Six Blind Men and the Elephant: The Challenge of Concussion

What is a concussion? Currently there is no MRI or CT scan that can create an image which shows what a concussion looks like (I saw some technology last week at RSNA that is getting close). 

When I had breast cancer two years ago, I was shown a white spot on a computer screen, and that spot defined my cancer. It was 2 cm in length and width. After the cancer was removed, more details were filled in about what kind of cancer I had. No one ever asked me again if I was sure I had cancer?

With a concussion, there is no visual image or scan to show the effects of this trauma on the brain. (Yes, there are functional MRIs and high tech tools in research labs, but they are showing function and no high school kid has access to them.) Doctors rely on patients to describe their own personal experience of the concussion... "How does your concussion feel to you?"

Because concussions are such intensely personal experiences, there is no one right answer for what a concussion looks like or feels like. This challenge of description can be seen in the old fable of the six blind men and the elephant.

Six blind men were asked to determine what an elephant looked like by feeling different parts of the elephant's body. The blind man who feels a leg says the elephant is like a pillar; the one who feels the tail says the elephant is like a rope; the one who feels the trunk says the elephant is like a tree branch; the one who feels the ear says the elephant is like a hand fan; the one who feels the belly says the elephant is like a wall; and the one who feels the tusk says the elephant is like a solid pipe.
A king explains to them: All of you are right. The reason every one of you is telling it differently is because each one of you touched the different part of the elephant. So, actually the elephant has all the features you mentioned.1

In the same way, "what is an elephant" is defined by different people according to their personal experience of touching one part of his body, a concussion feels different to every person as each experiences a different combination of symptoms. 

And we question people who have concussions, "Are you sure you have a concussion because it doesn't sound like a concussion to me?" We have our own experiences of what a concussion was like for a family member or a sports star and we use this to judge the concussion in front of us.

This is always interesting to me since no one ever questioned if I really had breast cancer? I wasn't asked probing details what it felt like or had to listen to a story how my case didn't sound like someone else's.

According to the excellent model by Mickey Collins from his paper, A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion, a concussion has six possible trajectories/areas or (if we can stick with the elephant model) six possible parts one can feel/experience.

 Source: "A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion"

Source: "A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion"

Starting at the bottom with the green circle and going clockwise in layman's terms: headache, neck, mood, balance, eyes, thinking/processing.

In the same way the elephant is experienced so differently by six blind men who only feel one part, with a concussion, some people will just feel symptoms in one area and others a different combination of two, three, four, five or six symptoms areas. And research is showing that women in general experience concussion in a different combination of symptoms than men. 

If a concussion is experienced by one person as injury which causes "neck and headache" issues, and by another person as an injury which causes "eyes and thinking" issues, we ask "which is a real concussion?' or "which is the more serious concussion?'"

With so much variety, it is no wonder why parents, teachers and coaches -- even some untrained doctors -- get confused what is a concussion, and what is not. We want to know what a concussion looks like - show us a photo, please!

Then there is also confusion on how to treat concussions and what is the "right way" to help someone heal from a concussion in school and at work. Well, according to the Collins' model which I personally support, the treatment depends on which of the six areas in which the patient is experiencing the concussion. Once the medical provider can figure out which of the six areas are affected then that combination of areas will determine the proper treatment and/or recovery plan. One size fits all does not work here.

I think this chart again from Mickey Collins' paper is an excellent summary as it shows that risk factors combined with the specific details about injury combined with trajectories involved = lead to which type of treatment and/or rehab is needed. I suggest reading Mickey's paper and please don't forget the story of the six blind men and the elephant when discussing concussions.

 Source: "A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion"

Source: "A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion"