• Gail Richards

Back to School; Back to Concussions

By Guest Blogger, Dr. Matthew Shem, DC, DACNB


With school about to start there will be an increase in organized sports participation and in many organizations this also means an increase occurrence of concussions. Often times schools proceed with the standardized protocol when it comes to return to school or return to play and I would just like to use this article to emphasize the importance of individualized care when it comes to recovering from a concussion.



Every concussive event is unique. What I mean by this is that depending on how one was hit, the force in which they were struck, the posture they were in upon collision, their awareness during the collision, the number of concussive events they have had in the past, the function of relative areas within their brain prior to the collision, the strength of their neck prior to the collision, etc can all contribute to how one responds to the concussive event.

The Centers for Disease Control and Prevention (CDC) defines concussion as a traumatic brain injury (TBI) caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, stretching and damaging brain cells and creating chemical changes in the brain. The most recent population data estimates 2.5 million traumatic brain injury–related emergency room visits, hospitalizations, and deaths occur each year in the United States(1), making it one of the most common neurological conditions.


Concussion may cause a variety of impairments that can impact an individual’s ability to return to meaningful activities such as an athlete returning to sport, a student returning to school, a civilian returning to work, or a service member returning to duty. Due to the frequency of concussions, which some reports estimate to occur every fifteen seconds in the United States, and the detrimental effects concussion can have on function, the Centers for Disease Control and Prevention (CDC) has labeled concussion a major public health issue that is accompanied by considerable personal and socioeconomic costs(2). The annual economic burden associated with concussion has been estimated to be $16.7 billion USD, with an estimated direct cost of $35,000 to $45,000 USD per patient(3,4).


First let’s lay out a general guideline of what happens during a concussion. During a concussive event your brain is exposed to a series of different vectors that can ultimately lead to torsion and sheering and even blunt force trauma of the brain to take place. When this occurs there are areas that are more have a proclivity towards experiencing more damage relative to another region. Imagine a wet towel getting rung out; when this takes place the center of that towel will undergo the most amount of torsion. The same things happens to your brainstem and it ends up placing a lot of stress on the midline structures of your brainstem, those being the centers that regulate your heart rate, the ability for your eyes to move, your sense of where you’re located in space, digestion, breathing, etc.


One real important area that I’d like to discuss in this article is called the vestibular nuclei. This area in the brainstem takes in information from the inner ear (vestibular system), your neck (proprioceptive system), and your visual system. Think of your eyes, neck, and inner ear as a triad that supplies information to the brain about where you are located in space. When one of these systems gets damaged and can no longer transmit the appropriate signal, the other two have to pick up the slack and work overtime in order to supply the brain with all the information it needs. Knowing where we are in space is crucial to us as humans because humans are designed to move. It's the same as when you get into your car to head to a place you’ve never been and you put the destination in your GPS. Your GPS has to know what your current location is otherwise you will never end up at the correct destination. These three systems need to work in unison and relay the same coordinates to the brain so that we can properly navigate this world.


When you have dysfunction in just one of these systems it makes it to where the other two systems must work harder to make up for the loss of information. When this occurs it can now lead to symptoms such as dizziness, headache, brain fog, balance issues, nausea, visual issues, cognitive impairment, memory loss, etc. Of these 3 systems, based upon my own clinical experience the vestibular system seems to be the system that is most frequently impaired, and often the most overlooked. In fact the literature actually states that “vestibular deficits in children and adolescents with a history of concussion are highly prevalent. These deficits appear to be associated with extended recovery times and poorer performance on neuro-cognitive testing.”(5) 



According to the CDC return to play consists of:


Step 1: Back to regular activities (such as school)


Athlete is back to their regular activities (such as school) and has the green-light from their healthcare provider to begin the return to play process.


Step 2: Light aerobic activity


Begin with light aerobic exercise only to increase an athlete’s heart rate. This means about 5 to 10 minutes on an exercise bike, walking, or light jogging. No weight lifting at this point.


Step 3: Moderate activity


Continue with activities to increase an athlete’s heart rate with body or head movement. This includes moderate jogging, brief running, moderate-intensity stationary biking, moderate-intensity weightlifting (less time and/or less weight from their typical routine).


Step 4: Heavy, non-contact activity 


Add heavy non-contact physical activity, such as sprinting/running, high-intensity stationary biking, regular weightlifting routine, non-contact sport-specific drills (in 3 planes of movement).


Step 5: Practice & ful contact 


Young athlete may return to practice and full contact (if appropriate for the sport) in controlled practice.


Step 6: Competition


Young athlete may return to competition.” (6)


While it is important to have standardized rules and guidelines that must be followed these guidelines are not uniquely designed for each individual in order to best support their specific impairment.


In a recent study they found that “Adolescents with post-concussion syndrome (PCS) and treated with vestibular rehab are nearly 4 times more likely to have medical clearance to return to sports within 2 months of initiating therapy.” (7) However, not a single one of the 6 return to play steps incorporates vestibular rehabilitation. This is by no means saying that every individual who suffers a concussive event requires vestibular rehab but I hope this emphasizes the importance of how complex concussion rehab can and should be in order to receive the best possible outcomes and ultimately get you back out on the field/court/arena as quick as possible.


References:

Cancelliere C, Coronado VG, Taylor CA, Xu L. Epidemiology of isolated versus nonisolated mild traumatic brain injury treated in emergency departments in the United States, 2006-2012: sociodemographic characteristics. J Head Trauma Rehabil. 2017;32(4):E37-E46.


Collins MW, Kontos AP, Okonkwo DO, et al. Statements of Agreement from the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting held in Pittsburgh, October 15-16, 2015. Neurosurgery. 2016;79(6):912-929.


Humphreys I, Wood RL, Phillips CJ, Macey S. The costs of traumatic brain injury: a literature review. Clinicoecon Outcomes Res. 2013;5: 281-287.


Marshall S, Bayley M, McCullagh S, et al. Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms. Brain Inj. 2015;29(6):688-700.


Corwin DJ, Wiebe DJ, Zonfrillo MR, Grady MF, Robinson RL, Goodman AM, Master CL. Vestibular Deficits following Youth Concussion. J Pediatr. 2015 May;166(5):1221-5. doi: 10.1016/j.jpeds.2015.01.039. Epub 2015 Mar 5. PMID: 25748568; PMCID: PMC4485554.


https://www.cdc.gov/headsup/basics/return_to_sports.html


Ahluwalia R, Miller S, Dawoud FM, Malave JO, Tyson H, Bonfield CM, Yengo-Kahn AM. A Pilot Study Evaluating the Timing of Vestibular Therapy After Sport-Related Concussion: Is Earlier Better? Sports Health. 2021 Nov-Dec;13(6):573-579. doi: 10.1177/1941738121998687. Epub 2021 Mar 6. PMID: 33682532; PMCID: PMC8558999.

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