We've Been Treating Concussions All Wrong(slate.com)
slate.com
We've Been Treating Concussions All Wrong
https://slate.com/technology/2024/03/concussion-symptoms-signs-treatment-advice.html
61 comments
imo, I think we've been publishing all wrong. We should publish more of things done correctly to inspire by example rather than whining about everything that is wrong in this world for a hundred pages.
We've been doing it all wrong, wrong.
We've been reading Slate all wrong. Perhaps we shouldn't.
Coming up soon: Taking media bait seriously ...
> You’d think that this would have meant a revolution in how doctors understand and treat concussions. It hasn’t.
The article takes a surprised tone that doctors haven’t updated their practices in line with the latest studies, but that’s not usually how doctors work. Doctors aren’t intrinsically academics, and aren’t necessarily hooked into the scientific literature. Doctors don’t get their orders direct from science, they follow the practices of their peers and network. New knowledge percolates slowly and conservatively through that network.
The article takes a surprised tone that doctors haven’t updated their practices in line with the latest studies, but that’s not usually how doctors work. Doctors aren’t intrinsically academics, and aren’t necessarily hooked into the scientific literature. Doctors don’t get their orders direct from science, they follow the practices of their peers and network. New knowledge percolates slowly and conservatively through that network.
It typically takes at least 30 years from a finding to becoming medicine. First it needs to reach sufficient consensus that it starts getting taught in medical school once that happens it then takes 10 years to become common place for it to be taught and then 10-20 for those students to become consultants and be in the position to dictate how a treatment is applied. Sometimes some findings can take a long time to get into textbooks or the textbooks on a topic to get updated and the initial stages take longer. But 30 years is about the best medicine can currently achieve in any volume.
I don't necessarily know if such consensus has been reached for return to normal with concussions, psychology and exercise researchers are trying to make Cognitive behavioural therapy and exercise and a general appeal to nature as the solution to everything in medicine at the moment and there is a lot of bad studies with low or very low quality results on that basis. I haven't followed concussion research so I don't know if that is what is happening here but I suspect its likely. I would just be aware that a lot of the replication crisis with medical research is due to this effect so you have to look at the studies and be aware of the alternatives.
I don't necessarily know if such consensus has been reached for return to normal with concussions, psychology and exercise researchers are trying to make Cognitive behavioural therapy and exercise and a general appeal to nature as the solution to everything in medicine at the moment and there is a lot of bad studies with low or very low quality results on that basis. I haven't followed concussion research so I don't know if that is what is happening here but I suspect its likely. I would just be aware that a lot of the replication crisis with medical research is due to this effect so you have to look at the studies and be aware of the alternatives.
> The article takes a surprised tone that doctors haven’t updated their practices in line with the latest studies
This isn't "new research" or the "latest study", this is now established scientific consensus.
> Doctors don’t get their orders direct from science, they follow the practices of their peers and network. New knowledge percolates slowly and conservatively through that network.
This is indeed part of the problem.
Doctors should get knowledge of new practices from medical school or CME, not haphazardly through gossip. As noted in the article, medical scools don't teach very much about concussions and clearly our new understanding of concussion treatments are not being dispersed with sufficient speed by CME.
We need to hold our medical system to higher standards, not give them a pass because the broken parts have been broken for a while.
This isn't "new research" or the "latest study", this is now established scientific consensus.
> Doctors don’t get their orders direct from science, they follow the practices of their peers and network. New knowledge percolates slowly and conservatively through that network.
This is indeed part of the problem.
Doctors should get knowledge of new practices from medical school or CME, not haphazardly through gossip. As noted in the article, medical scools don't teach very much about concussions and clearly our new understanding of concussion treatments are not being dispersed with sufficient speed by CME.
We need to hold our medical system to higher standards, not give them a pass because the broken parts have been broken for a while.
Wait, is Continuing Professional Development not mandatory for medics in your country? That's crazy. Like, that's so obviously necessary there was a Scrubs episode about it.
You definitely shouldn't have medics who are relying on long obsolete practices and just incrementally learning via the grapevine, get some regulations. It's bad enough that so many countries don't require CPD for software engineering. I don't care that you've been copying the source code into a dated folder every day since 1987, it's 2024 and you need an actual Revision Control System.
You definitely shouldn't have medics who are relying on long obsolete practices and just incrementally learning via the grapevine, get some regulations. It's bad enough that so many countries don't require CPD for software engineering. I don't care that you've been copying the source code into a dated folder every day since 1987, it's 2024 and you need an actual Revision Control System.
The doctors I know go to conferences all the time, so I'm not sure this is 100% accurate. Many also read medical publication journals.
Annecdotal experience: my kid got a concussion last fall (from horsing around in the hotel pool at a hockey tournament; hotel pools are more dangerous than youth hockey, I think), and the ER didn't give us much useful stuff, but the local DR did have us go through a concussion protocol which was shock that we sent him to school on Monday when he got injured on Saturday, but then try a bit more each day as long as symptoms don't get worse, go back a day if symptoms do get worse.
Avoid activities that have a high risk of head contact. That meant no ice hockey until he was cleared, but he was encouraged to do off ice drills.
Overall it didn't seem too bad. He felt better and was cleared in about 2 weeks, with some lingering behavioral changes for about a month after that. And he didn't feel great with some roller coasters we did at 4 months after.
But obviously, every concussion (or mild traumatic brain injury) is different.
Avoid activities that have a high risk of head contact. That meant no ice hockey until he was cleared, but he was encouraged to do off ice drills.
Overall it didn't seem too bad. He felt better and was cleared in about 2 weeks, with some lingering behavioral changes for about a month after that. And he didn't feel great with some roller coasters we did at 4 months after.
But obviously, every concussion (or mild traumatic brain injury) is different.
Second concussions can be life altering, so we want to be absolutely sure our concussed friends and family are recovered before they do anything energetic.
The article presents that you might not recover without doing energetic things. But yeah, you've got to be careful ... and judgement and risk taking can be negatively affected, so you've got to be more careful than usual. Activities will be more risky than usual, but doing nothing isn't good either.
No, that’s not what the article says.
If there is one thing developers can be relied upon to do, it’s this: if there is a Fallacy of the Excluded Middle, they will find it, fall into it, and then set up a household there. Just like the author did.
“Not doing energetic things” includes many more options than hiding in your bed sleeping.
If there is one thing developers can be relied upon to do, it’s this: if there is a Fallacy of the Excluded Middle, they will find it, fall into it, and then set up a household there. Just like the author did.
It’s one thing to avoid immediately going back onto a football field, where you might get hit again before you’ve recovered, or to work, which might be cognitively straining. But instead of *nuanced* advice that included downtime or a scaling back of activities, the recommendation became total rest.
A 2022 study published in the journal Pediatrics found that children who spent less than two hours a day on screens in the first week after a concussion had worse concussion symptoms after one month than did those who engaged in “moderate” screen time of two to seven hours a day.
“Not doing energetic things” includes many more options than hiding in your bed sleeping.
Wouldn't this be an inverse cause and effect? It's not that spending less time using a screen is detrimental, it's that a worse brain injury causes people to need more rest?
Tfa says this is the exact wrong thing to do.
I had a severe concussion 18 weeks before finals my 3rd year of college. Crashed hard mountain biking, broke my arm, and smashed my face. For 8 hours I was a broken record so the first hospital I visited sent me off to a trauma center in the next city over. I came out of that concussed state after they were asking me questions I should know the answer to, but couldn’t remember them for the life of me. I remember it feeling like my neurons couldn’t grab ahold of any connection. Funny enough, the two things I could remember was the speed of light and the Bohr’s magneton. After I said those two constants out loud, everything came back. To this day it was the most surreal feeling I’ve experienced.
That accident happened on a Saturday, and I didn’t sleep at all the next day for fear of going into a coma. I went to school and work on Monday, and managed to finish the semester without any issues.
I know I’m extremely lucky, but I think the fact that I went back to life as if nothing happened was what helped me recover so quickly. I still can recite 299,792,458 m/s as the speed of light and 5.788e-5 eV/T as if it’s the most hard wired connection in my brain.
That accident happened on a Saturday, and I didn’t sleep at all the next day for fear of going into a coma. I went to school and work on Monday, and managed to finish the semester without any issues.
I know I’m extremely lucky, but I think the fact that I went back to life as if nothing happened was what helped me recover so quickly. I still can recite 299,792,458 m/s as the speed of light and 5.788e-5 eV/T as if it’s the most hard wired connection in my brain.
That isn't the speed of light.
Probably meant to type km/s
Just the wrong number, at least for light in a vacuum. 299,792,458 m/s is the correct value.
This is the most terrifying exchange I've read on HN in a while
The smack to the head sent him into a parallel dimension with a different speed of light and he's just now finding out.
Harsh. Considering that most of us remember it as 3x10^8 m/s I was willing to roll with it.
Apparently he is a little off. 299,792,458 m/s according to Wikipedia
https://en.wikipedia.org/wiki/Speed_of_light
Apparently he is a little off. 299,792,458 m/s according to Wikipedia
https://en.wikipedia.org/wiki/Speed_of_light
Right, and that's a definition. Modern SI works by defining constants, so then when scientists figure out a way to measure more exactly they're actually refining our understanding of the SI units, the numbers (such as the speed of light in metres per second) never change any more, so that's convenient.
It is in a material with a refractive index of 1.001122387 ¯\_(ツ)_/¯
To anyone reading this now and thinking, “299,792,458 m/s is the speed of light!”: stairlane’s comment originally gave 299,456,352 m/s as the speed of light. Unfortunately they’ve since edited it to the correct value, thus ruining a very good exchange
I have a surprisingly similar anecdote! Face-planted skating during finals week in my first year at university. My first memories are some hours later in the waiting room at a hospital that my friends had brought me to, holding a notepad with some hand-written responses to "What happened?" and "Where am I?" because my friends had gotten tired of repeating answers to the questions I'd forget having asked every few minutes.
I only had a couple finals remaining, and my profs gave me deferrals as soon as they saw the state of my face when I showed up at their offices. Wrote them a week or two later without issue.
Didn't notice any lingering mental issues, though it's now been nearly two decades and a nerve in my face still feels a bit funny, and my current dentist pointed out that it seems like I've done some damage to some of my jaw tendons at some point. (But as it doesn't cause me problems, didn't recommend treatment.)
I only had a couple finals remaining, and my profs gave me deferrals as soon as they saw the state of my face when I showed up at their offices. Wrote them a week or two later without issue.
Didn't notice any lingering mental issues, though it's now been nearly two decades and a nerve in my face still feels a bit funny, and my current dentist pointed out that it seems like I've done some damage to some of my jaw tendons at some point. (But as it doesn't cause me problems, didn't recommend treatment.)
I don't have any concussions as far as I know, but my brain feels like this sometimes. I wake up and it just feels empty, there's very minimal internal monologue and it feels hard to recall anything of note. I've taken to loading up a bunch of Jeopardy questions into Anki and then doing 50 or 100 random questions over a period of a few minutes, and that seems to get my brain turned on and the inner monologue comes back, and I can recall things. I'd love to know why this happens.
Concussions are mild traumatic brain injuries. There’s a lot more to recovering from a TBI than ‘rest’ or ‘stay active’.
Looked at the concussion alliance website - it seems to be quite reasonable. https://www.concussionalliance.org/treatments
Looked at the concussion alliance website - it seems to be quite reasonable. https://www.concussionalliance.org/treatments
The subject of this article founded the concussion alliance website.
>“It’s a huge myth,” Gormally told me. In 2018, after his experience, he and his mom founded Concussion Alliance, a nonprofit that is dedicated to patient and provider education. “It’s so pervasive; it’s actively damaging people’s recovery.” The idea that cocooning may be harmful is completely new information to most patients Gormally meets.
>“It’s a huge myth,” Gormally told me. In 2018, after his experience, he and his mom founded Concussion Alliance, a nonprofit that is dedicated to patient and provider education. “It’s so pervasive; it’s actively damaging people’s recovery.” The idea that cocooning may be harmful is completely new information to most patients Gormally meets.
I mentioned in another comment this has happened to me before. Actually, at least three times I remember, twice when I was a kid and then once a bit over a decade ago. The "we" here is overstated. This kid received advice from an athletic trainer at his high school and a general practice PCP. You really need to be seeing a specialist in brain injuries. The last time I got a mTBI, it was actually reasonably bad and I could not even stand up without disorientation for nearly a month, but the treatment was absolutely not "go home and a rest." This happened while I was still in the Army, so sure, you can expect a specialized TBI clinic for presumably the employer second-most likely to results in TBIs behind the American NFL is going to know what they're doing better than a family practice dude who finished med school 30 years ago, can't possibly read the latest research from every possible sub-specialty, and mostly puts bandaids on and takes your blood pressure.
Such is the state of healthcare, though. Physicians are not wizards. You can't expect one person to know everything. The PCP probably should have referred him to a specialist, but barring that, you need to insist on seeing one yourself. Unfortunately, a kid isn't going to know that, so parents, please do the same for your kids.
As for the actual protocol I went through, it was retest weekly, continue going to work and running and what not, but don't play any sports, avoid the motorpool, light duty in the office instead, and I was barred from driving until I could pass all the tests, which took four weeks.
Such is the state of healthcare, though. Physicians are not wizards. You can't expect one person to know everything. The PCP probably should have referred him to a specialist, but barring that, you need to insist on seeing one yourself. Unfortunately, a kid isn't going to know that, so parents, please do the same for your kids.
As for the actual protocol I went through, it was retest weekly, continue going to work and running and what not, but don't play any sports, avoid the motorpool, light duty in the office instead, and I was barred from driving until I could pass all the tests, which took four weeks.
I'm stoked to see an article shedding some light on this! Yes, the best practices for how we treat concussions is shifting and some people are not getting the best advice post-concussion.
The discussion about who to blame is a little naive IMO. Doctors do not learn everything they need to know to be doctors in medical school. Largely, they learn the foundations of medicine that they need to be successful in a residency. In residency is where they will learn the things they need to know about how to treat patients in their specialty. The authors primary care physician was very likely taught about concussions in residency, before these new guidelines came out, and simply has not updated their practice to be in line with the new guidelines... Science changes and I'm sure it is hard to stay on top of each new thing that comes out but at the end of the day, that is the job of the physician to stay on top of new developments.
The discussion about who to blame is a little naive IMO. Doctors do not learn everything they need to know to be doctors in medical school. Largely, they learn the foundations of medicine that they need to be successful in a residency. In residency is where they will learn the things they need to know about how to treat patients in their specialty. The authors primary care physician was very likely taught about concussions in residency, before these new guidelines came out, and simply has not updated their practice to be in line with the new guidelines... Science changes and I'm sure it is hard to stay on top of each new thing that comes out but at the end of the day, that is the job of the physician to stay on top of new developments.
Very similar to the experience recounted by this engineer YouTuber[1], who is partly known for modifying his iPhone to add a headphone jack[2]. It's incredible the harmful effect that incorrect medical treatment can have.
[1]https://www.youtube.com/watch?v=Gs790JOeN3Y
[2]https://www.youtube.com/watch?v=utfbE3_uAMA
I wish we had better diagnostic tools for concussion. In our ER, the majority of patients with potentially significant head injuries are moderately to highly intoxicated, provide minimal history, and even though we generally CT all impaired patients with head trauma and hold them until they are no longer intoxicated, in many cases it can be difficult to differentiate a significant hangover from a concussion.
There's got to be some discoverable biomarker for it. If it's significant enough to affect gross brain function, it's got to have some effect on for example brain waste clearance, neurohormones, assorted growth factors, or produce some form of inflammatory markers.
It shouldn't be that hard if you really hold them until they are no longer intoxicated. The last time I had a mTBI was actually in a hospital, luckily enough (passed out from standing up after traction). All the standard tests, i.e. follow this pen with your eyes, stand up straight and touch something, were things I continued not being able to do well for weeks. Alcohol impairment goes away after a few hours.
Granted, they obviously get more mild than that, but the milder they are, the less they matter as long as it isn't happening repeatedly.
Granted, they obviously get more mild than that, but the milder they are, the less they matter as long as it isn't happening repeatedly.
> Alcohol impairment goes away after a few hours.
I think this is a gross oversimplification.
If memory serves, the rate of ethanol metabolism is something around 0.015 (units?) per hour.
In my ED, an average BAL for a patient that we realize is intoxicated (and choose to get a level) is probably 0.3 or so. 0.4 - 0.5 is common, and we see nearly 0.8 (in ambulatory patients!) from time to time.
So for 0.3, if you are maximally generous and consider "sober" 0.08 (the level for an automatic DUI in my state), you're looking at 15 hours of observation. Not exactly "a few."
Further, your own anecdote highlights exactly my point. How you you *know* you had a TBI? Because it felt like one? Because a doctor told you it was one? Because a physician's (subjective) assessment of your exam suggested it was one? Because your insurance would cover an inpatient stay for one if they listed that as the diagnosis?
Don't misunderstand, I do a relatively thorough neurological exam compared to my colleagues, but I have no pretenses as to the level of subjectivity in my assessment, or to the external biases that could potentially sway my judgment. A more objective measure would be greatly appreciated, both to help ensure that I was acting in patients' best interest, and frankly to help me compel others to act in appropriate cases.
I think this is a gross oversimplification.
If memory serves, the rate of ethanol metabolism is something around 0.015 (units?) per hour.
In my ED, an average BAL for a patient that we realize is intoxicated (and choose to get a level) is probably 0.3 or so. 0.4 - 0.5 is common, and we see nearly 0.8 (in ambulatory patients!) from time to time.
So for 0.3, if you are maximally generous and consider "sober" 0.08 (the level for an automatic DUI in my state), you're looking at 15 hours of observation. Not exactly "a few."
Further, your own anecdote highlights exactly my point. How you you *know* you had a TBI? Because it felt like one? Because a doctor told you it was one? Because a physician's (subjective) assessment of your exam suggested it was one? Because your insurance would cover an inpatient stay for one if they listed that as the diagnosis?
Don't misunderstand, I do a relatively thorough neurological exam compared to my colleagues, but I have no pretenses as to the level of subjectivity in my assessment, or to the external biases that could potentially sway my judgment. A more objective measure would be greatly appreciated, both to help ensure that I was acting in patients' best interest, and frankly to help me compel others to act in appropriate cases.
Scotty from the Strange Parts YouTube channel (fantastic) got a very serious concussion that he struggled to recover from for a long time. He made a few videos about it, and has more on his second channel regarding the interesting treatment he did (e.g. https://www.youtube.com/watch?v=mrNKhgAiR7E). I don't know anything about this stuff so they could be legit or snake oil, but what they do does seem to align with the premise of the article.
Red light therapy is a good tool to add to whatever protocol your doctor gives you.
https://www.vielight.com/category/traumatic-brain-injury/
https://www.vielight.com/category/traumatic-brain-injury/
I got smoked in the temple by a knee during jiu jitsu. I felt immediate pain that immediately subsided. No sypmtoms, so I kept rolling. When I got home, I realized that was pretty stupid and I started remembering hearing about people dying from minor blows to the temple. I stayed up late to make sure I was ok but still no headache or any symptoms. After several days of no symptoms, I eventually got a mild tension like headache that lasted for 3 weeks and felt generally run down, like I had just woken up all the time. And then I was fine. Long story short, head injuries are bizarre.
If you weren't ok you would black out so really best to get checked at a hospital.
I can hear my father saying "walk it off"...
The old man wasn't too far off the mark after all.
The old man wasn't too far off the mark after all.
The one thing you should absolutely not do is engage in anything that can give you another concussion. A second concussion before recovering from the first can kill you. So no, he was not anywhere close to the mark.
https://en.wikipedia.org/wiki/Second-impact_syndrome
https://en.wikipedia.org/wiki/Second-impact_syndrome
How did we get concussions so wrong in the first place? And how many patients were still being told the wrong thing?
no, the better question is why do we putting ourselves or encouraging our children to put themselves in situations where they get concussions? Does not seem worth it.
no, the better question is why do we putting ourselves or encouraging our children to put themselves in situations where they get concussions? Does not seem worth it.
Like climbing a tree? Childhood is all about risky exploration.
Youth sports are something else - the risks and the potential damage have been amplified mightily by attempting to emulate professional sports practices. So if that's what you're getting at, absolutely.
Youth sports are something else - the risks and the potential damage have been amplified mightily by attempting to emulate professional sports practices. So if that's what you're getting at, absolutely.
> Gormally was finally well enough to go back to school—and ready to put the whole experience behind him. But he kept getting concussions. Three more times over the next three years, he hit his head playing sports: twice in soccer, and once during Ultimate Frisbee. With each concussion, he received the same spiel from medical providers: “There’s not much we can do for you.” “Go home and rest.” “These things tend to get better on their own.” Each time, it didn’t feel as if they did.
Two things it feels like we've started to forget as a society: doctors aren't gods, they are fallible, they don't have the answer to everything; and you aren't immortal, you are also fallible, vulnerable.
Synthesizing those two things, and the quote: you need to take responsibility for your own health. There's people who do that; and then there's people who take months to recover from a concussion, and upon barely recovering immediately go back to playing hard contact sports, twice, and then get interviewed for a magazine piece about how wrong doctors are.
Two things it feels like we've started to forget as a society: doctors aren't gods, they are fallible, they don't have the answer to everything; and you aren't immortal, you are also fallible, vulnerable.
Synthesizing those two things, and the quote: you need to take responsibility for your own health. There's people who do that; and then there's people who take months to recover from a concussion, and upon barely recovering immediately go back to playing hard contact sports, twice, and then get interviewed for a magazine piece about how wrong doctors are.
I have been a part of MMA/Boxing in some way or another close to my entire adult life, and it has always been shocking how badly we treat concussions or blows to the head.
I've seen Olympic hopefuls being KNOCKED out and given the okay to compete by doctors. The macho attitude doesn't help. One personal anecdote I've seen, time and time again, that has helped is oxygen post-knockout.
every person I've spoken to who has gotten oxygen after a knockout or a hard match told me that they felt much much better vs the times they haven't. Not sure why or how.
I've seen Olympic hopefuls being KNOCKED out and given the okay to compete by doctors. The macho attitude doesn't help. One personal anecdote I've seen, time and time again, that has helped is oxygen post-knockout.
every person I've spoken to who has gotten oxygen after a knockout or a hard match told me that they felt much much better vs the times they haven't. Not sure why or how.
TLDR; If you get a concussion, don't do nothing and rest, but rather continue doing your daily routine. It'll help you recover faster
Stay away from bonks and mind-straining activities, but do other things including light (aerobic, not anaerobic) exercise. Increasing toward your previous levels over time.
I would add to this: If you’re a clumsy person who trips on treadmills, maybe walking on a treadmill should not be in the cards for you.
I would add to this: If you’re a clumsy person who trips on treadmills, maybe walking on a treadmill should not be in the cards for you.
Stay off the bicycle/skateboard/scooter eh. Take no chances - the worst case is very bad.
except: 1) avoid the possibility of head injuries, and 2) if you suffer more than slight symptoms from daily routine, dial it back
While avoiding head injury is a good path to pursue, sometimes the head injury finds you.
It can take very little whiplash of the skull to cause a concussion.
It can take very little whiplash of the skull to cause a concussion.
Sure, but there's only so much you can do to avoid such risks. We control the risks that we can control; the rest is up to luck.
I had a pretty bad concussion when I was very young and I still remember how distorted my short term memory was right afterwards and to a lesser extent weeks after. Couldn't imagine trying to be active nowadays under those circumstances.
* Measuring the economy
* Thinking about the long tail theory
* Giving kids allowance
* Understanding teen happiness
* Making risotto
* Talking about the movie Tár
* Making movies about Malthusian population explosions
* Thinking about herd immunity
* Legalizing marijuana
* Estimating the age of menopause
https://slate.com/search?q=all+wrong#gsc.tab=0&gsc.q=all%20w...
That's from the first two pages, there are at least ten.