Let's Talk About Concussions

Concussions get a lot of attention in team sports like football, soccer, and rugby, but really, artistic athletes need to be paying just as much attention and need to be as aware of the mechanisms, symptoms, and management of concussion. Just because we don’t generally purposefully tackle each other (I know this is debatable in some partner work ;) ), this doesn't mean we are immune to or not at risk of this kind of injury.

The literature available on concussions in performing artists is minimal compared to other sports. Regardless, we know they happen and know that these sports all have risks for concussions mechanisms. The little bit of research I was able to access regarding concussions in dancers showed that they were somewhat likely to know the mechanisms and symptoms of concussions, but were not likely to self report symptoms in the case of occurrence! This shows us 2 things:

1. Despite the understanding of the presence of concussion, there is a lack of understanding as to the potential effects of a mismanaged concussion

2. There is a culture within dance (ballet specifically for this study) that does not empower the athlete to speak up about their well-being. (While I know some great change is happening in this respect, I don’t think this is a new insight for most of us, and we still have a lot of work to do)

Let's start by talking about how this injury happens:

It is now understood that concussions are a functional injury, causing a disturbance in the metabolic processes of the brain, rather than a structural injury. This means that concussion causes a disruption in the energy use and creation process in the brain, rather than causing damage to the actual structures of the brain (Did you know the previous "brain bruise"/ coup-contre-coup hypothesis?)

Think of the brain as a Jello mold. When significant acceleration or deceleration forces are

translated through the brain, the brain "jiggles", causing a stretching of the individual nerve cells or neurons. When this deformation happens, the walls of the cell become permeable to calcium ions on the outside of the cell, and the rapid influx of these positively charged ions causes depolarization of our neurons, and therefore a huge surge of action potentials, i.e. electrical impulses.

So, a little less jargon-y, our brain cells start sending lots of strong signals very quickly through the brain and to the body. This is why we may see symptoms like a loss of consciousness, seizures, disorientation, and/or lack of coordination soon after the initial mechanism of injury. This first phase is called the excitation phase.

We need to be clear about this: it is the acceleration for to the brain that causes the injury, therefore, one does not need to be specifically hit in the head to suffer a concussion. Getting hit or falling on another part of the body that then translates the force up to the head, (e.g. slipping and landing on your butt, getting hit or falling on the side), can translate enough force to cause a concussion. Even whipping the head/neck back , e.g. if you lose control when doing a catch/fall on an aerial apparatus, or for specific choreography, can generate enough force to do the same.

Once more for my people in the back: YOU DO NOT NEED TO HIT YOUR HEAD TO GET A CONCUSSION.

Our nerve cell is now full of calcium ions and these ions loves to hang out in the mitochondria of the cell. Mitochondria are our little power plants, they are responsible for energy creation in the cell, but the presence of calcium interferes with their function and efficiency at creating energy. This is a big problem because, as the nerve cells wants to get pump the calcium out in order to restore function and ionic balance of the cell, this requires energy, but now our cell cannot efficiently create energy!

I know this sounds scary, but with proper management, mitochondrial function can be restored in about 3-4 weeks. However, if in this time, we encounter another concussion mechanism, and we drop our mitochondrial function even more, we risk severe and irreversible symptoms, and even death. While second impact syndrome is still somewhat debated in the literature, a second impact can turn the mild traumatic brain injury that is a concussion into a severe traumatic brain injury, something we are more likely to see from high speed collisions.

Symptoms

If you have the following symptoms following a mechanism, remove yourself or your athlete from activity and seek medical attention immediately:

• Neck pain or tenderness

• Double vision

• Weakness or tingling/ burning in arms or legs

• Severe or increasing headache

• Seizure or convulsion

• Loss of consciousness

• Deteriorating conscious state

• Vomiting

• Increasingly restless, agitated or combative

Concussions signs and symptoms are variable, therefore multiple facets of brain function need to be tested and monitored. Self-reported symptoms of concussion, presenting immediately after occurrence or within a few hours, can include:

• Headache

• Anxiety, nervousness

• Feeling slowed down

• Confusion

• Pressure in the head

• Blurred vision

• Not feeling "right"

• Drowsiness

• Neck pain

• Balance or coordination problems

• Difficulty concentrating

• Increased emotionality

• Dizziness

• Sensitivity to light

• Difficulty remembering

• Irritability

• Feeling in a fog

• Sensitivity to noise

• Fatigue or low energy

• Sadness

• Trouble falling asleep

Signs of sport related concussion can include:

• Balance impairments, gait unsteadiness

• Amnesia, neurological deficit

• Behavioral changes

• Cognitive impairment, e.g. slow reaction time, difficulty concentrating, impaired visual processing

• Decreased physical capacity

It is recommended that concussion assessments include testing of a variety of brain functions and neurocognitive capacity, as, due to the variability in concussion symptoms, no single test has an adequately high sensitivity (i.e. ability to detect the given pathology). Research shows that while dancers may be aware of concussion symptoms, they are less likely to report symptoms. This leaves it to the teacher to watch their students and advocate for them.

Management

The most important take away I can give you here is that if you suspect a concussion, remove yourself or your athlete from activity and go be assessed by a medical doctor or other qualified professional. Concussions are treatable injuries, however, if they are not appropriately cared for, they can become chronic and even have devastating outcomes. This is your brain, do not take a chance on it.

The old method of complete rest has now been shown to have worse outcomes than if one begins activity as soon as possible after injury. An athlete should rest for 24-48 hours after initial injury, and then begin sub-symptom threshold activity prior to gradual guided return to sport. When I say activity here, I mean SUB-SYMPTOM THRESHOLD, LIGHT INTENSITY, LITTLE TO NO RISK OF BONKING THAT NOGGIN A SECOND TIME. So, go for a short walk, do the dishes, read a book, as long as it doesn’t cause an increase or worsening of symptoms. Start with 10-15 minutes at a time, and slowly increase as your body allows. If symptoms come about, stop and take a little rest.

Work with your medical provider to create a graduated return to school/work and return to sport plan. These will be different based on what causes flare ups in your system but should include tests of several aspects of brain function and physical capacity. Full return may take time, and that is okay. Remember, it can take up to 3 or 4 weeks for our brain to be able to produce energy the same way it did pre-injury, this is not a return process we need to rush.

If symptoms persist, you and your medical provider must work to determine which systems are struggling and create and individualized rehab plan for them. This can include but is not limited to: manual therapy for the neck, vestibular or visual rehab, sub threshold exercise, nutritional or pharmaceutical intervention.

Let's wrap our heads around it:

Concussions are a functional injury due to acceleration or deceleration forces causing an impairment to the metabolism of our brain cells. Symptoms can vary widely, but any symptom is still a symptom! If you suspect a concussion remove yourself or your athlete from activity and seek care from a qualified medical provider. Concussions can be a scary injury but know that they are manageable and treatable with good outcomes if handled appropriately. We are learning more everyday about the physiology of concussions, both in their mechanisms and for their rehab.

Athletic Therapists are trained in concussion recognition and rehabilitation. This is your brain, we can’t mess around with it. If you suspect that you or one of your athletes has suffered a concussion, contact me here to book an assessment and start the road to recovery.

References:

Complete Concussion Management Inc. What You Need to Know About Concussions Educational Handbook. 2021. https://completeconcussions.com/resources/educational-resources/

Giza, C. C., & Hovda, D. A. (2014). The new neurometabolic cascade of concussion. Neurosurgery, 75 Suppl 4(0 4), S24–S33. https://doi.org/10.1227/NEU.0000000000000505

McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine 2017;51:838-847.

McIntyre, L., & Liederbach, M. (2016). Concussion Knowledge and Behaviors in a Sample of the Dance Community. Journal of dance medicine & science : official publication of the International Association for Dance Medicine & Science, 20(2), 79–88. https://doi.org/10.12678/1089-313X.20.2.79

Scorza, K. A., & Cole, W. (2019). Current Concepts in Concussion: Initial Evaluation and Management. American family physician, 99(7), 426–434.

Stein, C. J., Kinney, S. A., McCrystal, T., Carew, E. A., Bottino, N. M., Meehan Iii, W. P., & Micheli, L. J. (2014). Dance-related concussion: a case series. Journal of dance medicine & science : official publication of the International Association for Dance Medicine & Science, 18(2), 53–61. https://doi.org/10.12678/1089-313X.18.2.53