From the Editor

Understanding the bell-ringing of concussion
Back in the day, if we could count the coach’s fingers, we could go back into the game. Now we are more attuned to injury.
Alexandra Stillman, MD
Director of Concussion, Traumatic Brain Injury and Neurorehabilitation, Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center; Instructor of Neurology, Harvard Medical School, Boston, MA
Michael Alexander, MD
Concussion Clinic, Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center; Professor of Neurology, Harvard Medical School, Boston, MA
Rebekah Mannix, MD
The Micheli Center for Sports Injury Prevention, Waltham, MA; Sports Concussion Clinic, Division of Sports Medicine, Boston Children’s Hospital; Brain Injury Center, Boston Children’s Hospital; Division of Emergency Medicine, Boston Children’s Hospital; Associate Professor of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA
Nancy Madigan, PhD
Concussion Clinic, Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center; Instructor of Neurology, Harvard Medical School, Boston, MA
Alvaro Pascual-Leone MD, PhD
Chief of Cognitive Neurology, Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center; Professor of Neurology, Harvard Medical School, Boston, MA
William P. Meehan III, MD
Director, Micheli Center for Sports Injury Prevention, Waltham, MA; Director of Research, Brain Injury Center, Boston Children’s Hospital; Associate Professor of Pediatrics and Orthopaedics, Harvard Medical School, Boston, MA
Address: William P. Meehan III, MD, Director, Mitchell Center for Sports Injury Prevention, 9 Hope Avenue, Suite 100, Waltham, MA 02453; William.Meehan@childrens.harvard.edu
Dr. Pascual-Leone serves on the scientific advisory boards for Constant Therapy, Neosync, Neuroelectrics, NovaVision, and Starlab.
Dr. Meehan has disclosed holding intellectual property rights with ABC-Clio Publishing Company, Springer International Publishing, and Wolters-Kluwer; receiving grant funding from the Football Players Health Study at Harvard, which is funded through the NFL Players Association; and receiving philanthropic support from the National Hockey League Alumni Association through the Corey C. Griffin Pro-Am Tournament.
With the interventions suggested above, most patients with concussion have a resolution of symptoms and can return to preinjury levels of performance. But some have prolonged symptoms and sequelae. Approximately 10% of athletes have persistent signs and symptoms of concussion beyond 2 weeks. If concussion is not sport-related, most patients recover completely within the first 3 months, but up to 33% may have symptoms beyond that.52
Four types of patients have persistent symptoms:
Patients who sustained a high-force mechanism of injury. These patients simply need more time and accommodation.
Patients who sustained multiple concussions. These patients may also need more time and accommodation.
Patients with an underlying neurologic condition, recognized prior to injury or not, may have delayed or incomplete recovery. Even aging may be an “underlying condition” in concussion.
Patients whose symptoms from an apparently single mild concussion do not resolve despite appropriate treatments may have identifiable factors, but intractable pain (usually headache) or significant emotional disturbance or both are common. Once established and persistent, this is difficult to treat. Referral to a specialty practice is appropriate, but even in that setting effective treatment may be elusive.
Most important for patient education is reassurance. Ultimately, concussion is a self-limited phenomenon, and reinforcing this is helpful for patients. If concussion is not sport-related, most patients recover completely within 3 months.
The next important tenet in patient education is that they should rest for 3 to 5 days, then resume gradual physical and cognitive activities. If resuming activities too soon results in symptoms, then they should rest for a day and gradually resume activity. If their recovery is prolonged (ie, longer than 6 weeks), they likely need to be referred to a concussion specialist.
Back in the day, if we could count the coach’s fingers, we could go back into the game. Now we are more attuned to injury.
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