Sports Concussions and Traumatic Brain Injury: Making the Invisible Visible

In the last few years, American culture has become more conversant in the language of concussion and traumatic brain injury (TBI). Press coverage of both military veterans and football players experiencing extremes such as suicide has forced these tough-minded institutions to investigate and treat these unseen and often ignored injuries.

UVA, the NFL and TBI

UVA’s brain injury team, in fact, has played a leading role in performing the research and services to help treat and prevent brain injuries that occur on the field or in the line of duty. Both neurologist Michael Jaffee, MD, who has facilitated information-sharing on concussions between the Department of Defense and the NFL, and neuropsychologist Jeff Barth, PhD, member of the NFL Players Association’s Mackey-White Traumatic Brain Injury Committee, came to national attention for their work in a recent book and PBS documentary, “League of Denial.”

Donna Broshek, PhD, credits the NFL publicity around brain injury for raising awareness that has helped all athletes take concussions seriously.

“Now that the NFL is publicizing concussion safety and supporting concussion legislation for youth, it has had a big impact. We used to talk for years about safety and concussions and people would think we were making a big deal out of a minor injury. Because of so many publicized, very sad stories of former NFL players, it’s raised awareness of concussion safety.”

Broshek, and her colleagues Howard Goodkin, MD and Jason Freeman, PhD, are members of the concussion advisory committees for Charlottesville and Albemarle school systems. Broshek and Goodkin are also actively involved in the concussion management programs at St. Anne’s-Belfield School. Broshek points to another change with a major impact on the safety of young athletes: “Virginia passed a state law in 2011 mandating public school education and concussion safety protocols. It’s made a huge difference. Schools have to worry about sports concussion now; they have to manage it and follow a protocol for managing it, so the awareness has really increased. People realize you have to take it seriously, you can’t ignore it.”

The Double Whammy: Why Concussions Get Worse

So what makes a concussion so harmful? According to Broshek, it’s all about 1) the invisible nature of brain injury, and 2) the risk that increases when more than one concussion occurs.

Broshek explains, “People tend not to realize the seriousness of concussions because they can’t see them. An ankle break, knee brace – it’s so obvious that there’s an injury. A brain injury? It’s often invisible.”

Failing to recognize when a concussion has occurred and not getting appropriate rest to allow the brain to heal leaves people vulnerable to more concussions. For people under age of 24, “if they get a second impact within a very short period of time, it can cause exponential problems. So it’s really getting people out of activity after a concussion, giving them some time to rest, and beginning a gradual return to activity.”

The severe problems experienced by former NFL players seem to occur after years of “concussions and multiple subconcussive blows, just hit after hit after hit after hit with no rest periods.”  Rest is an important part of concussion management.

TBI and Concussion: It’s a Chemical Thing

What makes an injury a TBI, not just a concussion? “It’s an indication of severity. Concussions fall within the realm of mild brain injury. People often think TBI means that the injury is permanent,” Broshek says. “Most concussions cause temporary symptoms.”

“The interesting thing about a sports concussion is basically it’s a transmission of forces to the brain, so it doesn’t necessarily have to be a hit to the head – even a hit to the body can cause forces to be transmitted to the brain.”

For example, “when you’re watching a sporting event, and you see two players collide, and one player might get hit hard in the chest and the head snaps back and forward and what that actually causes is an acceleration-deceleration injury. The brain is moving back and forth in the skull, and that causes a metabolic disruption in the brain,” says Broshek.

This explains why concussions have been so invisible and ignored: Because this kind of injury typically doesn’t affect the structures of the brain, CTs and MRIs (brain scans) typically don’t show damage. “So you won’t see anything on an image, but it causes a neurochemical change so the chemicals that keep the brain functioning smoothly tend to get disrupted,” she says.

How the Brain Reacts After a Concussion

Perhaps surprisingly, the neurochemical reactions following a physical blow are responsible for the symptoms of a concussion. Because the brain operates on glucose, when the concussion happens, “The brain needs more glucose to get back to its starting point, but at that point the body can’t deliver the glucose to the brain, so there is an energy crisis in the brain. And that’s why people feel dazed, some people pass out, have a loss of consciousness, feel confused, or nauseous … anything that the brain does could be disrupted – all the thinking abilities, the brain’s ability to maintain your balance, and vision problems such as double or blurred vision.” Symptoms start to disappear as the chemicals in the brain return back to normal.

Concussions don’t just happen to athletes, of course. Little kids might fall out of trees or off bikes; seniors come in having experienced falls and car accidents. Broshek explains that both the very young and the very old tend to have more severe accidents and their injuries can be more complicated and harder to recover from, 30 days or longer.

How to Recover from a Concussion

The first thing a concussion requires for healing: Rest. Not only does the brain need to reset, but people should avoid physical activity that could risk another injury while recovering from the first.

Broshek’s advice is simple: Get good rest, eat well and avoid alcohol. Recovery time depends on gender and age, but is usually 5-10 days for a healthy adult.

Broshek emphasizes, though, that going too far in the direction of rest can actually be unhealthy for a healing brain. “Exercise is good for the body; you sleep better, think better, it improves your mood. You might not return to competitive sports just yet, but you need to get moving again after an initial period of rest. Exercise helps with cognitive function: Memory and learning. We recommend a gradual return to physical activity under the supervision of an athletic trainer so that exercise is started gradually while symptoms are monitored.”

Complicating Factors of TBI

Despite all the pioneering research the UVA team has done and continues to perform, Broshek underscores that “there are a lot of people who have played football, but not everybody has had those kind of devastating neurologic injuries we hear about in the media, so we don’t really know why some athletes are at greater risk for a poor outcome than others.”

For her, concussion injury often depends on factors unique to the individual. Broshek and other sports team health care providers recommend a baseline cognitive and physical assessment of players before an injury takes place, which then makes it easier to detect a concussion when and if it should happen.

“We do see concussions with prolonged symptoms and slower recovery” Broshek says. That’s when she looks for complicating factors like anxiety, history of multiple concussions, learning disabilities, ADHD, or other medical conditions —  all of which can affect concussion recovery.

Understanding the brain remains Broshek’s life work.

“There is so much we’ve learned about the brain — how it works, what different parts do, how the way you choose to think can affect your brain physiology — but there’s still so much we don’t know.  We do know that the brain is the source of who you are – your intellect and your personality – and protecting it is our goal.”

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