Transcription:
Identifying a Concussion & How to Support Recovery

Caitlin Whyte: Concussion awareness has improved a lot in recent years, but concussions are serious brain injuries that can have long-term effects if not managed properly. Dr. Emil Matarese joins us today and we'll discuss how to identify a concussion and how to provide support to someone who's recovering from one. Dr. Matarese is the Medical Director of Capital Health's Concussion Program, part of its Capital Institute for Neurosciences and an advisor for the New Jersey Brain Injury Alliance.

This is the Health Headlines podcast series. I'm your host, Caitlin Whyte. So Dr. Matarese, let's start with the basics. What is a concussion?

Dr. Emil Matarese: I believe a concussion is one of the most commonly misunderstood conditions in neurology. It is not a bruise or an area of swelling and bleeding on the surface of the brain as so many people think. Instead it's a chemical reaction that affects individual neurons or brain cells on a microscopic basis. Any individual whose head is forcibly shaken or shifted suddenly like a whiplash injury or a tackle, uh, causes the outer surface of the brain to shift. The brain itself is not actually attached to the inner surface of the skull, so it can move freely and it can strike the interior surface of the skull.

The area that actually becomes impacted on the skull inner surface can be temporarily disrupted. Those individual brain cells called neurons stop carrying their signals until the chemical injury on the surface of the brain is healed.

Caitlin Whyte: Now, if someone thinks they have a concussion, what are some signs and symptoms they might be experiencing?

Dr. Emil Matarese: Well, if you recognize that each part of the brain controls the different function of the brain, whichever part of the brain is impacted, then interferes with what the brain is controlling. That is why certain signs and symptoms of concussion can occur in many different ways. Most individuals who I treat that have had concussions will tell me they notice headaches or dizziness, sensitivity to light or sound. They can feel dizzy, nauseous, off balance, unsteady or they can even have vertigo.

Sometimes they can feel like they're mentally confused. They're disoriented. They're unable to clearly think. They feel like they're in a fog. They oftentimes have sensitivity to light or sound. They may just be more tired than normal and have disturbed sleep.

Oftentimes I see students have difficulty learning new information and retaining the information that they may be moody, more irritable, uh, have feelings of anxiety and depression, or sometimes they'll simply tell you, "I don't feel right." This is especially important in young children because the younger the age that's involved, the potentially more serious the concussion symptoms and long-term consequences can be.

But as you understand, the younger child doesn't have the vocabulary that an older child has. So many times I'll have a young elementary school student who's brought to me with a suspected concussion. And all they can say is, "I felt sick. I felt sick. You know, I didn't know what was wrong with me. I wasn't right." And even younger will say, "My tummy hurts. My belly hurts" when there really is no pain there, but they don't have anything else that they can use to, uh, you know, give an example that they're having symptoms that are outside the norm.

Caitlin Whyte: Now, talking about those younger patients, is there anything that coaches or parents or teachers should look for that would suggest a concussion?

Dr. Emil Matarese: This is hugely important and thank you for asking that question. We need to be vigilant because so many times, uh, concussions occur off the sports fields. In general, most concussions do occur off the sports field. Ninety percent when you look at all ages, are activities around the house, simple slip and falls, things that are not under the vision of a coach or an athletic trainer.

So somebody could have a concussion and not realize it. And something else that oftentimes I think goes unrecognized is that concussion symptoms don't all occur at one time. You can have a concussion and symptoms can occur immediately.

For example, you can have a concussion where you hit your head and you lose consciousness. So there's some immediate effect or you may suddenly see stars or suddenly have a severe headache or feel dizzy or nauseous or vomit. But concussion symptoms can sometimes be delayed. They oftentimes are delayed. The whole syndrome of what a patient's going to experience can be delayed. It could be delayed minutes, hours or even 24 hours, it could be the next day.

And oftentimes that next day, the student will forget what they did the day before. They may have been roughhousing with their brother. They may have, you know, had a slip and fall. They may have bumped their head on the beam in the attic. It didn't seem like much, and it's hard for them to relate the next day that there was a concussion. Uh, things that you, as a parent, coaches, teachers, nurses in school, oftentimes they're the ones that pick up on the concussion. And I'm grateful for them because if a concussion is not recognized and a student is further injured, it could be potentially catastrophic.

So the things that I look for and I ask you to look for, does the individual look different? Do they look confused? Are they dazed? Did they seem to be more forgetful? Are they forgetful for things that happened before the injury or after the injury? Do they look unsteady? Are they off-balance? Do they look drunk? Clumsy? Uh, slurring their speech? Walking in a funny way? Uh, any loss of consciousness of any sort also that's another important thing that we look for. Are they more irritable? Has their personality changed? Are they more easily aggravated? Are they saying or doing things they normally wouldn't do? Have they forgotten the play if they're in the middle of a game? Have they forgotten the score? You know, do they remember what their position was in the field?

During the class, I oftentimes rely on the teachers who oftentimes know, you know, the intricacies of a student's behavior, even better than the parents. If they're suddenly not as involved, they're not as verbal, they're not as attentive to their work, they're more distractible, they're staring out the window, they seem to have their head down, their eyes covered. They just don't seem to be their normal self. We want to take every one of these signs or symptoms seriously and have them looked into.

And oftentimes, I recommend that, especially for the coaches and the athletic trainers, if an individual takes a hit where they were forcibly knocked down or they had a blow to the head and they just didn't see them a hundred percent back to their normal self, even though they're denying any new symptoms, you're better off keeping them off the field for the remainder of that game, waiting for the next day, getting them checked out, because if somebody has a significant trauma, that could be a concussion. And again, as I said earlier, it could take up to 24 hours for symptoms to show. And if that's the case, you know, we really would be missing an opportunity to help those students get back on track, because there's therapy that we can do. There's things we could do to facilitate their return to normal life.

There are also some danger signs that I want you to recognize. If somebody may or may not have had a visible blow to the head, if they suddenly seem drowsy, greater difficulty keeping them awake, if they have a rapidly increasing headache, nausea, vomiting, they have complaints of weakness or numbness in arm or leg, their coordination is impaired, they're slurring their speech, these could be medical emergencies.

Oftentimes at the onset of a blow to the head or an injury, it may seem like a concussion, but it actually could be a bleed, a hemorrhage or an aneurysm that ruptured, a swelling and infection. So if somebody has these more serious danger signs, this needs to go to the emergency room immediately, 911 to the closest emergency room for a potentially lifesaving event. And you want to go to one that is at the least a concussion center trauma center, and not just any local clinic down the shore, up in the mountains. You want to make sure you're going someplace that knows what they're doing and has the equipment and the staff to take care of you if there's an injury that's more serious than a concussion.

Now having said that, it makes it sound like a concussion isn't that serious. Well, in most cases, concussions are temporary conditions. They're totally reversible. The individual has complete recovery, you know, without any long-lasting deficits, but not always. Not always.

There's something called second impact syndrome. Second impact syndrome. And this is a condition that can occur when an individual who has a concussion suffers a second concussion before they fully recover from the first concussion. In that situation, it is possible for the brain to have sudden rapid swelling where a patient can go on and become unconscious and die within minutes. It's because of this very serious consequence that we have these rules and these protocols in place.

So many times parents especially, but I also see it in coaches and trainers, uh, they want those kids back on the field, especially the older children, where there are college scouts in the audience watching. They’re looking for a full scholarship. They don't want to miss a game. They're the star. And if they've had a concussion and they didn't fully recover and had a second injury, it could be potentially catastrophic.

And the second blow, and again, it's very poorly understood why this happens, but the second injury could occur within minutes of the first injury, days or even up to weeks. And even at the mildest of second injury could in cases lead to the second impact syndrome. Fortunately, most individuals who have the second blow or multiple blows do not die, but instead they can be left with severe physical or mental disability.

Most often in my practice, I see it as cognitive impairment, higher executive functioning, you know, that which separates us, you know, from the animals, our intelligence. And unfortunately, so many times what I see in my office are the scholar athletes. They're the best in class or the best on the field. They're the ones that have these injuries. They push through anything. They'll suck up the pain. They don't care. They won't complain about it. But they can be left with intellectual impairment and it's a tragedy.

I've quite a few students in my practice that were scholar athletes that were top in their class who had these injuries, who then required special assistance, accommodations, couldn't go on to, you know, achieve their goals in life. You know, I've seen it too many times where they were injured in high school, failed out of college, you know, failed out of graduate school. Although they had all the potential there, they, you know, had these injuries that were not taken seriously. So I can't stress enough how important it is. If you recognize a concussion, you make sure that person, you know, is treated, is evaluated and prevented from having further injuries.

You know, there are treatments for concussion as well. If we can see somebody early after a concussion, there are certain therapies that we can start. Probably the most basic and the simplest of therapies immediately after a concussion is allowing that brain to rest. Remember earlier I said that the injury to the brain is actually a chemical change. There is an electrical-chemical component to how our nerves carry current. Well, that chemical injury has to heal before our brain can return to normal.

And simply resting one to three days, simply resting, physical rest, no playing sports, no jogging, no weightlifting and mental rest, no texting, no using the computer, no studying, allow that brain to heal, to heal. Any part of our body requires blood. It requires oxygen. It requires nutrients. And if there's a part of your brain, that's trying to heal and needs that increased supply of building blocks, and yet you're studying and dragging the blood supply, shifting it, shunting it to other parts of the brain, you delay recovery. Same thing with exercise. If you insist on going outside and doing your jog and practicing your sport, you're shunting blood from the brain to these other body parts, delaying your recovery.

So by not doing that initial one to three day of rest, you oftentimes will delay recovery, prolong the duration of your symptoms and, you know, delay your ability to get back to full swing in school and also, you know, full swing on the sports field. Because as you know, you know, I think one of the most important things for a student especially is to get back to school. That's their job. Everyone talks about getting back to sports and sports are hugely important. However, sports are not as important as learning. And we want these students back in the classroom, back doing their studies, you know, back understanding, expanding their brain function. And if we do the initial rest and then allow the students to go back to school in a graded manner, you know, slowly bringing them up to speed as they tolerate. And this is where having somebody who's a concussion specialist or somebody who has special training in evaluation and treatment of concussion is important.

If you could see an athlete or a student early in this course, you could assist in getting them back to school based on their symptoms, what problems they're having. You can provide very specific accommodations for the school, for the teachers, for the administration, to have those kids get back in a way that will not be painful or uncomfortable for them, but still allow them to learn until they can achieve their full capacity again. So I think that return to school is hugely important.

Accommodations such as having the student to have a structured rest during the day, limiting their exposure to light by having to wear a cap or sunglasses. Front and center in the class where they're less distractable. Avoiding all sports, gym, recess to avoid further injuries. Increasing the size of the print on the paper so they can see it easily. Not having them use the computer, instead downloading whatever's on the computer to print until this heals. You know, giving them some extra time and delaying testing and projects until they're able to do it.

So there's things we can do to return them to school in a safe way that they can tolerate it. Because keeping them out, keeping them hibernating in a dark room, you know, preventing them from returning to class and their studies oftentimes delays their recovery as well. So we want to get them back as important members of the school.

There is a return to play process for those students that want to play sports or have to participate in gym. That six-step process begins with the first step of rest. And then once their symptoms completely recover and once they have a normal neurologic examination, if they've had a prior impact test, a pre-screening test of their cognitive functioning, if they have that repeated and it returns back to their baseline, they could begin a step-wise progression in return to sports. Each step increasing the physical activity, the mental activity, and, you know, rapid changes in body position.

Because oftentimes, if somebody has a concussion, if you increase your physical activity prematurely, your concussion symptoms will worsen. So it's one more safeguard that we have in place to make sure that that student, that athlete is truly safe to return to their sports and their gym or even military duty for that matter. So I think that all is terribly important.

Caitlin Whyte: Now, if you aren't exhibiting these more obvious symptoms, I mean, can you just assume you don't have a concussion?

Dr. Emil Matarese: No, you also need to rely on those around you. "Is there anything that you saw that's different about me?" But if a student or an athlete has a significant blow to the head or takes a strong hit, ice hockey, going into the glass, you know, football going onto the ground, you want to at least watch them after 24 hours. If there's no symptoms and, you know, they were cleared by-- I oftentimes, uh, still think it's very important when possible to have a medical professional see them. That's really the gold standard. You know, there may be circumstances where that's not possible, but I still think somebody should see them to clear them before they go back to playing, because we don't want to take any chances in that regard.

The other thing that I think it's important for you to know is that you don't have to have a blow to the head to actually have a concussion. Thirty percent or less of concussions actually had a blow to the head. And we used to think that you had to have loss of consciousness to have a concussion, less than 8% of individuals who've had concussions had loss of consciousness.

So a lot of times the signs can be very subtle and it's not until they're back to their class and they're trying to do work as normal. So they may have a concussion Friday night game, feel fine Saturday, Sunday, and then go back to school Monday and find that, "Gee, I'm trying to do this project, I'm trying to follow what this computer program is saying. I'm trying to understand what she's saying and taking notes and I'm having trouble doing it." So again, you may not recognize the signs or symptoms of concussion for days. Not that they weren't there, but they weren't obvious until they're back to doing what they normally do. So it's not such an easy picture in every, every individual. We just want to make sure we're doing the right thing for every student though.

I keep saying students, because we now recognize that the younger the brain, the more immature the brain, the less developed the brain, the greater the risk of injury, the greater the risk of initial injury and the more prolonged duration of the symptoms and the greater the risk of long-term permanent injury.

Prior to the past years, we used to think of concussion as being something in professional athletes and college athletes, high school athletes. You never thought about the middle school. You never thought about the elementary school students. Well, these students are now better trained, they're stronger, they're faster, they're better skilled. We have sports that we are practicing for, you know, all year long.

It's no longer a sport is a three-month endeavor. You practice, you play games, the season's over in three months and that's it. Now, these students starting at much younger ages as well are training all year long. They're going to specialty camps. They have individual coaches that improve their ability. So the hits are harder. You know, they're more potentially serious, because it's now happening to younger brains.

And it's important, especially as I said earlier, remember these younger kids don't necessarily have the vocabulary to describe what they're experiencing. I can't tell you how many middle-school students I see in the office that have no clue. It's something like vertigo means lightheaded. What is that? They don't know. I'll ask them, "Do you have it?" They'll say no. And their parent will say, "Do you know what that means?" "No." So you really need to, you know, be that detective, you know, in many cases to make sure that we know exactly what's going on there.

Caitlin Whyte: So if I suspect that my child has a concussion, where do I start with finding treatment?

Dr. Emil Matarese: Well, the easiest is a concussion center. You know, we're very blessed at Capital Health to have a fully functional concussion center. And that's at both campuses, both our Hopewell campus and our regional campus, you know, have concussion centers, individuals who are specialty trained in evaluating and treating concussions.

As an outpatient, we also have a concussion program where we can see individuals in our office within a matter of days. I mean, personally, I think somebody should be seeing the first one to three days maximum. So many times people think, "Oh, it's not that bad. I'm just going to rest. I'm gonna let it, you know, run its course" and symptoms persist. The earlier you get in, the earlier we get you the treatment that you need, the faster you get better.

And treatment is specifically based on the kind of problems you're having. For example, if somebody is dizzy, if they're off balance, if they're unsteady, if they're are having trouble reading because their eyes aren't moving in sync, that's a common problem I see. Most individuals can't tell what's wrong with them. All they can tell is, "I'm having trouble seeing, things are going in and out of focus. My vision is blurred. I got a headache when I try to study." It's because their eyes aren't lining up and it's a common thing I see with concussion.

There's specific therapy that we can do. It's called vestibular therapy, where we have specialty trained therapists work with you to improve your balance, to improve your coordination, your walking, and even your eye movements. And in certain circumstances, there's even greater subspecialty available to work on those abnormal eye movements that we also have, uh, available to provide our students or athletes.

There's physical therapy that also can work with physical injuries. You know, when somebody has a concussion, oftentimes there's collateral damage. They could have a whiplash injury, they can have a shoulder injury, they can have a back injury, they can, you know, perforate an eardrum, they can dislocate their jaw. So oftentimes individuals will present with the complaint of headache. "I have a headache." "Where is it?" "It's somewhere. I'm not quite sure where it is." " What brings it on? What helps it?" "I'm not sure." And it may not be the concussion. It may in fact be the whiplash injury causing trauma. There could be an occult fracture. There could be sinus injury. There could be the inner ear injury. You want to have this checked out. And again, having them just suck it up because it's not that bad a pain is not good medicine. It's not good advice to offer to anybody at any age.

Caitlin Whyte: Is there anything that athletes and their parents or coaches can do to prevent concussions from happening in the first place?

Dr. Emil Matarese: There is nothing that's available that we can absolutely guarantee will not allow a concussion to occur. So many times we refer back to the type of helmet that an athlete is using. Is this helmet adequately insulated? Can we reduce the impact? Well, studies are being done in that regard where there are these energy-absorbing impact-absorbing materials that are being tested. But because the brain itself can shift freely inside the skull, you can't stop a concussion, uh, from ever happening.

You know, even a sudden jolt where the body stops, you know, is shifted forward or backwards and suddenly stops can cause a concussion. So even if your whole body was blister packed, insulated, there's no way that you can absolutely prevent it. Wearing a helmet will reduce the risk of bleeding into the brain or reduce the risk of skull fracture, but not a concussion.

The only way that we recommend that all athletes, you know, do in order to prevent a concussion is to play fairly. I think, you know, following the rules, you know, eliminating all the dirty plays, not trying to "take out, you know, the good player" that we see so many times. "We got to get them out. We got to injure them. You got to hurt that guy." Well, I've seen it too many times where these students come in here and, you know, just for the one score, you know, to get that extra point to win the game, to leave somebody physically and mentally injured for months, it's just so wrong. So I think, you know, fair play is something that we've recognized, you know, for many, many years.

I mean, back in the early 1900s, I think it was 1906, Teddy Roosevelt as president wanted to outlaw football, because the Ivy League football teams were having multiple athletes on the field dying. It was one year they called it the Harvest of Death where there were 19 football players killed in this Ivy League because of improper equipment, improper rules. You know, a lot of the basic rules that we have now weren't in place, the safety. And he came right out addressing our nation saying that if we could just have a sense of fair play, if we could just follow the rules. And if we can do it where we care about, you know, our opponents and play it as a game, we have a much better chance of not having these kinds of injuries.

So even before the time of insulation and padding and helmets, it was recognized there's ways for us to reduce not only concussion, but these other more serious and potentially deadly injuries that these athletes were getting because they weren't properly protected.

Caitlin Whyte: Great, doctor. If anyone is listening and has more questions about the concussion program at Capital Health, where can they learn more?

Dr. Emil Matarese: Well, I would recommend that they go to our website for Capital Health. We're happy to see any student or athlete who's had a concussion and there's other information that's available on our website about concussion. So I think there's good sources that are available easily through our system. And I welcome any questions or any issues. And we also, as a community service, offer presentations to community groups, to athletes, you know, teams. We go to the teachers in schools in our area and present to them how to do accommodations in the classroom. So if you're interested in any of those things, also go through our website. We'd be happy to help you.

Caitlin Whyte: Great, Dr. Matarese. Is there anything else you want to add to our discussion here about concussions?

Dr. Emil Matarese: I just wish you all safe and healthy sports. Sports are hugely important. I don't want the idea that you can have multiple concussions and go on and have dementia as we've seen in so many of these older football players to scare you and your children from playing sports. Sports are hugely important in our development. It's what's going to keep our youth healthy. It's also an important way of learning how to become a good citizen and to work with individuals that are different from you.

Uh, I think it's hugely important for us to stress the importance of safety on the field and following the rules and recognizing concussions. If an athlete is suspected to have a concussion and shares that with one of their friends or one of their co-players sees that someone or an athlete with a concussion, you're not a rat by telling the coach or the parents, you know, or the athletic trainer. You could be saving their life. So don't hide it. You know, get the help you need, get evaluated and live a healthy long life.

Caitlin Whyte: Well, thank you so much for sharing this important information with us today, Dr. Matarese. To make an appointment with Dr. Matarese call (215) 741-9555. That's (215) 741-9555. And to learn more about the Capital Institute for Neurosciences, visit capitalneuro.org. This is the Health Headlines podcast series. I'm Caitlyn Whyte. Stay well.