1. Concussion: Understanding Mild Traumatic Brain Injury

2. What is a TBI? Traumatic Brain Injury
Brain is damaged due to an outside force or entry or foreign object
Since our brain defines who we are, the consequences of a brain injury can affect all aspects of our lives, including ADLS and our personality.
Symptoms may appear right away or may not be present for days or weeks after the injury.

3. TBIs
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

4. 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
The word comes from the Latin concutere, which means "to shake violently."

5. What happens to the brain? What does it feel like?
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

6. 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)

7. Common signs of mild TBI
confusion or feeling dazed
clumsiness
slurred speech
nausea or vomiting
headache
balance problems or dizziness
blurred vision
sensitivity to light
sensitivity to noise
sluggishness
ringing in ears
behavior or personality changes
concentration difficulties
memory loss

8. 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

9. Common signs of mild TBI (cont.)
Nausea
Due to the swelling of the brain and the release of neuro-chemicals
Headaches
Most common sign of a concussion

10. 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

11. 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
Domestic Violence

12. Concussion Grades
Concussions are graded as mild (grade 1), moderate (grade 2), or severe (grade 3), depending on such factors as loss of consciousness, amnesia, and loss of equilibrium.
In a grade 1 concussion, symptoms last for less than 15 minutes. There is no loss of consciousness.
With a grade 2 concussion, there is no loss of consciousness but symptoms last longer than 15 minutes.
In a grade 3 concussion, the person loses consciousness, sometimes just for a few seconds

13. 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

14. 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

15. 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

16. Similar symptoms in civilian and military populations
Headache
Confusion
Nausea
Mood and behavior changes
Sensitivity to light and noise

17. 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

18. 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

19. 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

20. Alpine ski racer Lesley LaMasurier
Started skiing at age six
Attracted by challenge and speed
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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. Treatment for concussion
Brain must “rest”.
Symptomatic treatment only
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
Wake them up every 2-3 hours for the first 24 hours

32. Treatment for concussion (cont.)
Treatment has to be individualized
The main treatments are for:
Pain relief
Sleep issues
Mood and behavioral issues

33. Treatment for concussion
MD might order a CT or MRI
Why?
Should not return to activities until symptoms have resolved
Could be hours, days, or weeks

34. 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

35. 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

36. 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

37. Rehabilitation protocols in the military
A multidisciplinary team tracks every TBI patient
This team includes:
Neurologists
Physical therapists
Occupational therapists
Speech therapists
Psychologists
Neuropsychologists

38. 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

39. How are psychological effects of TBI addressed?
Early intervention with psychotherapy
Cognitive behavioral therapies
Empowering the individual with related knowledge and education

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. Documentaries In Their Boots: Part 1 In Their Boots part 2
Frontline: League of Denial