The following is an edited transcript of an MDAdvantage podcast with Steve Adubato, PhD, and Anthony Alessi, MD, that was recorded on June 13, 2022. Dr. Alessi, a board-certified neurologist and Director of the NeuroSport program at the University of Connecticut, offers insight into what characterizes a concussion and how its definition and treatment options have evolved over time, touching also on advice for physicians treating this type of injury, other conditions with similar symptoms, and the importance of relying on a physician for a diagnosis.
We’re joined by Dr. Anthony Alessi, a board-certified, Connecticut-based neurologist in private practice. Could you tell us a little bit more about your background and how you come to be joining us today?
ALESSI: I am a board-certified neurologist who developed a subspecialty in sports neurology when I started working in the mid-1990s with a variety of professional and collegiate sports teams. I now direct the NeuroSport program at the University of Connecticut. Sports neurology has really been an evolving field and changes daily in terms of what we know about concussions, head injuries and the sequelae after a head injury.
ADUBATO: The term concussion is thrown around a lot. Can you provide a simple layperson’s description of a concussion?
ALESSI: It is interesting that you approach concussions from there, because throughout my medical school experience and even my residency at the University of Michigan in the early 1980s, I don’t think I heard the word concussion more than five times. The word concussion is a fairly vague term. We can best define a concussion as a syndrome or a group of symptoms that are transient, neurologic and result from a biomechanical force being applied to the brain. In other words, a blow to the head that produces neurologic symptoms would be defined as a concussion. A concussion is part of the range of traumatic brain injuries. The most severe in this range would be traumatic brain injury from a gunshot wound or other penetrating trauma to the brain. A concussion is on the totally other end of this spectrum. Some people use the term mild traumatic brain injury because there are no changes seen on a CT scan.
ADUBATO: How common are concussions are, particularly in youth athletics?
ALESSI: Concussions are very common, accounting for about 3.8 million emergency room visits per year. However, it is also important to know that not every blow to the head is a concussion. We’ve all gotten up suddenly in our attic, hit our head, and seen stars for a second or two, but that doesn’t mean you had a concussion. It is important to see a professional if you have symptoms that persist.
ADUBATO: You have stated, “If you’ve seen one concussion, you’ve seen one concussion;” meaning, obviously, not all concussions are the same. How much variation are you talking about?
ALESSI: Every person is an individual, and no concussion is the same as another. In trying to make the treatment of concussions simple, we have developed protocols. However, the protocol is not a list of rules, but rather a guideline. Physicians need to consider individual differences as they approach the treatment of a concussion. Some people may have more of a problem with headaches; others may have a problem with sleep; and still others may experience dizziness.
“The protocol is not a list of rules, but rather a guideline. Physicians need to consider individual differences as they approach the treatment of a concussion.”
ADUBATO: What advice do you have for physicians who may be treating a patient who believes they’ve been concussed? Where should they start?
ALESSI: To begin, there are some important questions for the physician to ask along with taking a good history. Physicians should determine the mechanism of the concussion and should get an idea of how severe the blow was to the brain. For example, there is a big difference between someone lifting their head up and hitting a shelf versus running full speed into a shelf. The physician should then define the symptom course. Did the symptoms come on immediately, or did they develop over the next 24 to 48 hours? The treatment guidelines have certainly changed over time and continue to change. In the past, physicians used to do this thing called cocooning, where we would lock away patients with concussions away in a dark place with no television, etc. We’ve gotten away from that, and now within 48 hours we want people doing some aerobic activity, such as walking or riding a bicycle. We have found that people who start exercising soon after a concussion recover much more quickly, which is almost the direct opposite of what we used to prescribe.
ADUBATO: What can you tell us about post-concussion syndrome?
ALESSI: We’re trying to get away from the term post-concussion syndrome. When we talk about post-concussion syndrome, a lot of people think the concussion is still going on. By definition, the persistent symptoms aren’t considered persistent until three months after the injury, and at that point, you really just want to treat those symptoms. It doesn’t mean the concussion is still ongoing. We really want to get that person back to some activity and therefore should try to focus on the individual’s symptoms.
ADUBATO: Are there other related symptoms or conditions that could potentially be confused with concussions?
ALESSI: Yes, there are numerous conditions and causes that may mimic a concussion. For example, a patient who gets migraine headaches may hit their head and as a result get a migraine headache. That doesn’t necessarily mean they had a concussion. Chances are they had a traumatic migraine, which can be treated accordingly. It is not uncommon to see concussion-like symptoms come on with dehydration. A person may have hit their head, but the real problem was that they were really dehydrated, and the symptoms subside just by rehydrating. Another thing we see a lot of is cervical spine injuries associated with a whiplash motion. We see this particularly with children because their neck muscles aren’t very well developed. The issue may be with the neck, but this also can produce a headache that can be mistaken for a concussion.
ADUBATO: Why is it so important to rely on physicians who have experience with diagnosing and treating concussions?
ALESSI: We’ve tried to simplify the treatment of concussions with protocol. We have these standard symptom surveys for use on the sidelines to assess a series of symptoms. What is interesting, however, is that if you gave that same survey to people with just a migraine, it would look like they had a concussion. If you gave it to someone who just had a poor night’s sleep, it may look like they had a concussion. The survey was administered to college students who had nothing to do with sports and never had a concussion, and it was found that, based on their responses, two thirds would not be able to return to their sport if they had had one. The questionnaire is quite general. That is why it is so important to have a physician or other healthcare provider who is skilled and experienced in seeing concussions to put symptoms into context, especially when it comes to sports and being able to return to sports.