Concussion

A concussion is a mild traumatic brain injury (TBI). It happens when a bump, blow, or jolt to the head, or a hit to the body, causes the head and brain to move quickly back and forth. That sudden movement can stretch and stress brain cells and briefly change the way the brain works. A concussion is a functional injury rather than a structural one, which is why it often does not show up on a standard CT scan or MRI. Most people recover fully, but every concussion is a real brain injury that deserves prompt attention and careful management.

Concussions are common, especially in contact and collision sports. The Centers for Disease Control and Prevention estimates that 1.6 to 3.8 million sport- and recreation-related concussions occur in the United States each year, and the true number is likely higher because many go unreported. Young people sustain most of these injuries, and the risk is highest in sports such as football, ice hockey, soccer, and lacrosse, with concussions more likely during competition than practice.

A concussion can result from a direct impact to the head, from acceleration-deceleration forces that make the brain move back and forth inside the skull, or from a blast wave.

Symptoms

Concussion symptoms can affect how a person feels, thinks, acts, and sleeps. Some appear right away. Others may not show up for hours or days, so it helps to watch for changes over time. Symptoms are different for each person and may change during recovery.

Signs others may notice

• Appears dazed, stunned, or confused
• Cannot recall events just before or after the hit (memory loss)
• Forgets an instruction or assignment, or is unsure of the game, score, or opponent
• Moves clumsily or seems unsteady
• Answers questions slowly
• Loses consciousness, even briefly (this happens in only a minority of concussions)
• Shows changes in mood, behavior, or personality

Symptoms a person may feel

• Physical. Headache or a feeling of pressure in the head, nausea or vomiting, dizziness or balance problems, blurry or double vision, sensitivity to light or noise, and feeling tired or sluggish.
• Thinking and memory. Feeling foggy, groggy, or slowed down, trouble concentrating or remembering, and just not feeling right.
• Emotional and mood. Feeling more emotional than usual, irritable, anxious, sad, or down.
• Sleep. Sleeping more or less than usual, or trouble falling asleep.

Symptoms in infants and young children

Young children may not be able to describe how they feel, so caregivers should watch for:

• Changes in eating, nursing, or sleeping habits
• Unusual or excessive crying that is hard to console
• Loss of interest in favorite toys or activities
• Irritability or changes in mood
• Unsteadiness while standing or walking

Causes

A concussion is caused by any force that makes the head and brain move rapidly, whether from a direct hit to the head or from a blow to the body. Common causes include:

• Falls. The leading cause overall, especially among young children and older adults.
• Sports and recreation. Contact and collision sports such as football, soccer, ice hockey, basketball, and lacrosse, along with activities like cycling, skateboarding, and skiing.
• Motor vehicle crashes. Collisions involving cars, motorcycles, and bicycles, including those affecting pedestrians.
• Being struck by or against an object. A frequent cause in both sports and everyday life.
• Assault and violence. Including physical assault and, in infants, abusive head trauma.

When to seek emergency care

Most concussions are not life threatening, but a hard hit to the head can sometimes cause more serious bleeding or swelling inside the skull. Call 911 or go to the nearest emergency department if a person who has had a bump, blow, or jolt to the head or body shows any of these danger signs:

• One pupil larger than the other
• Drowsiness or being unable to wake up
• A headache that keeps getting worse and will not go away
• Slurred speech, weakness, numbness, or loss of coordination
• Repeated vomiting or nausea
• Convulsions or seizures (shaking or twitching)
• Unusual behavior, increasing confusion, restlessness, or agitation
• Loss of consciousness, even briefly

For infants and toddlers, also seek emergency care for any of the danger signs above, or if the child will not stop crying and cannot be consoled, or will not nurse or eat.

A person with a suspected concussion should be removed from play right away and should not return to sport on the same day. Returning to activity too soon, while the brain is still healing, raises the risk of a repeat concussion, which can lead to a longer recovery and, in rare cases, dangerous swelling of the brain. When in doubt, sit them out.

How a concussion is diagnosed

Only a healthcare provider can diagnose a concussion. Because a concussion changes how the brain works rather than its structure, it usually cannot be seen on a standard CT scan or MRI, and most people do not need a brain scan after a concussion. Imaging is used mainly to rule out more serious injuries, such as bleeding or a skull fracture, when danger signs are present. Instead, providers diagnose and track a concussion through:

• A clinical evaluation. A history of the injury and an exam of thinking, memory, balance, coordination, vision, and reflexes.
• Symptom assessment. Checklists that rate the type and severity of symptoms and follow how they change over time.
• Neurocognitive testing. Computerized tests of attention, memory, and reaction time. Comparing results after an injury with a baseline test taken beforehand can help guide recovery and return-to-play decisions. One widely used tool, ImPACT, was developed at the University of Pittsburgh.

Research from the University of Pittsburgh has shown that memory problems following an injury, rather than a brief loss of consciousness, are a stronger predictor of how severe a concussion is and how long recovery may take.

Treatment and recovery

The goal of treatment is to let the brain heal while preventing a second injury. Most people with a concussion feel better within a couple of weeks. Care usually includes:

• Relative rest, then a gradual return. For the first day or two, ease back on physical and mental activities that make symptoms worse. Complete rest in a dark room is no longer recommended. Light activity, such as short walks, can usually begin within a few days as long as it does not noticeably worsen symptoms.
• Returning to learn before returning to play. A person should be back to regular activities, such as school or work, before starting the steps back to sport.
• Careful use of medication. Ask a provider before taking any medicine. Acetaminophen is often used for headache. Avoid aspirin and other blood thinners unless a provider approves, and avoid alcohol and recreational drugs during recovery.
• Close monitoring. Watch for any new or worsening symptoms, which can be a sign to slow down and contact a provider.

Returning to sport: a step-by-step process

After a concussion, return to sport follows a gradual, supervised progression. Each step usually takes at least 24 hours, and a person moves to the next step only if no new symptoms appear. If symptoms return, they should stop, rest, and step back. Return-to-play decisions are medical decisions made by a healthcare provider. The current six-step progression, based on the international Concussion in Sport consensus, is:

1. Back to regular activities, such as school, with clearance from a provider to begin the progression.
2. Light aerobic activity, such as walking or stationary cycling, to gently raise the heart rate. No weightlifting yet.
3. Moderate activity with some body or head movement, such as jogging or lighter-than-usual weightlifting.
4. Heavier, non-contact activity, such as running, a regular weightlifting routine, and non-contact sport drills.
5. Full-contact practice, once cleared by a provider.
6. Return to competition.

When symptoms last longer

Most people recover within a few weeks, but some have symptoms that linger, such as ongoing headaches, dizziness, fatigue, sleep changes, trouble concentrating, or mood changes. This is sometimes called persistent post-concussive symptoms. Recovery still happens for most people, and targeted treatment, such as physical therapy, vestibular therapy, or a gradual exercise program, can help. Having more than one concussion, or returning before fully healing, is linked to longer recovery, which is why careful management of each injury matters.

Prevention

Not every concussion can be prevented, but the risk can be lowered:

• Wear properly fitted protective gear. Use a helmet suited to the sport or activity, including for biking, skating, skiing, and contact sports, and replace it after a significant impact. Mouthguards help protect the teeth and jaw.
• Learn and follow the rules. Good technique, fair play, and rules that limit dangerous contact all reduce head injuries.
• Make homes and play areas safer. Improve lighting, add handrails and nonslip mats, and keep stairs and floors clear to prevent falls, the leading cause of concussion.
• Buckle up. Always wear a seat belt, and use age-appropriate car seats and booster seats for children.
• Consider baseline testing. For athletes in contact sports, a preseason neurocognitive baseline test gives a useful comparison if a concussion later occurs.
• When in doubt, sit it out. Any athlete with a suspected concussion should stop playing and be evaluated before returning.

Care at UPMC/Pitt Neurosurgery

Neurosurgeons and specialists at UPMC/Pitt Neurosurgery evaluate and manage concussion and the full range of traumatic brain injury, from mild concussion to severe injury that requires surgery. The department has a long history in sports concussion care and research, including the development of the ImPACT neurocognitive test at the University of Pittsburgh. To learn more about our team, visit our faculty directory.