CONCUSSION

After a concussion, the symptoms that occur differ from patient to patient. Some common symptoms of mild traumatic brain injury and concussion are:

• Fatigue
• Headaches
• Visual disturbances
• Memory loss
• Poor attention/concentration
• Sleep disturbances
• Dizziness/loss of balance
• Irritability-emotional disturbances
• Feelings of depression
• Seizures
• Nausea
• Loss of smell
• Sensitivity to light and sounds
• Mood changes
• Getting lost or confused
• Slowness in thinking

Symptoms may not even appear for days or weeks after the injury.

While sport-related concussions are the most commonly talked about, concussions can happen from falls, car accidents, or other traumatic events.

The good news is over 80% of patients diagnosed with a concussion usually get back to normal within three weeks, but some may have symptoms that last longer. Not reporting a concussion puts you at risk for lasting damage.

A central issue in assessment and recovery from concussion is that it is not currently defined in terms of pathophysiologic processes but in terms of self-reported symptoms and cognitive performance. Thus “recovery” from concussion is determined by the resolution of “clinical symptoms” and “functional disturbances”. However, without the inclusion of modalities measuring underlying pathophysiological processes affecting the brain such as Qeeg, assessment of recovery from concussion remains incomplete. Fortunately, there are modalities which can provide the clinician with useful physiological measurements.

Common measures such as CT scans and fMri scans, commonly used for concussion screening, fail to detect the concussion. Studies have proven that routine CT scans after head injury can still return normal results, even though the patient may still have an early brain injury that puts them at risk for long term brain damage called CTE (Chronic Traumatic Encephalopathy) or TBI (Traumatic Brain Injury). Qeeg, which does show the concussive injury but also has limitations in that other factors can also cause the same Qeeg pattern changes observed. However, if a baseline pre-injury Qeeg is available, the changes to the brain from a concussion become significantly clearer and more reliable and can then be used repeatedly to follow treatment progress and support a return to sport.

Post-concussion syndrome happens when concussion symptoms stick around for weeks or months after the injury. It occurs in approximately only 20% of concussion cases.

Post-concussion syndrome can disrupt everyday activities, including school and social activities, and can feel like it will never improve. When unrecognized or untreated, post-concussion syndrome can seriously affect daily life. It is well established that individuals diagnosed with the post-concussion syndrome can show marked impairments in reaction times, visual motor processing, gait stability, postural balance and dynamic gait. Because the symptoms of concussions sometimes go unnoticed or are self-reported and tend to subside within 1–2 weeks, many athletes fail to seek immediate and proper medical care.

Insufficient follow-up and treatment are the main reasons for post-concussion syndrome and increases the risk of a longer concussion recovery time and returning to sport too early. Proper understanding and measuring of concussions are essential to treat the psychological and physiological factors which, in turn, can lead to a rapid post-concussion recovery period.

It is not uncommon to hear of many aspiring high school athletes who purposely avoid reporting their concussions to prevent being “benched” during subsequent games. Though almost all recreational participants express their concern about post-concussion syndrome, most competitive athletes keep quiet about their minor physical discomforts or even deny considerable pain for the sake of pursuing their career goals. This decision increases the potential for repeated head trauma. Athletes have been shown to suffer from cognitive deficits up to three years after their brain injury incidents, exhibiting lower performance on select neuropsychological tasks.( Munia, T.T.K., Haider, A., Schneider, C. et al. A Novel EEG Based Spectral Analysis of Persistent Brain Function Alteration in Athletes with Concussion History. Sci Rep 7, 17221 (2017). https://doi.org/10.1038/s41598-017-17414-x)

Repeated head injuries can be very serious. Chronic Traumatic Encephalopathy (CTE) is associated with repeated head traumas — concussions or sub-concussive hits — that are not allowed to properly heal. It is a progressive degenerative disease found in individuals who have been subjected to multiple concussions and other forms of head injury. CTE has been most commonly found in professional athletes participating in gridiron football, ice hockey, professional wrestling and other contact sports like AFL, Rugby and Football, who have experienced head trauma, resulting in characteristic degeneration of brain tissue and the accumulation of tau protein. Individuals with Chronic Traumatic Encephalopathy may show symptoms of dementia such as memory loss, aggression, confusion, and depression which may appear within months of the trauma or many decades later. Concussion and mild Traumatic Brain Injury is also believed to increase one’s risk for ALzheimers.

A number of well-known American athletes have been affected by the condition with serious consequences that included suicide, psychosis and even homicidal incidents to such an extent that athletes are now well aware of the future risks and choosing to leave their sporting careers earlier.

Unfortunately, there’s no easy answer in concussion prevention. Some parents think that keeping their children out of contact sports will prevent concussion.

However, a concussion can also be caused by non-contact sports, car accidents, and falls.

There are a variety of concussion “prevention” toys available on the marketplace. These devices claim to help prevent a concussion. However, there is little research available to support claims that a device can prevent a concussion.

The best plan is to get educated on concussion symptoms and acquire baseline testing. If your school or sports league does not offer baseline testing, reach out to Neuroperformance.

After proper education, baseline testing is a great way to be prepared if you get a concussion.

Baseline testing is increasingly being used and recommended in the USA and only just beginning to emerge here in Australia (neuropsych testing only). Baseline testing typically involves neurocognitive testing that allows you to document the healthy brain function of an uninjured test taker.  If they suffer a head injury, post-injury testing is believed to identify the cognitive deficits incurred and help you make concussion treatment decisions. At Neuroperformance, we still see value in including neurocognitive testing and use the COGNIFIT battery of neuropsych tests.

The reliability of traditional cognitive assessment tools is debatable, yet it is critical to assess concussion and mild traumatic brain injury (mTBI) with high accuracy to avoid post-concussion syndrome.

Numerous other diagnostic tools exist, but few are cost-effective. Many investigative options have been proposed to diagnose and characterize concussion. CT is the most commonly used imaging modality—mainly because it is quick, widely available and relatively inexpensive. While CT can rule out significant trauma, it does little to help the provider in a concussion workup. MRI and neuropsychologic testing get us a bit closer, but are much more time-consuming and expensive, especially the latter. Newer work positron emission tomography (PET), functional MRIs (fMRIs), and certain biomarkers (e.g., GFAP, UCH-L1) is intriguing but not ready for prime time.

Rethinking electroencephalography (EEG) in concussion: The power of QEEG.

Perhaps surprisingly, EEG was used as early as the 1940s to establish a qualitative link between TBI and abnormal brain function. Despite decades of research, standard EEG never emerged as a first line diagnostic tool for concussion. This has perhaps changed with the advent of more sophisticated technologies such as QEEG (quantitative EEG) and advanced EEG diagnostic algorithms. In broad-ranging 2017 literature review 460 articles from between 1996 and 2016, Authors Ianof and Anghinah concluded that conventional EEG is only useful in the evaluation of post-concussion epilepsy, but “not useful as a routine screening measure among individuals with mTBI or postconcussive symptoms.” Their assessment of QEEG, however, was just the opposite. In concussed individuals, QEEG showed immediate reduction in mean alpha frequency, with increased theta, increased delta, or increased theta:alpha ratio.2 While the authors highlighted the fact that no clear EEG of QEEG features are unique to mTBI, their research revealed patterns of QEEG abnormality that correlated with acute, subacute and chronic concussion. From these results, the authors conclude QEEG “appears promising as a diagnostic assessment for mTBI and post-concussive symptoms.”

In a systematic literature review of studies examining resting state EEG (rsEEG) following concussion, Conley et al. found that concussed athletes rather consistently exhibit abnormal theta oscillations.3 The authors also noted that compared to pre-injury baseline or controls, concussed players had lower theta power, increased theta coherence, or increased frontotemporal theta power.3 Importantly, abnormalities in theta oscillations are associated with difficulties in attention goal directed cognition, decision-making, athletic performance, memory and sleep. They are also associated with anxiety and suicidal ideation. Larger studies will be required to determine if there are consistent pathognomonic features on rsEEG to determine the severity of concussion and predict outcome and risk of recurrence.

QEEG as a tool for pre-season screening, post-concussion assessment, and long-term follow up

The Committee on Sports-Related Concussions in Youth (USA) writes in Sports-Related Concussions in Youth: Improving the Science, Changing the Culture, that QEEG “can detect differences in performance and neural responses in concussed versus non-concussed student athletes in high school and college even when behavior measures fail to do so… Such results suggest that QEEG techniques could provide a more effective means to identify athletes with impairments following concussion and to predict when they might more safely return to play.”4

While it remains difficult to elucidate any EEG or even QEEG changes that reliably occur in individuals with concussion (post injury) and that are absent in healthy controls, the power to detect meaningful changes in my view, lie in BASELINE pre-and post-concussion comparisons. Since QEEG acquisition is now significantly more affordable, there is a strong argument for QEEG screening for athletes as part of their preseason health physicals. This data would be an invaluable comparator for concussion assessment to help identify theta wave changes and other indictors consistent with acute TBI and concussion.

More studies are always needed. However, in my view and in considering the other areas within which Qeeg is being used, there is a credible and established basis both in the literature and in practice, particularly when the risks are so high and a lack of anything of value currently available, for this tool to be used at this point as a baseline and post-concussion comparison. This provides a very powerful, and uniquely individualized tool to identify brain changes; target and implement recovery treatment that is personalized, and monitor the brains recovery. This may be helpful in being more informed around return to sport readiness and thereby possibly reduce the risk of long-term impacts such as CTE.

Give Neuroperformance a call for your Pre-Season, Baseline cognitive and Qeeg testing.

1.Langlois JA, Rutland-Brown W, Wald MM. The Epidemiology and Impact of Traumatic Brain Injury: A Brief Overview. J Head Trauma Rehabil. 2006;21(5):375-378.

2.Ianof JN, Anghinah R. Traumatic Brain Injury: An Eeg Point of View. Dement Neuropsychol. 2017;11(1):3-5. doi:10.1590/1980-57642016dn11-010002

3.Conley AC, Cooper PS, Karayanidis F, et al. Resting State Electroencephalography and Sports-Related Concussion: A Systematic Review. J Neurotrauma. 2018. doi:10.1089/neu.2018.5761

4.Committee on Sports-Related Concussions in Youth. The National Academies Collection: Reports Funded by National Institutes of Health. In: Graham R, Rivara FP, Ford MA, Spicer CM, eds. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington (DC): National Academies Press (US); 2014