Concussion- Dr. Ujjwal Shakya, DPT, DMT, SCS

Jan20th 2017

Concussion has been the “HOT TOPIC” during recent NFL settlement, NCAA college settlement and recently mismanagement of concussions during World Cup Soccer 2014. Lot of us probably has heard about concussion during recent ESPN coverage. I thought it would a great topic to cover and educate everybody. My goal is to educate about concussion, bring awareness, how to prevent the second impact, learn about signs and symptoms, Rehab (return to sport), MMA & boxing guidelines.

So, what is concussion and why there is so much fuss about it?

According to the Consensus statement on Concussion in sport (Zurich), concussion is “A complex patho-physiologic process affecting the brain, induced by traumatic bio-mechanical factors”. It is a mild traumatic brain injury which results from direct or indirect impact to the brain.

Well! in simple terms, concussion can result from trauma to the brain and that trauma could be from direct hit to the head, face or neck OR indirect effect to the brain from hit somewhere in the body (tackling, body shots from boxing, kicking) OR shaking of brain from sudden car stops, acceleration, roller coaster. This all could result in trauma to the brain and possible causes “brain not functioning well”.

Now think about brain as “Jello” and skull as “Jar”, brain sits on the skull as “jello on the jar” – jello on the jar is pretty stable with normal movement but a violent quick jerk or rotational shake could cause jello to be disturbed. Concussion is a result of that quick jerk or rotational shake of the brain which is inside the skull.

Let’s make an analogy. Brain is like a “transformer” (not the movie) with lots and lots of wires and those wires goes all the way to the bulbs so; it can generate light in the room. Now think about this, those wires are like our nerves and those bulbs are like our muscles. The point is -> it does not matter how expensive or LED or new bulb is, if there is a problem with connection -> bulb is not going to work efficiently.

So during concussion, it affects the brain itself which has all the nerve connection and these nerves goes all the way to the muscles. So, the POINT is you might be the strongest person but if brain is not working properly, it will affect your function regardless of your strength and physique. Since, it affects brain, it affects its functions like memory, emotion, vision, sensitivity to light/sound/touch and anything brain is capable of doing.

Let’s talk about some of the facts and numbers. TBI (traumatic brain injury is a leading cause of death from sports related injuries -> concussion is regarded as mild TBI -> This is important -> People can actually die from this. There is 900 sports related traumatic brain injury deaths per year (CDC). Sports and recreational activities contribute about 21% of all TBI among American children and adolescents. 68,000 concussions are registered annually from US High School football only. Concussion in Football in US is well documented but it is not the only sport that has concussion, sports like field hockey, ice hockey, soccer, basketball, wrestling, boxing, MMA are not far behind.

According to the American Academy of Neurology, 16 % of high school football players during 2005-2008 who lost consciousness during a concussion returned to the field the same day. This is very critical point as it can result in second impact of concussion which can cause devastating result. We can talk or do as much as we can but sometimes injuries like concussion are bound to happen in sports. So, it is difficult to avoid every time but what we can avoid or have control is the “second impact of concussion” when the player is still having post concussive symptoms (with better education and awareness). But, research suggests the trick is sometimes the post concussive symptoms do not appear after two or more hours after “that hit” which make it very difficult for medical staff to diagnose concussion during the game/ sport when symptoms are not there even after that “that vicious hit” to the head. Luckily, recent rules and better education/research has enabled to pull players out of game as soon as concussion is diagnosed.

Concussion is not like muscle torn or bone fracture where you can get diagnose or have an idea by performing a physical examination. There is no gold standard to diagnose concussion. It is diagnosed by looking at the cumulative neurological examination by a medical professional. Sometimes, he/she who has concussion may walk or perform normal physical function or may “look normal” from outside but may have neurological issues like unable to recall memory, unable to focus or concentrate.

Also, brain is not like muscle or bone where you can get hit multiple times and can get stronger. Idea is not to get hit, though sometime you cannot run away from that but you can improve reaction time, peripheral vision, improve muscles and joint stability around the neck/core strength to absorb the hit -> but don’t beat yourself on your head, you are only going get dumb 😉

Signs and symptoms are very important as this is the best way you can know that you may have post concussive symptoms: 1) There can be loss of consciousness but most of the time there is no loss of consciousness so, don’t be surprised. 2) Amnesia (memory loss – forgetful, unable to recall things) 3) Headaches or “in a fog” like feeling 4) Emotional outburst, behavioral changes (friend or family can see this coming) 5) Sleep disorder (it could be more or less) 6) Diminished reaction time (slow in everyday activities) 7) Dizziness or change in walking 8) For family and friends – socially – (they may feel “Just not right”  don’t know what it is but something does not feel right).

If you feel any one of those symptoms you may not be ready to go back in the ring or game or any sports. The best way to minimize symptoms is to rest initially (no cell phones, computer, TV, dark room, “take it easy” with normal activities) as much as possible. Remember, this is a brain injury so idea is to limit brain functions (neurologic functions) in the beginning as brain is probably getting bombarded initially after “that direct or indirect hit”. Initially, activities that increase heart rate and blood pressure can make it worse like weight lifting, running and any physical exertion activities.

According to the International Symposium on Concussion in Sport (Zurich Conference), Stage 1 = no activity, absolute brain rest Stage 2 = light aerobic activities Stage 3 = sport specific activities Stage 4 = full contact Stage 5 = return to play

There is no time table on how long it takes from one stage to different stage; it will depend on individual basis and it is best that professional determines either to go to next stage or please avoid jumping into next stage without completing the previous stage.

Brain is very close to visual (eyes) and vestibular system (inner ear organ which gives a sense of balance and where you are in the space). Any trauma to brain can possibly result in impairment of these systems.

For any athlete or fighters, it is very important to get baseline testing every year so you can compare yourself when you have post concussive symptoms to see where you are from your baseline. There are few options some of the popular ones are ImPACT testing which is a computerized test which looks at brain function, others are SCAT 3 test, BESS test which are more physical and cognitive test.

If you want easy and poor man test, some of examples for baseline testing: 1) Get a timer see how long can you stand on one leg with eyes open and eyes closed. Do it three times and record it. You are checking your balance here (visual and vestibular test) 2) Subtract 3 from 100 all the way to 50 and see how long it takes. Time it. You are using your brain here. Record it and check every year. If you suspect of any post concussive symptoms, retest it.

Gone are the days where you get “ding” in the head and “see the stars revolving around the sky” and then go back to game immediately. It is not ok. Just because one does not know the ramifications of going back to the game after that “ding”, it is not ok. There are so many evidences, where brain is getting inflamed/ damaged after getting those multiple hits which is resulting in decline in cognitive function later in life. Some of the former NFL players are going through this currently and brain study of some dead players has suggested the impact on the brain.

Again, in no means these are here to help to diagnose concussion on our own but merely for education. Seek professional help if in need.

(Next blog is going to about concussion on Prevention, high performance Vision training with research, strengthening concerns post concussion, MMA and boxing guidelines to return to sport following concussion and many more)


1) Broglio, Steven et al. Cognitive Decline and Aging. The role of concussive and subconcussive impacts. 2012. 2) Stewart, Gregory et al. Comprehensive assessment and management of Athletes with sports concussion. 3) Sports Symposium 2014. Philadelphia Eagles- NovaCare Conference. 4) Cantu RC. Second Impact Syndrome. 5) Consensus Statement on Concussion and Prevention in sports. 1997 6) Center for Disease Control and Prevention (CDC).