#Concussion and mild #TBI – connected, but distinct – Part 2 of 2

Concussion is the cause. mild TBI is the effect

Continued from Part 1

The logical disconnect started when I first heard Robert Cantu, M.D. give the official definition of Concussion:

Concussion: Derived from Latin concussio(n-),
from the verb concutere ‘dash together, shake’

That surprised me. So, I looked it up. Sure enough, there it was in black-and-white. Here, I was talking about concussions as a collection of symptoms and issues, slowed processing speed, emotional lability, or sensory hypersensitivity. And I was hearing a lot of other people talking about concussions in precisely those terms. I (and everyone else) was using it interchangeably with “mild traumatic brain injury” or “head injury”.

But the meaning of the word “Concussion” doesn’t have anything to do with the brain injury itself. It actually has to do with the action which causes the brain injury — the shaking of the brain, as well as how it dashes against the inside of the skull.  Like the word “percussion” – from the Latin percussio(n-), from the verb percutere ‘to strike forcibly’.

Hm. Conundrum.

So, the word “concussion” is NOT about the injury itself. It’s actually about the source or cause of the injury. It’s about the action of the brain and skull which produces the injury, not the injury itself.

“Concussion” was closer in meaning to the word “collision”, than it was to “brain injury”.

There are many other concept pairings that mirror this:

Cause	Result
Slip and Fall	Broken Leg
Jogging	Shin Splints
Lifting Heavy Weights	Slipped Disk
Car Accident	Facial Lacerations
Concussion	Brain Injury

So, to be totally clear, Concussion is the actual event of having your brain shaken and/or dashed against the inside of your skull. The proper term for what you get as a result of that, is Traumatic Brain Injury. It’s intimidating, yes. It’s scary, yes. Considering what a “black box” the brain is to most people, including plenty of General Practitioner docs, labeling an injury as “a brain thing” elevates it to a mysterious niveau shrouded in secrecy and confusion.

Unfortunately, it happens to often, that giving into the intimidation and steering clear of “that brain stuff” is about the worst thing you can do. You’ve got to talk about the brain. You’ve got to talk about the injury as what it is — a neurological issue, which may or may not clear up in the space of a few weeks.

When talking about Concussion treatment, I think this point is absolutely critical. We can’t afford to keep mixing up our terminology.

A doctor doesn’t treat a car accident. They treat the injuries after a car accident.

You don’t recover from a collision. You recover from the injuries you received from that collision.

A doctor doesn’t treat a fall. They treat the contusions, sprains, and other trauma from the fall.

When a doctor treats a “Concussion”, he/she is treating a brain injury. Not the impact itself. Steering clear of calling a thing what it really is, makes it very difficult to understand and treat.

As for the Concussion itself, once the impact was over and the brain stopped being shaken and dashed against the skull, the Concussion stopped. The injured individual subsequently acquired a brain injury.

Impact and effect. Two different things.

When you’re talking about concussion prevention, you’re talking about preventing the action of the brain and skull and neck (and perhaps the whole body) which produces a brain injury. By association, you’re going to be mitigating at least some risk of brain injury — often addressed with protective gear and different techniques of play/tackling. But you’re not going to 100% eliminate the threat of brain injury, by preventing conditions that produce concussion. Due to the force (mass x linear acceleration) of the moving body, there is only so much that a helmet or a different technique will do to reduce the force of the brain inside the skull. Two players moving fast can still collide with the force of an automobile accident, helmets or no. And the brain, sitting in its somewhat protective envelope of fluids, is going to move. It is not staying put.

When we interchange the terms “concussion” and”brain injury”, we’re really talking about is two different things — cause and effect… action and result… connected and interrelated… but not identical.  Nor interchangeable.  We confuse the two, and in the process, we fail to identify the actual problems that need to be fixed. We fail to understand the nature of them. We fail to adequately assess the impacts of them. And we certainly can’t fix them.

What’s more, we’ve got folks on all sides of the issue “stepping on each others’ toes” because they are all claiming to do the same thing — prevent and treat concussions — when they would more effectively divide their activities between preventing concussions and treating the resulting brain injury. Professionals, academics, policy-makers, product designers, manufacturers, and everyday people who are campaigning against concussion, are mixing their terminology, conflicting with each others’ agendas, getting pissed off at each other, and failing to unite around a common cause… all because there’s not a clear distinction about what we’re actually dealing with — for real.

So, where does this leave us?

While generally annoying (and sometimes infuriating), this situation leaves us with a lot of opportunities to explore. Those opportunities can be found in:

1. Redefining the problem(s) more accurately than at present
2. Tackling (so to speak) the individual problems separately, according to expertise
3. Collaborating on the issues, with distinct experts combining their expertise in complementary ways
4. Raising awareness about the true nature of concussions and brain injury
5. Discussing the details of each aspect with candor and courage
6. Measuring actual outcomes of steps taken
7. Continuously monitoring the progress we’re making, recognizing where we succeed, and where we fall short
8. Developing public policy that supports a deeper understanding of concussion and TBI, so organizations and individuals can make smarter choices based on fact, rather than fear

First, I think our definitions of Concussion and mTBI could use some refinement.

Here’s my proposal, drawing on the UB definitions above:

• mTBI = an alteration of brain function, resulting from mechanical force or trauma which may or may not involve loss of consciousness (See the AANS definition of Concussion)
• Concussion = a shaking of the brain, possibly involving impact against the inside of the skull, which may produce mTBI
• Post-Concussion Syndrome (PCS) = persistent symptoms of mTBI past the period when the individual should have recovered (3 weeks)
• PCS is an indication of mTBI (rather than qualifying as one)

Ideally, we’d have a comprehensive term to “wrap around” the end-to-end phenomenon.

Since there are multiple stages in the development of a TBI after concussion, it may not be realistic to have one catch-all term. However, what we now call “Concussion” might be more accurately termed “Concussive Brain Injury” — CBI, for convenience.

Second, we need to “chunk out” the issues that are specific to each phase of CBI, to address each specifically and effectively.

We need to divide and conquer, so to speak, like so:

The realm of Concussion prevention is the First Line of Defense. However, it’s never going to be 100% guaranteed. Focusing intently on Concussion prevention, as though it is a potentially fail-safe approach (it’s not, and it never will be), actually sets us up for reduced access to the help we really need.

For when that First Line “fails” to protect, there’s a “Zone of Dismay” you need to pass through, in order to effectively treat the TBI that results. The First Line defenders have to admit that their approaches weren’t fail-safe, the folks who were 100% behind that First Line of Concussion Defense have been let down — and confusion, frustration, and an inevitable sense of betrayal ensues.  It’s this Zone of Dismay, I believe, that often blocks injured individuals from getting the help they need. What First Line defender would ever want to admit that their approaches are limited? And what individual(s) who placed their faith in them, wants to be let down?

But clearly, when there’s an injury, brain injury treatment needs to be pursued. Here’s where the diagnosis and treatment come in. And the monitoring after the treatment ensues. You have to understand how things are going, if they’re working, if they’re not… and address and adjust accordingly.

Third, the parties on both sides of the Zone of Dismay need to collaborate

There needs to be clear communication between the two sides, so that they can most effectively address their own individual piece of the puzzle. CBI prevention and treatment cannot possibly be done properly in isolation. You need a team approach, a team effort. Brain injuries change over time. They present differently from person to person. So, whether it’s open communication between helmet manufacturers and coaches/teams/school districts… free flow of diagnostic information to determine Return To Play/Learn/Work… continued communication between patient and healthcare providers… or any other parties involved in the situation… the more quality information gets passed along, the better the chances of a positive outcome.

Fourth, everybody needs to quit playing around and get real about Concussion and Brain Injury.

Players, coaches, parents, teachers, employees, employers, peers, superiors, collaborators, providers, consumers… everybody needs to get a clue about what the true nature of this type of injury is. People need to learn about the symptoms, the effects, the impact, and just how widespread it is. Coaches need to admit if they’ve had a long history of head trauma, while playing their sport, and factor in their choices and behavior accordingly. Enough of the denial. Enough of the half-measures. Brain injury from concussion can be a lasting thing — and sometimes a deadly thing. If it doesn’t kill you right away, it can chip away at you, bit by bit, over the years, till you end up a shell. A homeless, institutionalized, imprisoned, or otherwise incapacitated shell.

We as a society are grossly under-educated about not only the terrible outcomes possible, but also the potential for full recovery. There’s a common thread in cultural conversations about brain injury: that it changes you forever and you will never be the same after. It makes for big news and it catches people’s attention. But is it the whole story? No. But we don’t often hear the other side. This version of the story is, in my opinion, the biggest, most chilling factor in people’s fear of facing up to brain injury. There’s such a dismal prognosis, in general — thanks, in part, to the alarming findings of CTE in football players, young and old, and in the recorded incidence of TBI in the prison population. We as a society certainly don’t help the general populace face up to concussive brain injury. We scare the living sh*t out of them. Yes, it gets funding — a lot of funding. But at what cost?

Fifth, everybody involved needs to discuss the facts with candor and courage.

Many folks who have experienced concussive brain injuries are living full lives, many of them having recovered remarkably well, compared to their official prognosis. Moreover, millions of individuals have been clunked in the head, and kept on living their lives, regardless. Getting worst-case about it, just makes things harder. But information and realistic discussion about what’s what will go a long way towards making communication possible.

Communication covers all quadrants — athletic, medical, employment, academic, domestic… And people need to have the right information. When someone’s got the wrong idea, others need to speak up — like when a CBI is making you miserable, but you keep getting pressured to get back to normal. You’ve got to speak up. And those who are looking out for brain-injured folks need to speak up, when they see them making poor decisions and going in the wrong direction. The truth helps – but you have to welcome and work with it.

Sixth, we need to measure the results of what we’re doing.

We need to track the steps we’re taking to see if they actually work. What works for some, will fail for others. But if you don’t measure it, you can’t manage it.

We need some common measures for CBI severity, other than the Glasgow Coma Scale, which doesn’t help much with estimating the impact of a concussion. There are other ways to measure, and we need to find them. Again, this is going to take some coordination, and I haven’t the faintest idea how that’s going to happen. Nevertheless, I’m just going to put it out there, in case someone wants to take on that task.

Seventh, real recovery takes continuous monitoring, and adjusting to beef up the strong points and minimize the screw-ups.

Because we will screw up, now and then. It’s human. And we learn. We adjust. We need to make it permissible to err — and then learn in the process. People who are terrified of being proven wrong, or shown to be in deep error, don’t tend to be very forthcoming. So, we need to conceptualize our prevention and recovery approaches accordingly — leaving ourselves some wiggle room for lessons learned.

Just as important, is tracking the stuff that goes right — and focusing on that. CBI can be a real b*tch, and recording the times when you’ve come out on top is very, very important — for you, and those who care about you.

Lastly, it would be helpful to have uniform public policies in place that are based on facts, rather than fear.

Nobody likes to get sued. Nobody wants a generation of young football players and cheerleaders, ice hockey stars, and soccer superstars set up for misery in life (sooner or later). Nobody likes to sit by and do nothing, while an epidemic rages. Policies are accordingly enacted, with states and municipalities putting protective measures in place. But are the policies always comprehensive and based on fact?  It would be a miracle, if they were. Information about concussive brain injury changes and grows and shifts with each passing week, it seems. And guidelines are updated. How policies can be kept in line with the latest emerging findings (some of which may be important to consider ASAP)… that’s another conundrum.

So, that’s my modest proposal.

Distinguish between Concussion and Brain Injury, recognizing the two are different and distinct sides of the same coin, and they feed back into each other.

Concussive Brain Injury (CBI) affects thousands upon thousands of people each year, and the ways we talk about the injury itself is impacting our ability to address it.

The terminology is jumbled, confusing the event (Concussion) with the effect (Brain Injury), and that makes it difficult to discuss — and treat.

Ultimately, I believe that “chunking out” the issues will not further complicate an already fragmented issue. I believe that it will enable the most appropriate resources and experts to focus on the specific aspects they are most qualified to address. Rather than spreading ourselves so thin across the conceptual landscape of the “Concussion Crisis”, we need to break down the elements, tackle them one by one, and piece together a more comprehensive and textured approach to what is clearly one of the most significant health issues of our day.

But as long as we keep fighting over owning the whole territory, a comprehensive solution that will serve the wide range of concussively brain-injured individuals, will continue to elude us.