A Story of Post Concussion Syndrome from the Frontlines.

Rachel’s story is a cautionary tale that teaches us the importance of the Four Rs: Recognize, Respond, Rest and Reassess.  After her first hit to the side of her face during a game on September 22, 2010 which produced headaches and dizziness, she continued to play with severe symptoms for the next three days. The First Three Rs tell us that she did not Recognize the hit to be a concussion, that she did not Respond and leave the game and that she did not followup with Rest. Would the outcome have been different if Rachel had known about concussions? I am sure she wonders herself.

Dr Engelland

My name is Rachel Abrams and I am a junior in college. In high school I played soccer, softball and basketball. I went to college and was set out to play soccer and softball there. To anyone else September 22 is any other day, for me it is forever etched in my mind; I call it the devil’s day. I never thought anything of concussions; I was uneducated of this injury. I was one of the goalkeeper’s on the women’s soccer team and was having the time of my life. Then came September 22, 2010, when my life changed.

I received my first concussion on this day, during one of our soccer games at college. It was during one of our games, I was in goal and I received a corner kick from the opposing team. I misjudged it a little bit, caught it against the side of my face and continued playing. After the game I had headaches, I didn’t think anything of it and practiced the next three days, even with the headaches getting worse. Our athletic trainer then diagnosed me with a concussion and I was kept from playing. Then it got worse, my symptoms got worse, now experiencing nausea and increased headaches. I went to the emergency room at a local hospital where they did a MRI or CAT scan, I don’t remember exactly. From there on my symptoms got worse, with the addition of fatigue and I had to see a neurologist just to be completely checked out. I was suffering from fatigue, headaches, nausea, and had a slight hearing loss in one of my ears. My neurologist diagnosed me with a mild concussion and said I was out indefinitely. I had to take a week off of going to classes and in the next few weeks I was diagnosed with post concussion syndrome.

For the next nine months I experienced severe headaches every day, almost all day long. I couldn’t do any physical activity for about 90% of that time. I had many symptoms, most of all it was headaches. I was also nauseous almost every day for the first three or four months. I was always tired; I experienced a great deal of fatigue, but could never sleep. I had a lot of memory issues and I had a little bit of balance problems. I was on many different medications during these months, probably fifteen or more. At one time, I was taking twelve pills a day, a few in the morning but most at night. The medications were for all of my different symptoms. I was taking sleeping pills that could have side effects of hallucinations, which of course I had when I would wake up at night. My neurologist and I were trying all kinds of medications; with stopping ones that weren’t working I had to deal with rebounding. With going through this for so long, I believe I became slightly depressed because these headaches mess with your mind and you don’t think they will ever end. I had some nights where I would pray that either the headaches were gone in the morning or that I wouldn’t wake up. I finally got through this; I believe that I was finally 95% headache free by mid June.

I decided to go back to playing soccer in the fall of 2011, with headgear to protect my head. September 22, 2011 came around; I was warming up in goal, my teammate took a shot, it hit the side post, came back and hit me on the side of my head. I became very fatigued and slow thinking, I was diagnosed with a concussion. I then went back on some medication. I experienced a lot more memory problems and I had very bad balance. I began taking ImPACT tests. I started off doing horrible on these tests and almost always came out of them slow thinking, with a bad headache and completely exhausted.

This time around I dealt with the concussion better, I knew how to make the headaches decrease. I came off of the medications within the first few months. This concussion also lasted around 9 months also but I finally got through it. My neurologist and I figured out that I have probably had at least four very mild concussions before these two but never thought about it. So it is determined that I have had six concussions in my life. The hardest but easiest decision I have ever made was to never play competitive sports again. My sports career is over, it was hard to deal with but I can’t risk my health, which is most important.

How am I now? I still get headaches at least once a week, my balance is much better, I have a slight memory problem and I am not on any medication. I am a stronger person, having gone through this. What I want to do is educate people and support people who may be going through something like this. There is no reason that concussions should be put on the back burner.

Kobe Bryant Speaks Out

Kobe BIt’s one thing when a state law or a policy that comes down from above says that resting is the best treatment for concussion. But it’s another when a star player like Kobe Bryant has something to say about it.

Commenting in the LA Times and re-quoted on Slamonline.com, Bryant said of his teammate, Paul Gasol who has missed five games due to a concussion:

“I was a little angry with him the other day because he’s coming to practice and coming to the games,’ Bryant said. ‘Stay home. Cut all the lights off. Just rest. Let your brain rest. But he wants to be around [the team]. That’s the type of teammate he is.”

What Bryant is recognizing is that healing from a concussion requires athletes, especially at the NBA level to do something that often runs counter to who they are. That’s to withdraw from the limelight, the locker room, the home territory with the friends and teammates and be quiet and REST.

According to the basketball blog site TrueHoops, the NBA has gotten serious about concussion management. Even though the degree and frequency of hits may not be what we see in the NFL, they are implementing a multistep protocol to keep players safe in the short and, maybe most importantly, the long run. Under the guidance of Dr Jeffrey Kutcher, the program is taking hold. Kutcher is quoted on Slamonline as saying: “the policies need to reflect the fact that it’s a team effort to diagnose concussions and look out for injuries, because the injured athletes oftentimes don’t know they’re injured.”

It does seem surprising that we have very little to offer injured players other than vigilance—no medication, no shots (meaning vaccinations), no therapy of any kind. But as Bryant says: ‘It just takes time. There’s nothing you can do really to expedite it. It’s not a muscle. You can’t massage it. There’s nothing you can do. You just rest.’”

photo from superbwallpapers.com via Googleimages

How Long Will Concussion Symptoms Last?

37EEG_mit_32_ElectrodenThose of us on the front line in the concussion world and certainly all injured people would like to know if it will take a few hours, or days, or if the debilitating symptoms of concussion are likely to persist. For some recovery can take many months. For some life is never quite the same. Ever.

A fascinating if somewhat disheartening study was published online this week showing us just how much we really don’t know about concussions.

In the revamped JAMA Pediatrics journal online, Drs. Zemek and others from Canada published their ambitious review of the literature to see if they could define the predictors (or “prognosticators”) of prolonged recovery from concussion in pediatric (ages 2-18) patients. The murkiness starts with the fact that there is not a consistent definition of concussion, post-concussion syndrome (PCS) or full recovery. So with these limitations in mind, the researchers did their best to determine what we know about predicting.

They culled fifteen studies that met strict criteria after a review of over 500 published papers in the world literature. In sum their findings show that in large studies the risk of PCS (defined as more than a month of symptoms following injury) was increased in older children who had sustained loss of consciousness, headache and/or nausea/vomiting. In smaller studies there appeared to be some correlation between initial dizziness after the injury and prolonged recovery (PCS).

Another soft finding from the review that many “feel” is true is that certain conditions predispose to prolonged recovery. Those include children and teens who have had a previous head injury, learning difficulties, or behavioral problems. However, none of these associations with prolonged recovery were strong predictors.

The authors conclude that “because there is no method to predict which children will experience prolonged symptoms vs which will have a rapid recovery, clinicians must continue to recommend conservative management including both cognitive and physical rest, followed by a stepwise return to activities for all children.”

We remain without a good “test” or means to determine whether a concussion is mild, moderate or severe until we see how long the process of recovery will take. No estimation of severity can be made at the time of the injury. We still do not have a clue about who will recover when.

But we have a fantastic opportunity to do some good research to try to find out. Now that the majority of the states in the US have mandated some sort of concussion protocol and management program at the middle and high school levels, there is a tremendous opportunity to collect solid data. And we also need to keep looking for and tracking markers (biological or behavioral tests) that might help predict who will play the next season and who cannot.

image from curebird.com via Googleimages

What We Can Learn from Hillary’s Concussion

hilary-clinton-ill_2439936bAlmost everyone knows Hillary’s litany of woe by now: stomach virus, dehydration, fainting spell, head injury, concussion, out of work, blood clot in head.

Even though there are many unanswered questions surrounding this story, there is a lot we can learn from her experience. Here are a few lessons that come to mind:

Concussions are not just an NFL problem. Concussions happen in stupid ways, even stupider than playing at being a gladiator on Sunday. Tripping on the sidewalk, banging a head on the hall locker, falling from the chin-up bar, getting hit by a stray ball as a spectator—all of these events have resulted in concussions in patients of mine.

Recovery can be prolonged. while most people get better in a few weeks, it can take longer for some and the apparent severity of the injury at the time of the fall may not be indicative of the seriousness of the concussion.

Rest is essential: Hillary was sent to “work from home” which I have criticized because the mainstay of treatment for a concussion is REST. Unfortunately there is as yet no medication that promotes brain healing following a concussion. The only thing we can offer is both physical and cognitive, or “brain work,” rest.

Withdrawal from activities is part of rest. In our wired times, it is really really hard to put down the screens—television, mobile phone, iPad, computer. But it has been shown that this kind of brain work, even though it might feel like relative “rest” is not helpful to recovery.

Complications are rare. Whatever Hillary’s blood clot is connected to medically, it is a rare phenomenon. Again, most people heal from concussion without any major consequences. There should be no drive to get more CT scans or MRI’s in the average person who sustains a head injury just because of Hillary’s story. Hopefully there will be more medical information forthcoming to put this in perspective and calm us all down on this score.

And Finally,

People may doubt your symptoms. It’s never a good time for the Secretary of State to have a concussion and be on bed rest  but the timing of this injury caused a nasty flare among conservatives who doubted her willingness to testify in the Benghazi hearings. However, it really IS all in the head of the person who has been injured. It’s extremely rare to have any sort of radiological evidence to PROVE that the symptoms are real. It’s why I entitled my book as I did. We need to trust ourselves if we are the concussed person and trust the patient if we are a bystander, family member, boss, or caregiver.