2014, all 50 states and the District of Columbia passed laws requiring school districts to address concussion safety.
In 2010, Virginia began requiring schools to educate coaches, players and parents about concussions. When a student is suspected of having a concussion, the law requires he or she be removed from play for at least 24 hours. State-certified athletic trainers do a sideline assessment immediately. Before returning to play, students must be cleared by a licensed medical provider. In Northern Virginia, schools also require neuropsychological testing and clearance by the school’s head athletic trainer before a player returns to the field.
The effects of concussion extend to the workplace and classroom, as well. In 2009, when Rylie Power suffered two concussions within six months while playing travel soccer in Midlothian, her grades immediately began to suffer. Her school did not yet have any policies in place for accommodating students with brain injuries. Luckily, because of the ongoing push for concussion awareness, her teachers understood that her headaches, fatigue and difficulty thinking were the result of her brain injury. “People were understanding and willing to work around my issue,” says Power, who is now 21. Teachers extended deadlines, altered reading-intensive assignments and conducted one-on-one sessions after school.
In 2014, the Brain Injury Association of Virginia and the Virginia Athletic Trainers Association successfully lobbied for the state’s concussion rules to be extended to the classroom. Now schools must provide academic accommodations for all students experiencing concussion symptoms.
Yet while the risks of concussions in sports get a lot of attention, they are not the only cause of this serious injury. Concussions—or mild traumatic brain injuries (mTBIs) as they are also called—are one of the more common injuries U.S. service members suffer in improvised explosive device attacks. People can also get concussions slipping on ice, falling from trees and riding in cars. In fact, of the 5,127 children and young adults in Virginia who were hospitalized for concussions between 2004 and 2014, almost half were injured in car accidents. Among older adults, falls were the most common cause of head injuries.
The Centers for Disease Control and Prevention estimates that traumatic brain injuries accounted for around 2.5 million emergency room visits, hospitalizations and deaths in the United States in 2010. Experts say this statistic vastly underestimates the real prevalence of brain injuries because it only includes people who sought treatment for severe injuries. It doesn’t include those seen in doctors offices or—and this is the part that worries public health officials—those who simply chose to ignore getting hit on the head.
It’s often very hard for a young athlete to step away from the sport that caused an injury. Power says that after her second concussion, it was less of a decision than a mandate from her parents and doctors. “It was hard to wrap my head around at that age,” she says of the process of giving up the sport that had been at the center of life for over a decade. “As I was recovering physically, I had it in my head that I would be back to normal soon.”
Concussions are like fingerprints
Concussion is an injury to the brain that causes a temporary change in normal brain function. Unlike the more severe traumatic brain injury, which involves visible damage to the brain like bleeding or swelling, concussions damage the brain at the cellular level.
When a person hits their head, explains Dr. Ali Ganjei, director of rehabilitation at Inova Hospital System and a member of Inova’s concussion program, “the sudden trauma causes a shake-up of the brain cells and most importantly the wires of the brain. What we get is microscopic damage to these wires.” In response, the cells jump into action trying to repair themselves, and that in turn disrupts normal cell activity. These changes can lead to headaches, feelings of dizziness and nausea, memory problems, confusion and sensitivity to light and sound. Friends and family members may notice changes in mood or behavior.
The other term for concussion is mild TBI, but the use of the word mild can be misleading, according to Dr. Gerard Gioia, director of the Safe Concussion Outcome Recovery and Education Program at Children’s National Health System. “I always put it in quotes,” says Dr. Gioia, who also thinks the word concussion may be too soft. “Mild TBI is anything but mild.”
Concussions cannot be seen using the brain imaging technologies available today. Therefore doctors must rely on the reported symptoms and health history of the patient to determine whether a person’s headaches are the result of a concussion or part of some other medical issue, or if the patient’s apparent irritability is a sign of brain trauma or just a bad day. “Assessing the severity of concussion is purely subjective and depends on experience of examiner,” Dr. Ganjei says. That subjectivity, coupled with the fact that no two people will respond to the same hit in the exact same way, makes concussions hard to diagnose. “Each concussion is as unique as a fingerprint,” Dr. Ganjei says.
Concussions can have long-term effects as well. Researchers are still working to fully understand the exact link between multiple concussions and degenerative brain diseases such as chronic traumatic encephalopathy, Alzheimer’s disease and dementia. According to Dr. Edward Allcock, a rehabilitation specialist at Virginia Hospital Center, the link between concussions and brain disease is intuitively obvious, especially when it comes to multiple concussions. “The brain can only absorb so many insults before permanent damage occurs,” he says.
Treatment
Patients in Northern Virginia have good options for concussion management. A decade ago, the SCORE program at Children’s National Health System became the region’s first comprehensive concussion management program. Now three additional area clinics bring together a range of medical specialties to treat all aspects of a concussion in one setting.
Even outside these clinics, there is a high degree of collaboration and coordination among concussion physicians in the region, according to Julie O’Brien, the nurse navigator for Inova’s concussion program. She frequently connects patients to providers in neighboring programs if there is an issue that Inova’s 41 concussion providers can’t address. She also helps patients navigate Inova’s concussion-related resources, like neuropsychological testing, even if they want to stay with their primary physician in another system.
That assistance and coordination is particularly important, says Victoria, a patient at Inova’s concussion clinic, when the person dealing with a concussion has to coordinate his or her own care. “When you sustain a concussion, it can be difficult to think clearly about where to start,” says Victoria, who asked that her real name not be used. She added that because symptoms of concussion change over time, it can be hard for a busy person to even be certain their headaches and fatigue are in fact caused by concussion. “You can’t diagnose yourself,” she says. “Julie was able to listen and get me to the right people.”
Getting a new patient appointment with a neurologist in Northern Virginia usually means a wait time of three to six months, but the concussion clinics help patients bypass the wait times and be seen within days—and sometimes hours—of taking a hit, says O’Brien. This is important because timely intervention is a critical part of concussion management. Kaiser Permanente even uses video conferencing so people visiting their local clinics can speak with a neurologist trained in concussion management the same day, even if that provider is at a different location.
Recovery
The difficulty in properly diagnosing concussions is part of what makes them dangerous. A growing body of research is showing that while most people recover from a single concussion within a few weeks, those who return to normal activities too soon are in danger of causing lasting damage to the brain. Even a small hit can overwhelm a still-recovering brain.
“The biggest problem with concussions is that people just don’t understand that if you have a concussion, you are at high risk for another concussion because they are additive,” says Kaiser Permanente’s Dr. Shamim.
Just as concussion symptoms vary, recovery times are different for each person, too.
A 2013 Institute of Medicine report found that most people recover from a concussion within two weeks of the injury, but in 10 to 20 percent of cases, concussion symptoms persist for a number of weeks, months or even years.
The previous medical thinking was that as long as a patient had symptoms, rest was the gold standard. Now experts say this is not only unrealistic, but it’s also probably unwise. Instead, they now recommend what is known as active rehabilitation. “The research is now showing that desensitization is the way to go,” explains Inova’s Dr. Ganjei.
Brett Gustman, a certified athletic trainer at Fairfax Family Practice’s Comprehensive Concussion Clinic, explains that giving the brain a break from intense cognitive stimulation and then gradually resuming normal activities makes more sense. This is particularly true for busy teenagers who rely on their electronic devices for just about everything. “There has to be a balance between rest and stimulation,” says Gustman. “You have to use your brain as you recover.”
If a patient has lingering symptoms after a period of graduated rest, rehabilitation specialists then work with them to manage symptoms and improve their day-to-day functioning. Dr. Allcock, the rehabilitation specialist at Virginia Hospital Center, notes that, depending on the patient, this frequently involves some combination of medication, cognitive rehabilitation, physical therapy and behavioral health counseling. Sometimes figuring out what works can be a process. “If a person is not making improvements, you need to reassess them to see if something more is involved and provide therapies or additional supports to them,” Dr. Allcock explains.
Six years after her concussion, Power, now a senior at James Madison University, still experiences symptoms daily, especially when she is exposed to noise or a lot of visual stimulation. “It tends to sneak up on me at random times,” she says. Concerts are tough; going out to restaurants or parties with a lot of people and trying to hold a conversation con be challenging. “TBI is often discussed as an event—but it’s a chronic process that affects every aspect of a person’s life,” says Power.
It’s important to realize, however, that not every problem is caused by concussion. That’s because, as Marjorie Franke found when she ran onto the field at the T.C. Williams game last season, the behaviors that look like concussion can just as easily turn out to be something else. In that particular situation, the teenager was having an off day; he wasn’t feeling like himself, but he hadn’t taken a hit. Franke has no regrets about stopping the game. In fact, she says, the incident only underscores the importance of raising public awareness about how complicated it can be to identify a concussion. “We are still educating people,” Franke says. “There is still room to grow.”
Area Multidisciplinary Concussion Programs:
Children’s National Safe Concussion
Outcome Recovery & Education Program
202-476-7267
Comprehensive Concussion Center
703-391-2020
703-776-4700
Novant Health Sports Medicine & Concussion Management
703-368-3161
Concussion Resources:
Concussion Recognition and Response App
The Brain Injury Association of Virginia
( February 2016 )