Concussion Awareness Starts With the Ones We Don't See

Today is National Concussion Awareness Day, recognized each year on the third Friday of September. Awareness efforts have accomplished a great deal, and that deserves recognition. A generation ago, a hit that left an athlete dazed was called "getting your bell rung," and the expectation was to shake it off and keep playing. Today, most coaches, parents, and athletes know that someone who takes a hit and seems off should come out of the game. Every state has youth concussion legislation. Sideline recognition used to be a niche skill. Now it is common knowledge.

The ones that concern me are the concussions nobody counts. The athlete who shakes it off and finishes the game. The child who bumps their head on the playground and seems fine by dinner. The driver who is told after a car accident that the scan is clear and goes home. Many of these injuries are never reported, never diagnosed, or diagnosed as something else. Most of them would recover well if someone recognized them early.

Many concussions are never reported

In a survey of 1,532 high school football players, 15.3% said they had a concussion during the season, and fewer than half of those players reported it. The reasons deserve attention. Two-thirds of the players who stayed quiet didn't think the injury was serious enough. About 41% didn't want to be pulled from competition. Roughly a third didn't realize they had a concussion at all.¹ That study is now two decades old, and awareness has improved since. But those three reasons are the same barriers that education efforts still work against today.

Even concussions that do reach a clinician are undercounted. In a large pediatric care network, 82% of children with concussion were first seen in primary care, 12% in an emergency department, and 5% in specialty care.² Many national counts rely on emergency department visits or high school and college athletics data, so they likely underestimate how often children are injured. One-third of the children in that study were under age 12, a group that surveillance focused on high school athletes misses entirely.

Many are missed even when someone seeks care

In one study, 56% of patients who met clinical criteria for mild traumatic brain injury on interview had no documented brain injury diagnosis from their emergency department visit.³ Those patients leave without knowing what symptoms to expect or when to follow up. Concussion is also easy to mistake for something else, because its symptoms overlap with so many common problems:

• Headaches get attributed to stress or dehydration.

• Dizziness gets blamed on the inner ear.

• A teenager's trouble concentrating, irritability, or fatigue gets read as a school problem, an attitude problem, or ordinary adolescence.

• After a car accident, neck pain and headache are often filed under whiplash alone.

None of those explanations is unreasonable. The problem comes when a concussion hides behind one of them and goes untreated.

What to look for

A concussion does not require being knocked out. In a national sample of high school athletes with concussion, only 4.6% lost consciousness, while 93.4% had a headache.⁴ Dizziness or unsteadiness was reported by about three-quarters, difficulty concentrating by more than half, and confusion or disorientation by nearly half. Watch for these changes after any blow to the head, or any hard jolt to the body:

• Headache, pressure in the head, or nausea

• Dizziness, balance problems, or blurred or double vision

• Sensitivity to light or noise

• Feeling foggy, slowed down, or just "not right"

• Trouble concentrating or remembering

• Changes in sleep or mood, or new irritability

• Looking dazed, confused, or slow to respond, which others may notice before the injured person does

Symptoms don't always appear right away. They can emerge or worsen over the hours after an injury, which is why someone who looks fine on the sideline still needs to be watched.⁵

Seek emergency care immediately for any of the following:

• A headache that keeps getting worse

• Repeated vomiting

• A seizure

• Weakness or numbness

• Slurred speech

• Increasing confusion or agitation

• Unusual drowsiness or difficulty waking

• Any loss of consciousness

Playing through it doubles recovery time

Continuing to play after a concussion has a measurable cost. In one study of adolescent athletes, those who kept playing after their injury took an average of 44 days to recover. Those removed immediately took 22 days. The athletes who kept playing were 8.8 times more likely to have a recovery lasting three weeks or longer.⁶

A follow-up study found that the risk grew the longer athletes stayed in. Compared with athletes removed immediately, those who played for 15 minutes or less after injury were 5.43 times more likely to have a prolonged recovery. Those who played for more than 15 minutes were 11.76 times more likely.⁷ Even a few minutes matters.

Delays in care after the game matter too. In a study of adolescents and young adults, some athletes were first seen 8 to 20 days after injury. Compared with athletes seen within a week, they had 4.7 times the odds of a recovery lasting longer than 30 days.⁸

Missed does not mean permanent

None of this is meant to frighten anyone. A concussion that was missed is not necessarily a more dangerous concussion. It is an unmanaged one. In that same study of delayed care, athletes recovered in a similar amount of time after their first evaluation, whether they were seen early or late.⁸ Recognition changes the course, whenever it happens. When a hit was brushed off and something still isn't right, an evaluation weeks later is still worthwhile. Persistent symptoms usually trace back to specific, treatable problems, such as:

• A vestibular system that hasn't recalibrated

• Eyes that aren't working together

• Post-traumatic headache

• Anxiety that has grown during a long recovery

Identifying which of these is driving the symptoms is what makes targeted treatment possible.

Concussion Awareness Day is ultimately about the concussions no one saw. The more people who know what to look for, the fewer of those there will be. To learn more please visit us at www.PatelCI.com

References

1. McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported concussion in high school football players: implications for prevention. Clin J Sport Med. 2004;14(1):13-17. doi:10.1097/00042752-200401000-00003

2. Arbogast KB, Curry AE, Pfeiffer MR, et al. Point of health care entry for youth with concussion within a large pediatric care network. JAMA Pediatr. 2016;170(7):e160294. doi:10.1001/jamapediatrics.2016.0294

3. Powell JM, Ferraro JV, Dikmen SS, Temkin NR, Bell KR. Accuracy of mild traumatic brain injury diagnosis. Arch Phys Med Rehabil. 2008;89(8):1550-1555. doi:10.1016/j.apmr.2007.12.035

4. Meehan WP 3rd, d'Hemecourt P, Comstock RD. High school concussions in the 2008-2009 academic year: mechanism, symptoms, and management. Am J Sports Med. 2010;38(12):2405-2409. doi:10.1177/0363546510376737

5. Patricios JS, Schneider KJ, Dvorak J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. Br J Sports Med. 2023;57(11):695-711. doi:10.1136/bjsports-2023-106898

6. Elbin RJ, Sufrinko A, Schatz P, et al. Removal from play after concussion and recovery time. Pediatrics. 2016;138(3):e20160910. doi:10.1542/peds.2016-0910

7. Charek DB, Elbin RJ, Sufrinko A, et al. Preliminary evidence of a dose-response for continuing to play on recovery time after concussion. J Head Trauma Rehabil. 2020;35(2):85-91. doi:10.1097/HTR.0000000000000476

8. Kontos AP, Jorgensen-Wagers K, Trbovich AM, et al. Association of time since injury to the first clinic visit with recovery following concussion. JAMA Neurol. 2020;77(4):435-440. doi:10.1001/jamaneurol.2019.4552

About the author:

Shan Patel, PsyD, is a neuropsychologist and concussion specialist who completed his fellowship through the UPMC Sports Medicine Concussion Program. He is the Owner and CEO of the Patel Concussion Institute (PCI), a telehealth-based practice serving patients nationally via PSYPACT, and serves as Clinical Director of the University Orthopedic Care, Concussion Program, and Integrative Behavioral Health Program, overseeing operations across 14 hospital-based clinics in Florida.