The Neuropathology of Concussion

Willie Stewart, MBChB, PhD, FRCPath, explains what happens to the brain during a concussion and the lasting effects of TBI

Traumatic brain injury has been a subject of research for decades, and investigators are constantly learning more about the brain, effects of these injuries, and technologies to help in their assessment and treatment. While concussion, a type of mild traumatic brain injury, has increasingly gained attention within recent years, there is still much that researchers and health care professionals do not know about the damage caused to the brain. Dr. Willie Stewart, Consultant Neuropathologist and Honorary Clinical Associate Professor at University of Glasgow and ICS Scientific Advisory Board Member, outlines what we do, and do not know, about concussion and its effects on the brain and the body.

What happens to the brain during a concussion

The effects of moderate or severe traumatic brain injury are visible in brain imaging and recognizable in clinical exams. Patients with these more severe brain injuries occasionally die, allowing researchers to view the brain with a microscope and see structural changes.

The neuropathology of concussion is distinct from that of moderate or severe traumatic brain injury. “Concussion is much more challenging because there’s very little to see on imaging, unless you use really specific brain imaging techniques, which are at research level,” explains Dr. Stewart. “The clinical symptoms are heterogenous and often quite mild and hard to pin down. Patients don’t tend to die with acute, uncomplicated mild brain injury so we can’t look down a microscope and see exactly what’s happening to the brain.”

To illustrate what happens during a concussion, Dr. Stewart describes the brain as suspended as a semiliquid inside the skull. In all forms of brain injury, the skull moves rapidly, while the brain moves just slightly out of sync within it, causing the fine fibers in the brain to be stretched, pulled and, ultimately, damaged. “That damage interrupts the passage of signals in the brain, which leads to all the different symptoms people complain of,” Dr. Stewart says. The blood vessels and reactive cells within the brain can also be affected, contributing to those symptoms.

While severe brain injuries can be quantified using classification systems such as the Glasgow Coma Scale, there is no valid, objective assessment for concussion at this time. “There’s no blood test that can be done. No brain scan routinely performed. No clinical examination to elicit signs of concussion with any confidence. It’s all really subjective,” says Dr. Stewart. “And that’s where the problem, I think, lies in trying to figure out this disease. How do we recognize who really has a concussion?”

Possible long-term effects of concussion

While most people who suffer a single concussion will make a full clinical recovery within a short period of time, a small number will experience symptoms for months or longer. But long-term effects are generally believed to be a result of multiple concussions. “We don’t believe [a single concussion is] necessarily enough to lead to long-term problems. It requires the cumulative effect of exposure to multiple mild brain injuries or to one single moderate or severe brain injury,” Dr. Stewart says.

Researchers have recognized that exposure to repetitive brain injury can lead to long-term change in the brain. Dr. Stewart notes chronic traumatic encephalopathy (CTE), a degenerative brain disease found in people who have a history of traumatic brain injuries, as an example that has been captured in headlines in recent years, especially in the world of sports. However, while researchers can see physical differences when viewing a brain with a microscope, long-term effects such as psychiatric disease and personality syndromes are still difficult to define as directly associated with brain injuries.

So can the brain heal? The brain does have plasticity, which allows it to adapt to minor injuries when circumstances require it, says Dr. Stewart. “For milder forms or single injuries, some degree of recovery of function is undoubtedly capable. My concern is the cumulative effect of multiple injuries, one on top of the other. And that might not be repairable or recoverable.”

Weighing the health benefits and risks in sports

Despite the risk of head injury for athletes, Dr. Stewart also calls for balancing the concern for injury with a recognition of the health benefits of physical activity, including cardiovascular benefits and a decreased risk of obesity, diabetes and other diseases. This positive counterpoint may be overlooked due to a lack of information. “What we’re really lacking at the moment is any real understanding of what global, long-term brain health looks like in former athletes,” says Dr. Stewart. He points to his ongoing research with the FIELD study that aims to go beyond isolated cases of dementia in former athletes. Instead, it will take a broader view of the lifelong health of around 10,000 former soccer players, evaluating not only brain health but also other body systems and diseases, in order to more accurately weigh the risks and benefits of playing the sport.

But the message is clear: If in doubt, sit them out. It’s an initiative that health care providers and researchers in this field want the general public to take to heart. “If there’s any suspicion an athlete may have concussion, they should just be removed from play,” Dr. Stewart says.

While there’s so much left to learn about concussion, Dr. Stewart sees the increased public awareness of the long-term risks of exposure to brain injury as a positive sign. This awareness contributes to more researchers coming into the field, new ideas, emerging technologies for diagnosis and management, and studies that give further insight into how dementia develops. All of these new developments point to a clearer understanding of the brain and a world of possibility for the neuropathology of concussion.


Willie Stewart, MD, is a Scientific Advisory Board Member of the International Concussion Society. The International Concussion Society sponsored website Concussion.Org  is the number one destination for information related to concussion prevention, diagnosis and treatment. Our mission is to serve medical professionals, athletes, administrators, coaches, patients and the public by providing a central repository of accurate and scientifically vetted concussion research. Working alongside our world-class scientific advisory board, Concussion.org aims to be the most trusted global index on one of the most common, yet least understood, forms of traumatic brain injury. If you would like to be interviewed for an influencer profile, please fill out this form.

Neurological Complications of Repeated Concussions

Charles Adler, MD, PhD, speaks on the link between concussion and long-term neurological disorders

Immediately following a concussion, memory loss, blurry vision, loss of consciousness, and confusion are common. These symptoms can go away fairly quickly, making it easy for someone to think he or she has recovered. However, for those who experience repeated head injuries, there can be long-term neurological complications, says Charles Adler, MD, PhD, a neurologist in the Neurology department at the Mayo Clinic in Scottsdale and member of the International Concussion’s Scientific Advisory Board.

He recently spoke with us about the underlying damage that can be done after repeated head injuries, and how players can protect themselves from long-lasting effects.

How Repeated Injuries Affect Athletes

“Damage can be done to different parts of the brain, including the deep nuclei of the brain, which can lead to various Parkinson’s-like symptoms,” Dr. Adler says. “It can lead to damage of the cerebral cortex which can lead to cognitive and behavioral abnormalities.”

Dr. Adler says some abnormalities show up immediately after a head injury. Sometimes they don’t resolve at all, while in other cases they seemingly resolve but then evidence of neurodegenerative and behavioral disorders show up at a later date. There is also evidence for chronic traumatic encephalopathy, which can lead to both behavioral and neurodegenerative disorders.

Concussion in Young Children

While conversation around young children and head injury is common, people of every age are at risk.

“There is a lot of concern that younger age groups are at greater risk because the brain is still developing. Certainly, with young children, you have some reason to believe that there’s a potential increased risk. But I believe there’s a risk at any age of concussion, especially multiple concussions, leading to neurologic syndromes in the future,” Dr. Adler says.

What plays more of a role than age is activity level. Those who are very active or play contact sports are at greater risk of concussion, due to the nature of the activities. There is also an increased risk if someone resumes their activity level too soon after a head injury.

To prevent injuries, it’s important for parents and coaches to educate themselves on the key concussion indicators, as well as what to do after a suspected concussion and the importance of returning the athlete to competition after a concussion safely.

Signs and Symptoms

Difficulty with memory and other cognitive functions are common symptoms of neurodegenerative disorders, which can occur after repeated injuries. This can include the ability to concentrate, pay attention and multitask, as well as being able to comprehend when reading or hearing things, Dr. Adler says.

Additionally, difficulty with the following motor skills may also indicate the development of a neurodegenerative disorder: overall weakness, slow movements, tremor at rest, difficulty with walking, dragging a leg, shuffling the feet, and persistent and progressive twitching of muscles.

There are medications that can treat symptoms of cognitive impairment and Parkinson’s-like symptoms; however, there are currently no treatments that can cure or stop the progression of neurodegenerative disorders, Dr. Adler says. There are some medications that can potentially slow cognitive abnormalities, and researchers are currently studying medications that can slow the onset of motor abnormalities.

If an individual has already experienced multiple head injuries, there is currently nothing a healthcare provider can to do prevent the onset of a neurodegenerative disorder. Dr. Adler says this is why continuing research is invaluable and preventing concussion from the beginning is important.

Current Research

Researchers are currently working to understand how best to prevent neurological complications. This includes looking into when it is safe for athletes to return to play after an injury to reduce acute and chronic problems, clinical trials to improve function after an injury and research on biomarkers.

“There is a lot of work being done looking for biomarkers in the blood, spinal fluid or imaging biomarkers,” Dr. Adler says. “This could suggest improved safety, in terms of when somebody is less at risk for further damage.”

For additional information on concussion symptoms, diagnosis and treatment, visit our resource library.


Charles Adler, MD, PhD, is a Scientific Advisory Board Member of the International Concussion Society. The International Concussion Society sponsored website Concussion.Org is the number one destination for information related to concussion prevention, diagnosis and treatment. Our mission is to serve medical professionals, athletes, administrators, coaches, patients and the public by providing a central repository of accurate and scientifically vetted concussion research. Working alongside our world-class Scientific Advisory Board, Concussion.org aims to be the most trusted global index on one of the most common, yet least understood, forms of traumatic brain injury. If you would like to be interviewed for an influencer profile, please fill out this form.

The Female Brain and the Anatomy of Concussion

Doug Smith, MD, PhD, discusses the distinct anatomy of the female brain and the lasting effects of concussion

Female athletes are shown to have higher rates of concussion and longer recovery times, compared to their male counterparts in the same sport. While the higher rate of concussion may be due to women being more likely to report symptoms, researchers are taking a more in-depth look at why women typically take longer to recover and have poorer overall outcomes.

Dr. Doug Smith—Director of the Center for Brain Injury and Repair, Professor of Neurosurgery at the Perelman School of Medicine, University of Pennsylvania, and founding member of the International Concussion Society’s Scientific Advisory Board—explains how differences in the male and female brains may shine a light on new ways to diagnose and treat concussion.

The Anatomy of the Female Brain

At the moment of impact, when a head collides with another person or object, the brain’s movement can cause stretching and damage to nerve fibers called axons. Researchers think this internal structural damage in the brain—rather than the external impact or variables such as neck strength—is what causes symptoms of concussion.

“It seems like the predominant pathology is going to be something called diffuse axonal injury,” says Dr. Smith. “It’s damage to nerve fibers called axons that travel from one part of the brain to the other and form the white matter. We know that they are selectively vulnerable to become injured upon head impact.”

Dr. Smith likens the brain’s network of axons to an electrical grid. In the case of a concussion, the signals transferred across this network are disrupted. That insight drove him to take a closer look at the difference in female axons in comparison to male axons.

“What we recently discovered is that there’s a difference down to the nanoscale between the nerve fibers of these axons in male and female brains. And females might have a more complex network in their brain than males, but the skull is smaller from females to males,” explains Dr. Smith. “Maybe to get a similarly large or maybe even larger network in a smaller box, so to speak, what was changed was the architecture and size of the axons on average. If they’re on average smaller in the female brain, given the same mechanical force, that means they’re more likely to have damage to the internal skeleton.”

This damage can affect how signals are transmitted and block the transport of proteins down thin structures called microtubules. When these proteins cannot be transported, they can build up, which can lead to swelling and ultimately a disconnection of the axon.

“We think that the damage to these axons may contribute to delayed recovery,” Dr. Smith says.

Treatment protocols for concussion are continually evolving, so there isn’t a general recommended protocol yet, let alone a female-specific one. For example, in recent years, a treatment called “cocooning”—in which a person avoids lights, electronics and other stimulation for a certain period—was often used. But that’s changing as we learn more about concussion and the brain. “We’re turning toward active rehab or sub-threshold training, where you do some exercise to the point of feeling discomfort, just below that threshold and get the blood moving,” says Dr. Smith. Once a person starts this type of protocol, their rate of recovery can be used as an individualized “control” to guide further treatment.

Ongoing Concussion Research

While research on concussion is making progress, this field of study is still in its early stages. Researchers are looking to examine a wide range of individuals to gain a better and broader understanding of the brain. “Why do some who experience a concussion do well later in life, but others seem to have issues earlier?” asks Dr. Smith.

Identifying genetic differences between the sexes, as well as more subtle genetic markers, will help researchers pinpoint what makes one person more at risk for a delayed recovery, poorer outcome or even degenerative effects than another. “We would like to have some kind of screening tool, whether it’s genetic or otherwise, to identify individuals who would be most at risk,” says Dr. Smith.

In the meantime, Dr. Smith acknowledges that participating in sports can provide physical health benefits, a sense of teamwork and a mental boost. However, he also encourages coaches and athletes to look for ways to reduce the risk of concussion, such as penalizing aggressive play. Being aware of the risks and doing what’s possible to prevent brain injury is the first step, as the research on concussion, its effects and treatments continue.


Doug Smith, MD, PhD, is a Scientific Advisory Board Member of the International Concussion Society. The International Concussion Society sponsored website Concussion.Org  is the number one destination for information related to concussion prevention, diagnosis and treatment. Our mission is to serve medical professionals, athletes, administrators, coaches, patients and the public by providing a central repository of accurate and scientifically vetted concussion research. Working alongside our world-class scientific advisory board, Concussion.org aims to be the most trusted global index on one of the most common, yet least understood, forms of traumatic brain injury. If you would like to be interviewed for an influencer profile, please fill out this form.

How to Prevent Concussion During Winter

Follow these tips to protect yourself from slips and falls in the cold-weather months

There are many hazards associated with winter weather that can pose an increased risk for mild traumatic brain injury, or concussion. Everyday activities like driving the kids to school and shopping for groceries can become more dangerous when ice and snow are involved. Take extra precaution this winter to lower your risk for concussion with these 10 tips.

1. Wear appropriate shoes.

Purchase non-slip shoes with traction to avoid slipping on the ice or snow. The Military Health System recommends shoes with rubber soles that have treads or a raised pattern on the bottom.

2. Be careful when entering and exiting your vehicle

The University of Pittsburgh Medical Center (UPMC) suggests leaning on your vehicle and using it as support if you need to.

3. Keep an ice scraper in your vehicle.

Maintaining a clean, clear windshield will make driving conditions as safe as possible. Use a wintertime formula for your windshield washer fluid and replace tires with all-weather or snow versions if necessary.

4. Clear your sidewalks and driveway.

Work slowly when doing outdoor chores like shoveling to avoid slipping and falling. If you live somewhere where ice and snow are common, purchase rock salt to have on hand before a snowstorm approaches. The CDC notes that sand and cat litter can also be used for de-icing.

5. Don’t carry too much when running errands.

UPMC advises people to avoid carrying too much or walking with their hands in their pockets during icy or snowy conditions. Doing either of these things could make it difficult to regain your footing if you slip.

6. Make sure your clothes fit properly.

This is especially important if you’re participating in any winter activities like ice skating or skiing, as loose or baggy clothing can pose a fall risk.

7. Walk like a penguin.

The CDC notes that many cold-weather injuries happen due to sidewalks, steps, driveways and porches that are covered in ice. One way to avoid slipping is to walk like a penguin. This means maintaining your balance and center of gravity by walking with your feet and arms spread wide in a “waddle” fashion. Point your feet outward, spread your legs, walk flat-footed, take short steps and use your arms for balance.

8. Watch for black ice.

If ice appears wet on the surface, it might be black ice. Be mindful of this when driving, as black ice can make road conditions more dangerous.

Know the signs and symptoms of concussion. Because slips and falls occur so commonly in the wintertime, it’s important to know when a fall may have led to concussion. Symptoms of concussion vary, but some early signs include headache or a feeling of pressure in the head, temporary loss of consciousness, confusion, dizziness, nausea, vomiting, slurred speech and fatigue, according to the Mayo Clinic.

Keep these tips in mind during the winter season to prevent concussion in yourself and those around you.

8 Tips for Coping with Post-Traumatic Headache Over the Holidays

Loud music and bright lights can pose a risk for people with PTH. Here’s how to navigate the holiday season

The holidays can be a fun, busy time filled with parties, big meals and endless opportunities to deck the halls. But with those events comes loud music, bright lights, rich food and other triggers that can pose a risk for people with post-traumatic headache (PTH).

From high-school cheerleaders to firefighters, nearly anyone can experience PTH. PTH is a headache that occurs within seven days after someone has experienced a concussion. Symptoms of PTH include everything from dizziness and trouble sleeping to sensitivity and noise and mood changes. In addition to medication, treatment for PTH includes physical therapy and relaxation therapy. Emotional and psychological problems can trigger a headache, so relaxation during PTH recovery is crucial.

For someone experiencing PTH, the holidays can often be chaotic and problematic. Everything from bright holiday lights and loud parties to sugary food and alcohol can trigger PTH. Here’s everything you need to know about navigating the holidays with PTH:

1. Take the Time to Rest

Rest is one of the most important things to keep in mind when recovering from PTH. Although you might be tempted to RSVP yes to every invitation you receive, consider sitting some events out if you know they’ll be overwhelming or will cut into your sleep time. Strive to get the recommended seven to nine hours of sleep per night, as lack of sleep can exacerbate the symptoms of PTH.

2. Avoid Crowded Stores

Sensitivity to light and sound are two symptoms of PTH. Avoid crowded stores during the holiday season to alleviate these symptoms. If you must go shopping, try to find a quiet, isolated place upon arriving where you can relax if needed.

3. Wear Noise-Reducing Headphones

Hypersensitivity to noise is a common PTH symptom, and unfortunately, the holiday season is filled with noise: music at parties, people talking loudly at stores and family members debating at dinner. Carry noise-canceling headphones with you in case your environment becomes overwhelming.

4. Keep Sunglasses on Hand

In addition to noise sensitivity, light sensitivity is a hallmark symptom of PTH. Keep a pair of sunglasses or a hat on hand to avoid bright, twinkling holiday lights.

5. Go Easy on Holiday Treats

Nearly everywhere you turn during the holiday season, there’s a sugary treat waiting for you: donuts at the office, hot chocolate at happy hour and Christmas cookies at a family party. But sugar can exacerbate the symptoms of PTH. Limit your intake of sweet treats during the holidays if you’re recovering from PTH.

6. Skip the Alcohol

Although spiked apple cider and eggnog might be tempting, it’s best to avoid alcohol if you’re recovering from PTH, as drinking it can lengthen recovery time and further damage the brain.

7. Wear Proper Winter Attire

Wear shoes with good tread, which can prevent a slip or a fall that might lead to another concussion. Experiencing another concussion while still recovering from the initial one can lead to a series of complications, such as second-impact syndrome.

8. Ask for Help

Overexerting yourself will only make it more difficult to recover from PTH quickly, as anxiety, stress and other emotional problems can worsen symptoms. If you need help hosting a holiday party or decorating your home, don’t be afraid to ask a family member or friend for help.

Post-Traumatic Headache and Concussion

Trent Anderson, PhD, expands on what treatment options are currently available, and innovative research that may lead to new therapies

Every year, at least 1.7 million people in the U.S. experience a traumatic brain injury. The majority of these traumatic brain injuries are concussions, which can present as a headache and symptoms from confusion and blurry vision to difficulty sleeping and agitation. However, if the headache and symptoms that last days after the traumatic injury, the patient should seek treatment for post-traumatic headache from their health care provider.

Dr. Trent Anderson, a neuroscientist and associate professor at the University of Arizona’s College of Medicine in Phoenix and a member of the International Concussion Society’s Scientific Advisory, has spent years studying post-traumatic headache to better understand the underlying mechanisms behind it. “Research into concussion from my own laboratory focuses on understanding and examining new therapies for treating the headaches that often develop and persist following concussion,” he says.

Dr. Anderson spoke with us about what post-traumatic headache is, what treatments are currently available for it, and what research is being done on the condition.

What is post-traumatic headache?

Post-traumatic headache is a headache that starts within seven days of a traumatic brain injury. “Post-traumatic headache may occur after any traumatic brain injury, but is most common after a mild post-traumatic brain injury, which includes concussion,” Dr. Anderson says, adding that the prevalence of post-traumatic headache following a concussion is between 47 and 95 percent.

The symptoms of post-traumatic headache most closely resemble a migraine or tension headache. If the headache persists for more than three months after the initial concussion, Dr. Anderson says it becomes a condition referred to as persistent post-traumatic headache, or chronic post-traumatic headache.

How to treat post-traumatic headache

Post-traumatic headache can be difficult to treat, especially once it has transitioned into a persistent stage. No medications exist specifically for treating post-traumatic headache, at this time.

“As post-traumatic headache most often resembles migraine and tension headaches, the best current treatment strategies often use medications approved for these other types of headaches,” Dr. Anderson says.

However, these treatments aren’t necessarily effective in post-traumatic headache patients, he says. “And how these medications alter the brain’s recovery process from a traumatic brain injury remains unknown.”

Promising research on the horizon

Although post-traumatic headache resembles migraine, Dr. Anderson says it may develop in the brain differently and respond to treatment differently. “We believe this may be due to the complexity of having multiple ongoing injury and repair processes from the mild post-traumatic brain injury that may act to promote, resist or work alongside the development of headache,” he says.

Dr. Anderson and his research team at the University of Arizona have been conducting research in order to properly understand the mechanisms behind post-traumatic headache. They began their research by studying the physiological differences between migraine and post-traumatic headache.

Then, the team created animal models of post-traumatic headache to research how traumatic brain injury sensitizes the brain to headache. They are also studying biomarkers that might be able to predict who is more likely to develop post-traumatic headache following concussion.

“As basic scientists and clinicians, we have a lot of work to do to improve our understanding [of post-traumatic headache] and identifying who is at risk for developing it,” Dr. Anderson says. He hopes his lab’s research on post-traumatic headache using animal models will help lead to the development of therapies that could help treat the condition.

“The development of post-traumatic headache in patients can be devastating, but it provides a unique opportunity to understand how a traumatic brain injury, like concussion, can induce headaches in an otherwise healthy person and brain,” Dr. Anderson says.

Raising awareness for post-traumatic headache

There has been significant increased awareness about the potential complications and risks related to concussion in the last few years. But Dr. Anderson still sees room for growth when it comes to educating people on post-traumatic headache.

“We need to continue on this avenue to ensure patients, parents, physicians, coaches and the general public have the best available information to make informed decisions and help recognize the signs and symptoms of a concussion,” he says. “As part of this effort, I believe we still have significant work to do to raise awareness, particularly of post-traumatic headache.”


Trent Anderson, PhD, is a Scientific Advisory Board Member of the International Concussion Society. The International Concussion Society sponsored website Concussion.Org  is the number one destination for information related to concussion prevention, diagnosis and treatment. Our mission is to serve medical professionals, athletes, administrators, coaches, patients and the public by providing a central repository of accurate and scientifically vetted concussion research. Working alongside our world-class scientific advisory board, Concussion.org aims to be most trusted global index on one of the most common, yet least understood, forms of traumatic brain injury. If you would like to be interviewed for an influencer profile, please fill out this form.

Concussion Myths Debunked

Five common misconceptions of concussion

Popular culture has perpetuated several myths about concussions. This misinformation can be dangerous, as it can lead to improper protocol and treatment of concussions.

We’ve debunked five of the most common concussion myths so you can keep yourself, your family and your friends safe the next time someone experiences a head injury.

Myth 1: You Need to Lose Consciousness to Have a Concussion

This is one of the most pervasive myths about concussions, and it’s propagated by TV and films. This myth is particularly dangerous, as it can lead people to think they haven’t suffered a concussion because they never lost consciousness.

In reality, only around 10% of concussions include loss of consciousness, according to the University of Pittsburgh Medical Center (UPMC).

In addition, loss of consciousness doesn’t necessarily mean the concussion was more severe. A research study conducted by UPMC followed those who suffered from a concussion, including people who did and didn’t lose consciousness. Their research found that loss of consciousness did not mean the injury was more severe or that the person would have a longer recovery time.

Myth 2: You Have to Hit Your Head to Get a Concussion

Because football-related concussions are covered so frequently by the media, people might believe that concussions only occur from intense blows to the head during athletic activities.

Although concussions can be the result of a direct blow to the head in contact sports, they can also occur in non-contact sports and everyday activities. For example, concussions can be caused by an abrupt bump or jolt to the body that shakes the head, like whiplash in a car crash or a fall down the stairs.

Myth 3: You Have to Keep Someone with a Concussion Awake

People have long believed that it’s dangerous to let people with concussions sleep, for fear they’ll fall into a coma or lose consciousness without anyone knowing. Many believe that it’s important to monitor people with concussions and wake them up often to prevent this from happening. This misinformation, the BBC notes, comes from the thought that if a person is suffering from a brain bleed, or a hematoma, sleeping could lead to a rare, potentially fatal complication called a lucid interval.

However, internal bleeding in the brain is rarely associated with concussions, and if a person with a concussion has been cleared by a medical professional, it is safe for him or her to sleep.

In reality, sleep is beneficial for those who have suffered concussions. One of the best ways to treat concussion is through mental rest, and sleep is the perfect way to give the brain the cognitive rest it needs, according to the Cleveland Clinic. Everyday activities can be more tiring when recovering from a concussion, which is why sleep is so important.

Myth 4: If You Don’t Have Symptoms Immediately, You Don’t Have a Concussion

In some cases, concussion symptoms won’t show up for hours, days or even a week after an injury. In addition to early symptoms such as confusion, headache, dizziness and memory loss, more delayed signs and symptoms might include sensitivity to light and noise, irritability, difficulty sleeping, fatigue and depression, according to the Washington Post.

Myth 5: You Can Return to Play as Soon as You Feel OK

Because it can take up to a week for the symptoms of a concussion to appear, it’s wise for someone to wait to return to play until he or she has been cleared by a medical professional. Even though someone might feel physically ready to play, he or she needs to make sure they have had enough mental rest, too.

Entering play too soon can lead to dangerous and potentially fatal complications, such as post-traumatic headache—a headache that can persist for months—or second-impact syndrome, in which someone suffers a second concussion before he or she has healed from the first one.

Exercise in the Management of Post-Concussion Symptoms

Robert Scales, PhD, explains how concussion victims can exercise their way to better brain health

Cardiovascular health is directly related to brain health. “There’s a lot of people out there suffering from medical conditions where cardiology-based exercise physiology can help—and post-concussion syndrome happens to be one of them,” says Dr. Robert Scales, Director of Cardiac Rehabilitation and Wellness at the Mayo Clinic in Scottsdale, Arizona.

The phrase “Use it or lose it” applies both to cardiac and brain health, but, Dr. Scales says, with the right frequency, intensity, time and type (FITT) of exercise, “You can get it back quickly.”

This perspective dates back to a 1968 landmark bed rest study, where researcher Dr. Bengt Saltin recruited young men from the University of Texas Southwestern Medical Center to rest in bed for three weeks, measuring their heart function and fitness performance. This coincided with a dramatic decline in fitness, heart function and other metrics, including blood volume, says Dr. Scales. “Within 10 days of resuming exercise, blood volume returned to normal along with cardiovascular fitness and heart function. All of these measures continued to improve with consistent exercise training over a two-month period.”

The benefits of becoming active

The symptoms of a head injury include headache, dizziness, fatigue, insomnia, difficulty concentrating, memory lapses and a disturbed autonomic nervous system, which can throw off heart rate and blood pressure. Appropriately monitored cardiovascular exercise, however, can help improve the way the heart and blood vessels respond, which results in a slower stronger heartbeat. “Control of the blood flow to the brain normalizes and therefore, the symptoms can improve,” Dr. Scales says. “So, aerobic continuous exercise can work on some of the disturbances that happen when you get hit on the head, and start to help bring it back to what it should be.”

At the Mayo Clinic’s Heart Health and Performance Program, Dr. Scales manages a gym within a cardiology clinic and often works with patients with post-concussion syndrome—persistent symptoms beyond three months post injury. “My role is to help people become more active again from a cardiovascular standpoint, which prevents deconditioning and helps normalize some of the symptoms that these people may be having,” says Dr. Scales.

Based on research from John Leddy, MD, FACSM, FACP, Dr. Scales uses a scaling system for patients to identify their symptoms while they exercise so that they can exercise below the exertion threshold that exacerbates concussion symptoms like headache or dizziness. “A conservative but progressive plan improves exercise tolerance,” Dr. Scales says, eventually normalizing post-concussion symptoms.

There are strategic forms of activity for concussion recovery: recumbent stationary biking puts less gravitational pull on the bloodstream pumping to the heart; in aqua aerobics or deep water running with a flotation belt, the hydrostatic pressure of the water facilitates blood flow and improves cardiovascular efficiency in the body. With improved symptom management, athletes can then gradually return to more strenuous upright land-based exercise like jogging.

Exercise can normalize symptoms

Dr. Scales has helped train former NFL players who have endured numerous concussions over the years. “They’ve also experienced orthopedic injuries and metabolic changes that have adversely impacted their blood pressure, cholesterol, blood glucose and body weight. We find that they have aged prematurely, partly because of their sport,” Dr. Scales says. However, “Even with those individuals, we can help them normalize the symptoms and live a healthy life.”

The collaboration between neurology and cardiology, Dr. Scales believes, is an untapped potential therapy. “It can help people,” he says. “And I think as evidence-based research continues to grow, we will be able to write clinical practice guidelines that are more defined.”


Robert Scales, PhD, is a Scientific Advisory Board Member of the International Concussion Society. The International Concussion Society sponsored website Concussion.Org is the number one destination for information related to concussion prevention, diagnosis and treatment. Our mission is to serve medical professionals, athletes, administrators, coaches, patients and the public by providing a central repository of accurate and scientifically vetted concussion research. Working alongside our world-class scientific advisory board, Concussion.org aims to be the most trusted global index on one of the most common, yet least understood, forms of traumatic brain injury. If you would like to be interviewed for an influencer profile, please fill out this form.

What to Do After a Suspected Concussion

If you experience a head injury, follow these five steps

Concussions are a form of traumatic head injury caused by a bump or blow to the head, or even a subtle, sharp jolt. While their symptoms can seem minor or take some time to appear, concussions carry serious risks and can have long-lasting side effects. If you feel “off” after a head injury and think you might have a concussion, follow these five steps to evaluate your symptoms and figure out what to do next.

1. Immediately Respond

Don’t be dismissive about any form of head trauma: Concussions can occur from even a minor bump, and you don’t need to be knocked out to experience a concussion. If you’ve sustained a head injury during an activity, like playing sports, immediately remove yourself from play and take inventory of how you’re feeling. Symptoms of concussion might not develop until hours—or even days—after a blow to the head, according to the CDC. It’s best to take it easy and err on the side of caution. Ignoring the signs of a concussion—especially by resuming physical activity too soon after a head injury—can make those symptoms worse, make recovery take longer, according to the Centers for Disease Control, or even cause lasting side effects like post-traumatic headache.

2. Sit Out

Whether you’ve just pulled over after a fender-bender or removed yourself from play during a game, consult a medical professional if one is available, or call your a primary care doctor to discuss your injury. Recovery from a concussion takes up to two weeks for many people, or even longer for about 20 percent of the population, according to the Mayo Clinic. Don’t try to rush back into action until you’ve been cleared by a doctor.

3. See a Doctor

It’s best to seek medical attention as soon as you recognize concussion symptoms for an exam and diagnosis. Even if you felt well initially after your head injury, visit your doctor if you start to feel any concussion symptoms later. It’s not unusual for the effects of a concussion to be delayed by days or weeks. Post-concussive syndrome can appear even months after your initial injury. Untreated concussions can have serious, long-term effects, including post-traumatic headache and neurodegenerative issues, according to the Mayo Clinic.

4. Watch for Additional Symptoms

Concussion symptoms aren’t limited to head pain. Sluggishness, clumsiness and just feeling “off” are key indicators that your head injury could be more serious. Even if you don’t feel different immediately after bumping your head, you might still have a concussion and should watch out for the typical warning signs. Nausea, loss of consciousness and head pain are more noticeable symptoms of concussion, while others—like changes in your behavior or personality, or mood swings—can be harder for you to recognize. Concussion symptoms can vary from person to person, and they can emerge or worsen when you engage in physical activities or activities that require concentration. Be as detailed as possible in describing when your symptoms appeared and how severe they were; this can help a doctor determine the severity of your injury.

5. Recovery

Once you’ve been diagnosed with a concussion, follow your doctor’s prescribed treatment plan. There’s no one “cure” for a concussion, but following your treatment plan will give your brain the time and care it needs. It can take several weeks to recover from a concussion, and during this time you’re especially vulnerable to brain injuries like second impact syndrome—a second concussion before the first one had time to heal. So take it nice and slow. The CDC recommends asking your doctor for guidelines on when you’ll be well enough to drive or ride a bike and return to work. Get plenty of rest and avoid alcohol, drugs and physically demanding activities, and reintroduce things into your routine gradually.

People with concussion can return to playing sports and being active once their concussion has healed and they’ve been cleared by a medical professional. Returning to play should be done with the utmost care. Follow the CDC’s five-step approach to returning to physical activities safely. Ease in with light aerobic activities, gradually working your way back, and monitor your concussion symptoms closely during this time.

Concussion Teams: A New and Exciting Approach to Managing Concussion in the Emergency Department

Very few medical institutions have specialized concussion teams in place. Lawrence C. Newman, MD, FAHS, wants to change that.

Unfortunately, many patients that enter an emergency department or urgent care with a suspected concussion leave with little instruction for outpatient care. In fact, the trouble starts even before the patient walks through the door. “There’s no universally adopted protocol for concussion management in the emergency department,” says Dr. Lawrence C. Newman, Director of the Headache Division at NYU Langone Health in New York City. In a 2017 study published in the Journal of Neurotrauma, researchers investigated concussion protocols across emergency departments in New England and found that one-third of all departments did not have a critical practice guideline in place. A little more than half reported having a protocol, but there were inconsistencies in how each was carried out.

“The good news is that almost everybody who left the emergency department got some sort of written discharge instruction,” Dr. Newman says. “However, instructions were not consistent. Some patients were told they needed to follow up with their doctor, but it wasn’t stated when they should follow up. Other people were told they needed to follow up with a specialist, but no recommendations were given for who or what type of specialist they should see.” A recent study conducted in a large New York City emergency department reported similar outcomes.

The lack of a specialized concussion team and detailed practice guidelines has serious consequences for a patient’s condition. Patients are left to their own devices to determine when it is safe to resume physical activity. Dr. Newman wants to put an end to that, and proposes that hospitals establish a dedicated concussion care team with standardized guidelines for in- and outpatient care.

An outdated practice

Several years ago, the Acute Concussion Evaluation was published for use in emergency departments. However, “most people don’t look at it; most people don’t do it,” Dr. Newman says.

It’s not for lack of educational activities that ACE is not more widely used, he adds. Rather, it’s a lack of concussion awareness.

Dr. Newman explains that this is a pervasive problem not limited to emergency departments. “Even if people go to their primary care doctor or an urgent care center,” he says, “the information they’re getting is all over the place. It’s not based on guidelines, and a lot of times it’s based on old data. I’m still seeing patients who were told they needed to cocoon themselves for two weeks despite the fact that recent data shows that’s outdated.”

A new approach to concussion treatment

Under Dr. Newman’s proposed plan for standardized concussion care, a patient who arrives at the hospital with a suspected concussion would be seen by a neurologist who would then perform a complete neurologic exam.

If a patient is suspected of a stroke or heart attack, a specialized team is called in to fully assess the patient with sole regard for the specific condition. “That’s where my idea came from,” Dr. Newman says. “We have stroke teams, MI teams and rapid response teams in the hospital. If someone has a critical illness while they’re in the emergency department or admitted to the hospital, and they experience life-threatening complications, a rapid response team rushes to the bedside and tries to figure out what’s going on and gets the appropriate testing done rapidly.”

Rather than require additional resources, Dr. Newman’s concussion team calls for a redistribution of responsibility. “The team can be the neurology resident on-call and the attending neurologist on-call,” he explains. “If a patient has a headache, it makes sense for a neurologist, who knows how to treat headache and the different types associated with concussion, to treat the headache. Most times, however, neurologists aren’t even called to evaluate the patient.”

With a dedicated concussion team in place, physicians can ensure that a patient’s exam and diagnosis is correct and that an effective treatment plan is in place. “If the patient is ready to be discharged from the emergency department, we can make sure that they are given clear timelines and guidelines for how long they need to rest and when they can go back to school and resume physical activity,” Dr. Newman says. Additionally, they can be referred to an appropriate neurologist for outpatient follow-up.

Concussion awareness is key to patient care

Dr. Newman calls for an increase in concussion awareness, starting at the academic level. “Not every hospital, not even every academic center has a concussion program, but they all have neurology programs,” he says. “It’s just a matter of training the neurology residents on how to evaluate and treat concussion. If you have somebody who you’re considering has a concussion, you call the neurology resident trained in concussion management,” he explains.

By standardizing a hospital’s response to concussion, physicians are better suited to care for patients and prevent long-lasting effects from their injuries. “It’s a call to action that we can change,” Dr. Newman says. “Perhaps we can change the way concussion is addressed in the emergency room and if we do that, early intervention strategies can be employed similarly to what we have seen happen with heart attack and stroke. We can change the course of many people’s concussion scenarios by interacting early, and interacting correctly.”

Next steps

In response to the lack of a standardized concussion protocol, Dr. Newman is currently drafting and strategizing his own plan for a specialized concussion team and protocol with the help of his colleagues at NYU Langone Health. His hope is that both the team model and protocol can be implemented in emergency departments, urgent cares and the like immediately. “The simplest step is to have a lecture series on the acute evaluation of concussions, including how to evaluate concussions for the neurology resident, and what steps to take in the emergency room,” he says. It may also include drafting a guide that outlines the warning signs of a concussion, current treatment options and available resources once the patient leaves the hospital. This guide would be available in the emergency room and distributed to patients by the residents on call.


The International Concussion Society sponsored website Concussion.Org is the number one destination for information related to concussion prevention, diagnosis and treatment. Our mission is to serve medical professionals, athletes, administrators, coaches, patients and the public by providing a central repository of accurate and scientifically vetted concussion research. Working alongside our world-class scientific advisory board, Concussion.org aims to be the most trusted global index on one of the most common, yet least understood, forms of traumatic brain injury. If you would like to be interviewed for an influencer profile, please fill out this form.