Have a Concussion? Let’s Make it Worse and Find Out.
The world of sports is a dangerous place for athletes. The speed and power of athletes can sometimes result in collisions and injuries that can leave athletes sidelined anywhere from a few minutes to an entire season… or worse. But, only the injuries that we can see on the outside are easy to diagnose and treat. Injuries, with equal severity (if not more), happen frequently and can go unnoticed. An athlete’s brain is at constant risk of injury during sports. Even a small bumping of heads with another athlete can result in concussion. These brain injuries can leave people with a loss of memory, dizziness, blurred vision, and sometimes completely knocked-out. Diagnosing concussions can be tricky because athletes often do not show immediate or significant symptoms. According to Tracey Covassin, Bryan Crutcher, & Jessica Wallace (2013), the way athletic trainers and doctors assess whether or not an athlete is concussed or cleared for activity requires increasing concussive symptoms. So is there another way, or is the injured athlete’s depressing reality just a pro-longed road to recovery?
So what exactly is a Concussion?
Covassin, Crutcher, & Wallace define a concussion as “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces” (2013)…ok, but what the hell does that mean? Basically, a concussion is a type of traumatic injury to the brain that is caused when the head or body is hit, jolted, or whiplashed, causing the brain to smash into the inside of the skull. When this happens, the brain can swell and chemical changes occur in order to protect and recover from the blow. These chemical changes are what cause the negative side affects such as headache, dizziness, feeling tired, nausea, memory loss, loss of balance, and in some cases loss of consciousness. Along with these physical side effects, the brain’s ability to preform cognitive tasks is also inhibited (2013).
Cognitive Tasks and Concussions
Cognition is the process our brain uses in order to learn and make sense of the world around us. Cognitive tasks include everything from identifying faces and patterns, to remembering the meaning of the word “sports.” It is how we make sense of our experiences in life, and teach ourselves how to respond to certain events. It is how we assign meaning to the words “dog” and “cat.” and how we are able to remember what those two animals are. So, when the brain is affected by the chemical changes induced by a concussion, causing decreases in brain activation, all the seemingly simple and automatic everyday tasks become difficult. Remembering what two plus two equals changes from the difficulty of kindergarten level math, to the difficulty of an undergrad calc class (maybe not to that extreme but you get the point). But, that’s not the worst part… The worst part is this: in order to assess the severity of a concussion, or to understand if a person is still concussed, the injured person has to take a simple Post-Concussion Assessment and Cognitive Test (ImPACT) which entails a bunch of memory, click on the dot, and remember the shape type tasks. Wait, that seems pretty easy, right? Well, no, not right.
Tracey Covassin, Bryan Crutcher, & Jessica Wallace wanted to see if this simple ImPACT test was actually making concussion symptoms worse after completion (spoiler alert: it does). Not much research had been done on this topic, so these three psychologists designed an experiment in 2013 to answer the following question: Does a 20 minute cognitive task increase concussion symptoms in concussed athletes (2013)?
High school and colligate athletes (concussed athletes) were recruited for their experiment. These athletes were given an ImPACT test 3 and 10 days after rattling their brain. Covassin, Crutcher, & Wallace then observed a number of symptoms from the athletes who reported increases or decreases in their symptom severity on a 1-7 scale (Likert scale, where 1 is low and 7 is high). They used the ImPACT test because it is standard athletic protocol for athletes with head injuries to complete an ImPACT test. This test utilizes span tasks and non-verbal problem solving sets to measure an array of cognitive functions such as attention span, selective attention, working memory, response variability, problem solving and reaction time (click here for the full ImPACT test and website). After collecting the data from the athletes participating in the study, the experimenters then compared the results to a baseline concussion assessment, which were the athletes’ ImPACT scores from a pre-concussion, or perfectly healthy, test (2013). What they found is concerning for athletes recovering from a concussion.
The results of this study revealed that the post-concussion assessment test administered in order to figure out if an athlete can safely return to the field, court, or mountain, does in fact increase some concussive symptoms. Covassin, Crutcher, & Wallace found increases in symptoms that are typical of concussions such as headache, nausea, dizziness, visual problems and mental fogginess. In the table below, you can see significant differences in these symptoms from before and after the concussion/assessments. 
What Does This Mean for Athletes with Head Injuries?
As if concussions weren’t bad enough, it seems that the only way to continue along the road to recovery is to go backwards at times. The fact of the matter is that these cognitive tasks and assessments (like the ImPACT) are standard and necessary for determining where an athlete is along his or her road to recovery. That means that just when an athlete starts to feel better, we can only truly tell by making symptoms worse again. Is this really the only way to assess concussions?
Being an alpine skier who has suffered from multiple concussions, and gone through the process of straining my already beat -up brain doing tedious ImPACT tests, I want to believe there is some other way to assess a concussion without making symptoms worse. Maybe there is way to image the brain instead of forcing it to complete tasks that make your head spin and hurt. I think figuring out another way to assess concussions, with little brain activity required by the athlete, could speed up recovery and get athletes back in the game quicker than before.
Click here to read/download the full article.
Check out this other interesting article about assessing the cognitive consequences of concussions here.
Covassin, T., Crutcher, B., & Wallace, J. (2013). Does a 20 minute cognitive task increase concussion symptoms in concussed athletes?. Brain Injury, 27(13-14), 1589-1594. doi:10.3109/02699052.2013.823656
Images:
https://www.google.com/search?q=concussion&espv=2&biw=1347&bih=801&tbm=isch&source=lnms&sa=X&ved=0ahUKEwjAj8Oq2qrJAhUSo4gKHQTmC8wQ_AUICCgD#tbm=isch&q=football+concussion&imgrc=s-AKs9WljTngzM%3A
I think one thing that this article does not address is the attentional component of the ImPACT test and the effect that can have on concussed athletes. The study this article focuses on found out that concussion symptoms are worsened by the ImPACT test, but they did not have the opportunity to test what aspect of the ImPACT test is harmful to concussed people. Our class discussions mentioned that we may have a limited attentional capacity, which gets used in different quantities based on the difficulty of the task, but we did not discuss how that capacity varies among people with brain injuries (besides Dementia). It would be interesting to learn how someone’s capacity for attention changes when they are concussed, but that is likely harmful for the person being tested and therefore unethical. People with concussions are told not to do anything that requires them to focus or attend to something for more than a few minutes, which is much less than the regular attention span of about 90 minutes alotted for a task without our brains getting overly taxed or distracted. The ImPACT test can take un-concussed athletes 50 minutes and not tax their attentional resources more than any other task of a similar difficulty, but for people with concussions, 50 minutes of the test is harmful in part because it is 50 minutes of trying to attend to the task and perform well. It would be particularly interesting if future studies were able to discover which aspects of attention are most affected by concussions–attentional capacity and duration or if one type of attention is more affected than another. For example, this could be whether attentional shift (a voluntary change of where your attention is directed) is more affected than attentional capture (an unintentional change of where your attention is focused caused by some sort of stimuli).
I understand the article and I understand and respect Kacie’s comment but I think they both oversimplify the process of having a concussion and the necessity to assess the severity or existence of that said concussion. One of the basic idea’s of the ImPACT test is that it can asses whether or not someone who has received a hard hit to the head has a concussion or not, or whether or not someone who has had a concussion and gone through the concussion process may return to play. I think whatever test you develop will strain the user because that user will need to be able to perform cognitive tasks to return to play. Moreover we should look at our concussion protocol, for example in what situations are we administering a test, if there are obvious concussion symptoms and the athlete doesn’t feel normal than there is no need to conduct the test until the athlete has sat out and is ready to return to play. My article referenced the idea that an athlete with multiple concussions holds more severe and longer lasting symptoms than an athlete without concussion history, so a protocol change off of that would be a longer delay in concussion rehab for those with concussion history. I would also argue to a point made in the previous comment that attention IS addressed in the symptoms section of the article with the variable “difficulty concentrating” though possibly not directly written about in the article or blog as the the study looks at a range of symptoms that might effect someone as concussions can have varying and a wide range of effects on different people.
As someone who has had many concussions, I found this to be very interesting and a bit frustrating. As anyone who has had a concussion knows, the road to recovery can be long and difficult: missing school, missing sports, having to sit in a dark room day in an day out. Therefore, I have never been a firm believer in the ImPACT test because it is forcing you to use your brain, the exact thing you’re not supposed to do when you get a concussion. I understand that this test is used to determine how severe one’s head injury is but, like Clay said, if there are obvious concussion symptoms one should deem the injury a concussion, follow the necessary protocol to heal a concussion and side with safety.
Like Kacie mentioned, the imPACT test takes 50 minutes. As it is, some people experience a headache after taking the baseline test. You are staring at a computer screen for 50 minutes, testing your attention, reaction time and memory. Now put a concussed person in this situation and you are asking to prolong their recovery but a few days. As we have learned this year, we use our brain for just about everything: determining who that girl in the bakery shop is and where you know her from, trying to pay attention to something when suddenly you have an attention capture and trying to access that vocab word you know you studied. Concussions make doing all of these things and using our brains that much harder, so why purposely test a possibly concussed person on these things and make their injury worse? You don’t have someone come into the doctor office with a sprained ankle and ask them to run a mile and have the ankle swell just to make sure they actually do have a sprained ankle.
Although ImPACT testing seems to be the most efficient way to determine the severity of a concussion, I do believe there are other ways to deem a head injury a concussion. If a person is feeling a variety of symptoms for more than 24-48 hours, deem is a concussion. Even if it’s not and its just a simple bump to the head, it’s better to be safe than sorry and everything with the brain is clearly not perfect. Also, the simply “touch my finger touch your nose” test they do at doctor’s offices is efficient enough to determine if someone’s head is a bit off. If you can’t properly touch your finger to your nose and then your finger to a moving finger in front of your face, I would say you should probably take a few days off.
This is an interesting article, and in my senior seminar, we also had a discussion about whether computerized ImPACT test will make concussion worse. For example, as far as I remember from the discussion, a simple ImPACT test will be conducted right after concussion takes place, and another one will be conducted a few days later to see how the student recovers from the concussion. However, doing ImPACT test on the computer may violate the requirement of staying in a dark room for post-concussion recovery, argued by my fellow athlete classmates. Due to my discussion in class, I wonder whether this article used computerized ImPACT test, or paper-based ImPACT test. If the researchers used computerized ImPACT test, the negative effects caused by ImPACT may be due to effects from the computer, but not the test.
Test conditions may be another factor in this study. In my senior seminar, we read a paper about how baseline test is not consistent in different test conditions, group test conditions and individual test conditions. People do much better if they do the test on their own, without doing together with their friends. So I also wonder how the baseline test was conducted in the study.
I also wonder whether self-report severity of health condition is validated. It might be my personal misunderstanding that self-report may not be accurate because we also don’t understand ourselves well, and different people have different standard so it might be hard to compare the result.
One thing that all of the posts regarding concussions agree with is that there is an attentional component of tests such as the imPACT test. As described in the studies and posts, a common symptom of concussions is attentional control deficits. As someone who experienced a severe 4 month long concussion in high school, I can personally attest to the fact that attention impairment following concussions can be extremely frustrating and debilitating. But what exactly are the cognitive processes that are damaged from head collisions and how are they repaired?
Based on my knowledge, I would say that the working memory system is responsible for many of the deficits exhibited by concussed patients. The working memory can be thought of as the executive control system that both maintains information in the short-term memory as well as directs processing between that information and other memory systems. This control system decides which cognitive resources to expend in order to manipulate information- I would imagine that includes those needed for cognitive tasks included in the imPACT test. Attention is a critical feature of the working memory; information in the working memory is maintained by attending to the contents while simultaneously inhibiting distractors and other irrelevant information. So if attentional control in this working memory or some other cognitive system is impaired in concussed patients, I wonder if those impairments are similar to those in individuals with attention deficit disorder (ADD). Since there is medicine to treat individuals with ADD, would that medicine also aid concussed patients’ attention deficit symptoms? If so, how does the medicine act on the affected cognitive systems and processes involved?