A Heads-Up on Concussions

MILD CONCUSSIONS don’t get the respect they deserve—for how debilitating they can be, and for how many weeks, months or years the brain can take to recover completely.  Four months after hitting her head on a pole while rushing to get off a Metro train, DC artist and teacher A.M. still struggled, at first mostly with headaches and facial pain focused in her jaw.

But A.M.’s eyes caused her the most trouble in the presence of any light, indoors and outside.  Reading was difficult— black print on white pages—but especially anything on an electronic screen. In addition to its bright lights, a screen also continually flickers, making the eyes work harder.

“Sensitivity to light is the worst,” she said, “because everything involves light.”  Most of the time, even indoors, she wore two or three pairs of dark glasses.

A.M. also had trouble with noise, both the uncontrolled ringing of tinnitus and the amplification of voices, including her own, which sounded like a recording blasted through a loud speaker inside her head.

At the four-month mark, she received an official diagnosis of post-concussion syndrome with ocular-motor difficulties, a prescription for vision therapy and the prognosis that these could take months or even years to heal.

With a concussion, severity and recovery time are often unrelated to the original impact or its immediate effects, such as blacking out.  It’s almost impossible to detect how far the initial damage has spread, and every concussion is unique.

“Imagine you have a mason jar that is full of thick liquid and just big enough to accommodate a peach,” writes Lori Fox about her girlfriend’s head injury. “If you shake the jar violently, the peach sustains multiple impact points. When you take the peach out, the bruised places are visible. If you cut into the bruise, you will see the damage spreads beyond the area around the impact sites.”

“I just saw someone the other day who had a dog toy thrown at their head by their toddler,” said clinical neuropsychologist Alicia Sufrinko at the University of Pittsburgh Sports Medicine Concussion Program.  “The injury comes from the brain shifting inside the skull and affecting your nervous system.”

“Usually it’s only in retrospect that you can say how severe a concussion is,” according to Vanderbilt neurosurgeon Andrew Gregory.

Bruising caused when the brain moves back and forth inside the skull often affects the frontal lobes. These are responsible for cognitive functions, also called “executive functions,” such as attention and completing tasks; planning and organization; inhibition and emotions. Head injury can also cause fatigue, irritability, anxiety and insomnia.

Most people, including physicians, are unaware that sufferers should avoid triggers such as bright lights, loud noises and physical or mental exertion until the symptoms are gone, Gregory pointed out.

Said Sufrinko, “We give people a structured rehab program, and we follow up with them and make sure they get to 100 percent before we discharge them.”

Few physicians are also aware that, for symptoms that persist after three to four weeks, more aggressive interventions should begin, including vision therapy for eye problems, vestibular therapy for balance problems and cognitive therapy for difficulties with concentration and multi-tasking.  As with a stroke, undamaged areas of the brain can take over tasks from the damaged areas but need therapy and practice to master those tasks.

What can help predict recovery time is the total number of specific early symptoms, such as sensitivity to noise or light, difficulty concentrating, insomnia and balance issues. Others that appear less relevant include amnesia, tinnitus, loss of consciousness and hyper-excitability. Researchers are working on algorithms to help with these predictions.

According to a meta-analysis of more than 100 research studies, the likelihood of a lengthy recovery is also linked to the “development of subacute problems with headaches or depression,” as well as to a history of mental health issues such as depression. Other red-flag symptoms include neck pain, double vision and weakness or tingling in the arms and legs.

The strongest predictor of a lengthy recovery from a mild traumatic brain injury is painful headaches in the days immediately following the impact. For the first time in her life, A.M. had migraine headaches over a period of several weeks.  (Her family history of migraines made these more likely with a head injury.)  She had surgery to remove impacted wisdom teeth and treatment for TMJ.  After the migraines stopped, she continued having tension headaches and jaw pain.

The one effect of head injury with an unquestionable prognosis is loss of smell, because impact can completely sever the brain connections involved, and their functions cannot be replaced.

Once A.M. received her diagnosis, she started therapy for her brain to relearn how to coordinate the information received by her two eyes, needed for all visual activities, notably for tracking lines of print on a page for reading.  Simply receiving the post-concussion diagnosis helped her to obtain accommodations at work and to make other adjustments.  The only regret: that getting an accurate diagnosis and starting treatment had taken so long.

—Mary Carpenter

Every Tuesday in this space, well-being editor Mary Carpenter reports on health news you can use.

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