Concussions need immediate care, then a gradual recovery

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Today we're talking about concussions with Dr. Matthew Grier. He's an assistant professor of physical medicine and rehabilitation and co-director of the Concussion Clinic at Upstate.

Welcome to "The Informed Patient," Dr. Grier.

Matthew Grier, DO: Thank you. I appreciate you having me.

Host Amber Smith: Now, to start off with, are all head injuries that occur during sports necessarily concussions?

Matthew Grier, DO: Thankfully, no. So a cascade of events have to follow that event occurring, in order for it to qualify as a concussion.

Host Amber Smith: So how do you define concussion, or what are those cascade of events that have to occur?

Matthew Grier, DO: Concussion's considered a mild traumatic brain injury. And so, essentially, it results from a transfer of mechanical energy to the brain from external forces, resulting from either the head being struck directly with an object, the head striking a hard object or surface, or the brain undergoing an acceleration or deceleration moment without direct contact between the head and an object on the surface.

And also, it's important to look at the forces that were generated there. A good example of that are concussive injuries classically are from explosions, and just that trauma itself could be enough to create the atmosphere where concussion would occur.

Host Amber Smith: Now, those of us that watch NFL games see potential concussions every game, it seems like.

Can you watch a tackle and determine whether it's a concussion or not, or how do you diagnose that it was a concussion?

Matthew Grier, DO: Well, you're exactly right. There's so much force being applied. The difference is with the protective equipment, say, in football, which is designed to mitigate some of that force. So rather than the trauma or the direct force being transmitted directly to the skull, it's carried through the helmet or down to the shoulders through the padding that they wear.

But things that we watch for are the angle of the injury itself. So typically you're more likely to see concussive injuries when there's a torsional moment, or the body's twisted in space, or if the player was not prepared for impact.

Host Amber Smith: I see. Now, if you're in the hospital, and someone comes in with a suspected concussion, you won't have the benefit of having seen that collision, so how do you go about determining?

Matthew Grier, DO: We try to, as best we can, ascertain what occurred and how, and what forces were applied. Here at our clinic we see a host of different mechanisms causing concussions. Motor vehicle accidents, for example, are very common here. So we try to get the story as best we can from the patient if they're able to relay it. But what we're looking for really are some clinical signs that would indicate that there's been some structural damage.

One is, is there a reported loss of consciousness or not immediately following the injury? And if so, how long did that loss of consciousness occur for? That's a big one.

The second is, is there an alteration of the patient's mental status immediately following the injury or upon regaining consciousness? What we're looking for there is, there'd be evidence by reduced responsiveness or inappropriate responses to external stimuli. So essentially, like a flash of light, and a patient jumps across the room to try to get away from it.

We also look for, is there a general slowness to their response? Are they sluggish? Do they appear agitated? Are they able to follow simple commands and two-step commands accurately? And of course, their orientation. Do they know where they're at, why they're there, what day of the week it is, those types of things?

Host Amber Smith: So if there was a loss of consciousness, does that mean it was a concussion?

Matthew Grier, DO: It is more likely; it doesn't necessarily mean that. It doesn't give you a grade of the concussion. It just says that there was a significant force applied about the head if there's a loss of consciousness, unless there's other factors at play. Some things like we see here, people will get syncopal, or basically, their blood pressure drops quickly for a host of reasons, be it a cardiac reason, or be it their blood sugar is low.

And then they have a fall. And so it gets a little bit cloudier there, so it's always trying to put it into context of what's presented.

Host Amber Smith: And could a person have a concussion if they didn't lose consciousness?

Matthew Grier, DO: Yes. Yeah, and that's pretty common. You will see, typically, it's something I've taken to call "God's erase button," where the person won't remember the exact event, or they won't remember five minutes leading to it or maybe five minutes after, so that amnesia. And I call it God's erase button because reliving that can bring out other things down the road, like post-traumatic stress disorder or anxiety with driving, et cetera.

But the amnesia part's important, in terms of how long that persists for. People who are significantly injured and have a more severe concussion by our estimation, typically have longer amnesic periods. They may not remember the entire day prior, they may not remember the day going forward or two days after the injury, and they start remembering day-to-day events.

Host Amber Smith: We mentioned football. What other sports do you see concussions in, typically?

Matthew Grier, DO: If you look internationally, the No. 1 sport for concussions has remained rugby for some time. And I think if you've ever watched rugby, it's easy to understand why. But here, more regionally, we're looking at the contact sports.

Ice hockey would be pretty high up on the list there, too. I believe it's No. 2 in most of the scales I looked at.

Then we have lacrosse; that would be third.

Soccer actually is pretty common. We see probably more soccer players over here than football players in our clinic, and I think that's due to some variables and that it's not considered a contact sport, but yet people are moving at high speeds, and they're going for headers, or they're trying to pass looking right, and someone slide-tackles them from the left, and they're not prepared for it as much, and they really have no protection.

After that, wrestling. You would think it would be higher, but they do use different techniques of wrestling, and they're heavily trained how to keep their head midline. And they also wear protective gear as well. As the winter comes on, we'll see more basketball players as well. That usually occurs when they're going for rebounds or coming down from grabbing a board, for example.

And then our softball and baseball players would come in next.

And we've had a fair number of cheerleaders, especially the flyers, who are on top of the pyramid, so to speak, who get missed or dropped.

And then even volleyball would make the list of the more common ones.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Dr. Matthew Grier. He's an assistant professor of physical medicine and rehabilitation at Upstate, and we're talking about concussion.

So let's talk about how concussion is treated, starting from when the head injury happens. What is the concussion protocol for schools in New York state?

Matthew Grier, DO: So in New York state, and this is based on the Concussion Management and Awareness Act, which is from 2011, but also includes non-public schools effective in July, I believe, of 2023. Essentially, if any student, an athlete or not, is suspected of sustaining a concussion, either at home for the non-athletes or even the athletes, or witnessed, the first thing that is done is they are removed from play or academic participation for a period of at least 24 hours.

Now, depending on the environment where they're injured, there's a big discrepancy. So if this happens during a sporting event, there is going to be an evaluation done, typically at the field or at the court, by the athletic trainer, and by the medical personnel if they're available to do so.

The problem is the non-athletes, because a lot of these things happen, and so then we really have to rely on observation of school staff. is this person acting differently when they come to school, are they struggling to keep their eyes open? Are they putting their head down because of bright lights? Do they seem agitated?

And so then, they become the reporter and have to do the investigation. But if there's suspicion of concussion with them, the rules are the same. They're removed completely for at least 24 hours, until they're symptom-free, essentially. And then there's protocols for both your non-student athletes and your student athletes for returning to participation, both academically and athletically.

Host Amber Smith: At what point would they need or consider the Concussion Clinic?

Matthew Grier, DO: We kind of serve a unique role over here. We have a couple clinics where we're trying to get people in more readily, for these student athletes who were just injured or your non-student athlete who was just injured. So we have some specialty clinics to get them over here, and typically we're involved when symptoms are not improving or if they're actually going the other direction, and things are getting worse for them.

But we don't typically see people within a day or two of the initial injury. Most concussions, if you look at them kind of across the board, they improved within usually two months, about 82% of them, regardless of intervention. So we tend to get the people who did not improve, and that kind of falls into the world of post-concussion syndrome, where people have persistent symptomatology that was brought on by the event, that's not improving, and they need some further diagnostics and medical intervention, as well as our skilled therapists, to get back to their baseline and functioning.

Host Amber Smith: Well, it sounds like the majority do get better and are able to return to their sport, I assume?

Matthew Grier, DO: Yeah, the vast majority do. And in New York state and in most states, there's criteria for how you return them to sport.

Take a football player, for example. He is injured on say, a Sunday game. He's removed from all play for 24 hours. If he's reporting no ongoing symptoms at that time, and he's cleared by a medical professional, then he starts what's called the "return-to-play protocol," which is a graduated series of advancing exercise and cardiovascular work all the way up until, participating in contact drills again.

But each one of those steps takes 24 hours without recurrence of symptoms, so for someone to go from grade one, which is really light activity, like walking at an increased rate without an increase in symptoms greater than two points on a visual analog scale, meaning if he has a headache, and he reports a two and it doesn't get to a four, then they're OK to move on to the next level, which is again, just gradual increase in work.

And again, each step takes 24 hours without a recurrence of symptoms or worsening of symptoms. If they do not, let's say you're at a stage two, and you're doing a little bit more from a cardio standpoint, but your headache goes from a two to a five, then you're going to be knocked back down to stage one again, until they can be advanced.

Host Amber Smith: Some of this is subjective on the athlete's part, is that right?

Matthew Grier, DO: Yes, it is, and there's the difficulty. And some of the testingthat's available for sideline work is designed or configured really to try to tease that out, because so much of this is subjective reporting. So a lot of schools, in the area and also nationally, use computerized-based testing, which is usually administered to all of the athletes prior to the season and prior to participation, and then repeated at the time of the injury, when it's deemed appropriate by the medical staff, to see if there's a variance in and of themselves objectively on cognitive testing.

Host Amber Smith: Well, we've been talking about children or young adults, but concussions can happen to anyone. Are there differences in how they're diagnosed or treated in an older adult?

Matthew Grier, DO: Well, there is, and so it's interesting. Children typically take longer to recover from concussion than, say, your middle-aged adult, but it's bimodal, meaning that the kids take a little bit longer, then the elderly can take longer as well. And there's different reasons there in terms of why we think that that occurs.

But in children, you have a developing brain, you have connections being formed all the time. And then with concussion, you need to do a little bit of rewiring because with the force, there's a diffuse axonal injury, typically. What that means is the outside of the brain and the inside of the brain are connected by all these little inner neurons, and with the force applied to the brain, those areas travel at the same speed, but they don't stop at the same speed. The midbrain is denser or heavier. And so there's actually a loss of some of those connecting axons.

And that happens with adults, too. And the variance is how much room the brain has to move. And so in the elderly population, we see more cortical atrophy, or the brain gets smaller, as we age. But what that means is the skull does not, and there's relatively more room for that brain to be shaken around. But you're more likely to see bleeding events in the elderly, versus in children.

Host Amber Smith: If we're talking about the elderly, how does something like dementia complicate a diagnosis?

Matthew Grier, DO: It certainly does. And we've had countless patients who were on that borderline, maybe having some age-related memory changes, but they were kind of living with it or putting it off to just getting older.

And then after a concussive event, it becomes more fulminent. It's kind of the straw that broke the camel's back. And then we work here a lot with our gerontology department once we identify that this looks more like a dementia than a concussion, then we work with them as well for assistance and help with medication management there.

Host Amber Smith: Well, looking ahead, does a history of concussion set someone up for other medical problems in the future?

Matthew Grier, DO: Yeah, and this is a hot-topic issue, and it's in and out of the lay press all the time. To the best of my knowledge and a recent literature search on this, having one concussion, which you recovered from fully, does not seemto bring any long-term effect or risk for things like developing dementia or chronic traumatic encephalopathy.

Having repeated concussions is really the problem and why these return-to-play protocols exist, because we know if a brain is trying to heal, and it's injured again in that period, then likely the second concussion is going to be far worse than the first one.

So that's really what we're trying to avoid, by identifying these people early on and then gradually returning them to play, making sure, as best we can, that they are as safe as they can be and at a normal risk of injury for their sport.

Host Amber Smith: So it's cumulative damage over the years, over the decades, perhaps?

Matthew Grier, DO: Yes, perhaps. I think what we have to bear in mind, these protocols didn't exist, back even when I was in high school or college. They'd play college hockey, they'd brush it off, get you back out there. So I think we're seeing the effects of what happens when people rush back to participate more than anything else, versus what's this going to look like in 20 years if someone's gone through the return-to-play protocol, and they've had multiple concussions, but the brain was fully recovered before the second or third one occurred. I think you're going to see some different outcomes down the road, but the jury, to be fair, is still out on that.

Host Amber Smith: Well, I appreciate you making time for this interview, Dr. Grier.

Matthew Grier, DO: Sure. It was my pleasure. I appreciate your time.

Host Amber Smith: My guest has been Dr. Matthew Grier, an assistant professor of physical medicine and rehabilitation and co-director of the Concussion Clinic at Upstate.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

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