The anatomy of a concussion: How the perception of head injuries has changed

Published 10:28 am Sunday, March 8, 2015

While John Hendryx found the events of Oct. 11, 2013, frightening, he also found them a bit surprising.

Hendryx, then football coach at Northwestern High School in Kokomo, Indiana, had seen his star running back, Micheal Plummer, play and practice that week with no signs of any trouble.

Plummer started the first half of that night’s game at Peru on a tear and was on his way to a career-best game, running for 108 yards and a touchdown in under two quarters of play.

But before halftime, things took a turn for the worse. Northwestern got the ball back after a punt, and on his way out to the huddle, Plummer looked wobbly. He started to stumble, and down he went to the turf.

“From that point on it was a pretty scary situation,” Hendryx said. “I’m grateful they had a Lifeline available to get him over to Fort Wayne.

“I’ve coached a long time, a lot of years, and injuries are a part of football,” he added. “I’ve seen some that weren’t very good, but that’s probably the first time I’ve been on a football field and been really scared.”

A blow to the head

Plummer had been feeling symptoms of a concussion prior to the game, and took another blow to the head that night. Brain hemorrhaging caused his breathing to become labored, necessitating the Lifeline helicopter.

Hendryx, now the head football coach at Knox High School, said he and his staff have always been vigilant with head injuries, watching for signs and symptoms. Concussions are not something anyone wants to take lightly.

“There is a really big line between being tough and being smart. Kids have to know where that line is. You just don’t take chances.”

“It wasn’t anything we weren’t aware of,” Hendryx said. “The big thing out of it was there is a really big line between being tough and being smart. Kids have to know where that line is. You just don’t take chances. If you’re having troubles, you have to tell someone. Unfortunately, you get some of those kids that they won’t, and unless they have severe signs, you’re not going to know.”

Plummer sustained blows to the head the in the prior week’s game, and said he had a headache and experienced trouble sleeping that night, but after falling asleep at 5 a.m., woke up symptom free.

He remembers early portions of the Peru game, but the following two weeks are all blank for him. He spent his time in the hospital heavily medicated, he said, and doesn’t remember any of it.

Plummer’s road to recovery has been a long one, but he reports he’s doing much better.

“The only issue I have is partial vision loss that will most likely be with me for the rest of my life,” he said.

He was in the hospital for two weeks following the injury, and spent an additional month in a rehabilitation center. Other than the eyesight issues, he’s well on his way to a full recovery. He’s attending college classes and is hoping to be able to drive again soon. The eyesight issues have complicated that process, but new glasses and upcoming training have him optimistic.

“What I’ve learned through all of this, probably for other people, is to let someone know if you feel like something’s wrong with you,” Plummer said.

The doctor is in

Kokomo High School team doctor Joshua Kleutz, a sports medicine physician with Community Health Network, hears stories from parents who were former athletes during appointments with their children.

They’ll tell him things like, “I had concussions all the time back then, but we just went back in and played.”

It begs the question: Are there more concussions being suffered by athletes today, or is there simply more known about what to look for and how to diagnose them in the modern world?

“There’s certainly a much greater awareness, and now that we’re able to track it closer because people are reporting it; we see this huge increase in the numbers that are there,” Kleutz said. “But, it’s hard to say on a specific population, within the population if there’s been an increase or not.”

“There’s certainly a much greater awareness, and now that we’re able to track it closer because people are reporting it.”

Kleutz explained concussions are caused by a blow to the neck, head or body that causes the brain to impact one side of the skull and rebound.

At the microscopic level, the neurons, the tissue that makes up the brain itself, are bring stretched.

When they stretch, they release calcium and potassium ions, which cause a change in the local environment of the brain. It causes spasms in the blood vessels which travel to the brain, and as a result, those vessels constrict. As a result, blood flow to the brain is reduced. Additionally, when the brain is injured, it needs energy to heal itself. The only energy supply for the brain is glucose, or sugar, and that comes through the bloodstream.

“So, you have this supply and demand issue,” Kleutz said. “It’s not getting the blood or energy it needs to heal itself, and that’s what’s causing a lot of symptoms. … All of the symptoms primarily in some way are related to what’s happening down at that level.”

Symptoms include headache, emotional changes, sleep problems, as well as problems with memory and concentration.

Over time, the body will use up that spike in ions and the brain will go back to its normal state. The blood vessels open back up and enough glucose comes through that the tissues of the brain heal. At that point, individuals most often go back to feeling and functioning normally.

Second Impact Syndrome is thought be a phenomenon where an individual suffers a second concussion before the symptoms of the first one have subsided. It can cause severe swelling in the brain and other life-threatening symptoms.

Kleutz said the actual existence of Second Impact Syndrome is controversial. The number of cases where it’s been reported is very small. There’s not enough definitive medical evidence to say it is a problem, he said.

“Not everyone in the medical community believes it’s a true entity,” Kleutz said. “It is thought to be dangerous to be struck an additional time if you already have a head injury. Most likely it will increase and prolong the symptoms, but as far as actually causing the ‘second impact’ death or significant injury, it’s more of a theory than anything that’s actually been proven.

“It’s a complicated issue,” he explained. “You have to be careful because we don’t know if that child had a significant amount of swelling within their brain to begin with. Maybe it was made worse by some bleeding in their brain that wasn’t known before that. Maybe it caused all the wiring and communication within their brain to go haywire. There’s a risk of making your brain injury significantly worse, and that’s the big thing we worry about, but it’s an unclear and a bit controversial as far as what the term ‘Second Impact Syndrome’ actually means and consists of.”

The first line of defense

Lisa Tate has been an athletic trainer for more than 16 years. In that time, the perception and understanding of how head injuries affect a person has changed profoundly due to the amount of research that’s been done in the last 15 years.

Medical professionals have come to understand people, adolescents especially, don’t heal as quickly as was originally believed. Head injuries are handled more conservatively than they were years ago.

“But, I think as far as the knowledge of what goes on and the symptoms they go through, it’s similar,” Tate said. “We never would let anyone play with symptoms before, and don’t now. Those kinds of things have stayed the same.”

The biggest change from even a few years ago centers around showing of symptoms. Years ago, if an athlete showed symptoms of a concussion, but those symptoms quickly went away, athletes would return to game action as early as the same day.

That’s not so today, because although an athlete may seem to have recovered fast, new symptoms are likely to pop up later that are not experienced or observed immediately.

An athletic trainer is the first line of defense when it comes to recognizing symptoms in an injured player. When Tate observes an injury, the first thing she does is look for orientation.

“You start to assess to what degree are they concussed,” she explained. “With any injury, the first thing you want to look for is, ‘Is this an emergency?’ You look for the worst, life-threatening things off the bat. You want to make sure it’s not something like a neck injury, skull fracture, or that the person is not going unconscious.”

Once those immediate, emergency type-symptoms are cleared, the trainer then begins to assess the level of consciousness in the individual.

The biggest challenge Tate says trainers face is that players want to keep playing. Educating them about how important it is to understand the severity of a concussion is among her most important roles, in hopes of developing enough rapport with an athlete they won’t lie about their symptoms.

“We can only test so many things, but there’s still a level where the athlete has to be honest with you about how they feel.”

“We can only test so many things, but there’s still a level where the athlete has to be honest with you about how they feel,” she said. “So we go through any kind of physical test to look at their balance and their eyes, asking them questions about what just happened in the game. What play were they running? What’s the score? Just to check how ‘with it’ they are. But in the end they have to be honest with you or you’re going to miss something.”

Tate said the level of that “macho mentality” to remain in the game at all costs has been reduced as athletes grow to understand the risk. That’s been aided by families and parents becoming more educated about the subject.

An ultra-competitive athlete can’t escape the moment. They want to compete then and there are all costs, no matter how hurt they are. Tate has seen athletes with broken bones demand to remain in a game, refusing to listen to medical professionals.

“That still happens, but as they go home, their families understand how important it is,” Tate said. “You see less of the parents telling you, ‘They’re fine’ and being more involved. They’ll come to me and say things like, ‘He may not have come to you and told you, but he came to me this morning and told me he had a headache.’”

Athletic trainers often have the final say on whether a player can return to the game. Tate said coaches at Kokomo have been great in understanding the liability that may come with putting a player in harm’s way, and trust her expertise.

“There have been too many catastrophic injuries, be it heat illness or cardiac arrest, that the coaches really have pulled back and said, ‘Hey, if you say they can’t play, they can’t play,’” Tate said. “You can get an ultra-competitive coach in the moment just like you do an athlete, but they are able to step back and make a logical [conclusion].”

In recent years, local schools have implemented what’s known as Impact Testing, which provides trainers and coaches with a baseline of an athlete’s mental capacity prior to any head injury. It’s a way to establish something objective on something that can be so subjective. Tate says that since Impact Testing began, she’s yet to have a situation where she would have sent an athlete back to play, even though the test indicated they were not ready.

“It allows us to go back and trace our steps, and say, ‘Well, here’s where they tested cognitively before the concussion,’” Tate said. “The test does reaction time and memory recall. It’s not about your intellectual knowledge, but about how well you can recall things.

“Does the testing work? It’s another tool, and you can’t deny it’s good to have,” she concluded.

1. Initial Impact: Concussions occur when a person suffers a blow to the head or neck, an injury that most commonly occurs in events such as athletics and automobile accidents. According to the Indiana High School Athletic Association, 88 percent of the concussions sustained by its athletes occurred while playing football and soccer. In all, IHSAA athletes suffered 1,219 concussions during the 2014 fall sports seasons.

2. Trauma: The force of the impact causes the brain to strike the skull and rebound, striking the opposite side of the skull. Initial symptoms may include: headache, feeling of pressure in the head, temporary loss of consciousness, confusion, immediate short-term memory loss, dizziness, nausea and vomiting.

3. Varying degrees: In the case of a severe concussion, as the brain rebounds and collides with the opposite side of the skull, it also twists. That action can do damage to both the brain cells and blood vessels which supply the brain. That causes the brain to fill with an excess of potassium and calcium ions, instead of the glucose it needs to function properly.

4. Severe cases: Following a concussion, the brain begins to swell, which puts pressure on the brain stem. Increased pressure on the brain stem can cause problems with breathing and other basic life functions. In the case of a severe concussion, brain bleeding is common, as is long periods of unconsciousness.

Sigler writes for The Kokomo (In.) Tribune