What's a concussion? How many is too many? What if I hit my head on a door?
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When we fall, hit our head or are tackled to the ground, our brain can bounce or twist against the skull. The result is a mild traumatic brain injury, also known as a concussion.
The head injury to quarterback Tua Tagovailoa, witnessed by millions on prime-time television, has put the spotlight back on concussions in sports. But experts say concussions are an all-too-common injury in everyday life. Overall, about 7 percent of children have had concussions, according to 2020 data from the National Center for Health Statistics. But the risk goes up significantly with age. Among 12- to 17-year-olds, about 12 percent had concussions. Among adults, 29 percent report having had a concussion.
The Washington Post spoke to neurologists, physicians and others who study and treat concussions to answer common questions about head injuries, especially for children playing contact sports. Here's what they had to say.
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What are the symptoms of a concussion?
There are a range of physical, emotional and psychological symptoms. After the hit or fall, you may have a headache, nausea or vomiting, double or blurry vision, sensitivity to light and noise and feel sluggish, hazy or like you need to "wipe away cobwebs" from your brain.
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Losing consciousness, even briefly, or not remembering getting hit or events right before or after the injury, are also signs of concussion.
Signs reported by parents include confusion, answering questions slowly, repeating questions, behavior and personality changes or forgetting an instruction or assignment. Teens may talk about "pressure" in the head, feeling sluggish, hazy, foggy, or groggy and difficulty concentrating or remembering. A teen may describe "just not feeling right" or "feeling down."
"By definition, a concussion is characterized by things that are difficult to quantifiably measure," said Kristen Dams-O'Connor, a professor and the director of the Brain Injury Research Center at Mount Sinai Hospital in New York. She said she doesn't have "a formula" when assessing whether someone has a concussion. While there are some observable signs, doctors often rely on the symptoms someone says they have.
Some people with head injuries are sensitive to lights or sounds for days or even weeks after the incident. You may experience mood swings and have trouble sleeping, said Angela Lumba-Brown, a professor and the co-director of the Brain Performance Center at Stanford University. Symptoms may evolve over time, as well.
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How do I know if my injury is serious?
More serious symptoms to watch for include a headache that progressively gets worse, slurred speech, repeated vomiting or drowsiness and loss of consciousness.
Gerard Gioia, the chief of neuropsychology and the director of the concussion program at Children's National Hospital, said there are two conditions to consider when someone sustains a head injury: The force of the blow and whether the person is acting "functionally different" after the incident.
The words of wisdom often shared by experts are: "When in doubt, sit it out." Meaning, if you think someone has sustained a concussion, they should stop playing the sport until they're checked by a physician. Every state has a law on the books instructing that players with a suspected concussion can't play again until they're cleared by a medical professional.
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What if I hit my head on a cabinet or door?
Any hit to the head or body could result in a concussion, experts say. Dams-O'Connor said many people sustain concussions while doing "everyday" tasks, such as accidentally slamming your head on your dryer door. And the most common cause of a concussion are unintentional falls, Lumba-Brown says.
If you're an adult who lives alone and you hit your head, let someone know what happened so they can check in on you, Lumba-Brown said. If your headache gets worse and does not go away or if you're vomiting repeatedly, feel drowsy or have slurred speech, you should call 911 or ask someone to take you to the emergency room.
Chris Koutures, a pediatric sports medicine specialist in Anaheim, Calif., and the team physician for the U.S. men's and women's volleyball teams, said that "if it changes the way you think, how you act or how you feel, something's going on."
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Do people really see stars?
"Seeing stars" is a common description for a more serious concern. If the back part of your brain, known as the occipital cortex, is injured, your vision can be affected.
"People can see white spots, black spots or everything can look green or yellowish or gray," said Kenneth Podell, director of the Houston Methodist Concussion Center. "I've had patients fully awake that have lost vision for a couple seconds."
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What is second impact syndrome?
Second impact syndrome is a rare but possibly deadly phenomenon in which a person sustains a traumatic brain injury while still recovering from a preexisting concussion, says Stacy Suskauer, the director of the Brain Injury Clinical Research Center at Kennedy Krieger Institute.
"How we manage concussions is largely based around preventing a catastrophic second injury," Suskauer said.
It's a "paralyzing thought" for parents and coaches, because an athlete can suddenly die if they have the condition, Dams-O'Connor said. It's more likely, though, that by returning to play too soon, an athlete will prolong the recovery period of their initial concussion, she said.
Physicians say there is a "window of vulnerability" when an injured brain is more susceptible to another concussion and more severe injury. "We're not 100 percent sure what it is in humans," Podell said. "It's a tough study to do, but if you use the rat model it's two days out to four or five days out. Somewhere in that time frame you have to be real careful."
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How do concussions affect kids differently than adults?
We often think children have a miraculous ability to bounce back from an injury such as a broken bone, but "it's the exact opposite" for a brain injury, because a child's brain is still developing, said Mark Halstead, the director of the Sports Concussion Program at Washington University in St. Louis. Children often take longer to recover from a concussion.
Several brain injuries that accumulate over time can affect the "developmental path" for a child's brain, Gioia said.
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How many concussions are too many?
Experts say there's no "magic number." Halstead said you could put 10 concussion experts in a room and get 10 different answers to the question. For him, it depends on the patient, the severity of their symptoms and their goals for and outside the sport.
Halstead said he's most concerned about repetitive blows to the head over a long period of time, including what are called subconcussive blows - hitting a soccer ball with your head or two players colliding their helmets on the line of scrimmage in a football game.
"It's just common sense that repetitive injuries to a particular body part over a period of time is not necessarily a healthy thing for your body," Halstead said.
Repeated concussions and blows to the head increase risk for neurodegenerative diseases, including chronic traumatic encephalopathy (which has been prominently tied to football and boxing).
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Is there a point at which someone should stop playing contact sports?
The answer depends on who you ask.
Lumba-Brown said that she sees a string of "three, four or five" concussions as a "warning sign" to call it quits and switch to another, safer sport.
Gioia said the "progression of the injuries" matters more than the number of injuries. He asks: Has it taken less and less force to cause each subsequent concussion? Or is it taking longer for you to recover from the same type of head injury?
If it takes two or three months now to recover from a brain injury and it used to take a week or two, that may mean the brain is "not bouncing back as well as it did before," Gioia said.
That's when he starts talking to athletes about retiring.
Even if you are lucky enough not to get hit again, just by staying in the game, you double your recovery time, because of the added metabolic stress of physical activity, said John Leddy, a clinical professor of orthopedics and the director of the Concussion Management Clinic at the University at Buffalo.
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Are some people predisposed to getting a concussion?
Physicians know that a previous concussion puts someone at higher risk for another one. Some people may also have a genetic risk. Research has identified "genetic markers" that may make it more likely for a person to have symptoms of a concussion after a head injury, Lumba-Brown said.
Gioia said he wished there was a way to recognize whether someone is at high risk of a concussion, but science isn't there yet. Gioia said he's part of a group investigating whether there are "biological factors" such as a blood test or a brain scan, that could tell whether someone will take longer to recover from a concussion.
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What sports are at highest risk for concussions?
In a 2019 report, the American Academy of Pediatrics found that tackle football, girls soccer, boys lacrosse and boys ice hockey have the highest rates of concussion reports per athlete among high school sports.
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How long does it take to recover from a concussion? What's the treatment process?
It depends on the person and the severity of the concussion. Generally, experts say patients take three to four weeks to recover. Lumba-Brown said 20 percent of people require more than a month.
Until a few years ago, rest and recuperation required days - if not weeks - of "minimal brain stimulation," which amounted to no screens, no books and, if possible, very little exposure to light. The American Academy of Pediatrics updated its guidelines in 2018. Still, minimizing the use of screens, computers and video games is helpful, because using them slows down recovery - probably because they provide too much stimulation for the brain to handle during its recovery, research shows.
Physicians want children to return to school sooner; recovery plans are now step-by-step guidelines that slowly reintroduce activities as someone starts to feel better. There's evidence for doing light aerobic exercise once symptoms have stabilized, research shows.
"We're trying to find the fine line between overstimulation and total shutdown," Koutures said.
There is no "cure" for a concussion, but there is a neurosteroid in clinical trials that may be able to speed up recovery down the road, Lumba-Brown said. Until then, adequate sleep, staying hydrated and some light exercises, "if you can tolerate," them are the best steps toward recovery, she said.
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How do you convince an athlete to stop playing after a concussion?
Koutures, the pediatric sports medicine specialist in Anaheim, said all young athletes want to play "no matter what." But if they have a concussion, he tells athletes they can "blame the medical team," because the best decision is to sit out and not play.
"I tell them flat out you have one brain," Koutures said. "We can't transplant them."
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The Washington Post's Richard Sima contributed to this report.
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