Once common treatment of concussion

Head injuries at the time were treated as mere nuisances. Players reacted to violent head blows by trying to blink away their blurred vision, shake the ringing from their skulls, and trundle back to their huddles, unless they were flagged by sideline doctors. Even then, they generally returned quickly to action.  Boston Globe October 2017
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Neurological trauma and enduring change in survivors

Westborough, MA December 18, 2017 The British Medical Journal Lancet recently published a series of articles describing the long-term effects of brain trauma. The series is worth a serious read for those who are in the position to take care of trauma patients.

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There has been little change in our approach to handling the individual grind of caring for the TBI patient I must sadly admit.  Young and old it takes both patience and dedication to achieve the best outcomes with those we bring into our treatment continuum. “Survivors experience a substantial burden of physical, psychiatric, emotional, and cognitive disabilities, which disrupt the lives of individuals and their families, and pose huge costs to society” according the Lancet, 2017.  Many readers have read my post Updates in these pages where I have detailed well-known athletes like Formula 1 car driver Michael Schumacher and Mike Towell, the Irish boxer both of whom were seriously injured from TBI.  Towell died from injuries linked to second impact syndrome following a match in 2016.
Schumacher remains in a minimally conscious state in Switzerland.  He is conscious but does not speak or move about.  He requires 24 hour medical care and is living is a special suite adapted in his home that allows him to continue to receive the best care possible while being in his familiar setting surrounded by family and friends.  The cost of his care exceeds $ 100,000 per month.
Some reports suggest Mr. Trowell had sustained a brain injury in the early rounds of the fight.  “Essentially, “second impact syndrome” or SIS results from the brain’s inability to autoregulate cerebral perfusion pressure and swelling as a result of repeated cerebral trauma.” Sefton, 2016 on second impact syndrome and Mike Trowell
Autonomic regulation is the role of the brain stem that maintains the diurnal pattern of arousal for wakeful activity and sleep hygiene.  The brain stem regulates heart rate and respiratory drive as well.  These functions are vital to survival and comprise the autonomic nervous system.  The ANS functions as the brain and body’s alarm system signaling the need for fight-flight activation according to a Autonomic Storming post by Michael Sefton, Ph.D.
Lancet identifies the complexity of TBI and its multifactorial underpinning.  A growing number of patients are elderly that contribute to “heterogeneity of outcomes and consider ways forward for targeted management of severe TBI in the intensive care unit” as mentioned in the 2017 Lancet summary.  Improved management of TBI in the trauma centers and ICUs bring forth better rehabilitation candidates and better outcomes including return to home and eventually return to preinjury employment for many.  Surgical intervention crafted to decrease secondary injury to brain have been enhanced by improved diagnostic accumen, imaging and novel techniques such as radical craniectomy and cranioplasty for management of intracranial pressure and its associated edema.
The series also explains PSH or “autonomic storming” something that I have described in several posts and can be quite serious both in the trauma canter and later in the rehabilitation hospital   “Geert Meyfroidt and colleagues provide an overview of paroxysmal sympathetic hyperactivity, a consequence of acute brain injury, and discuss the promise of improved characterization and implications for management”. Damage to the system that regulates sympathetic and parasympathetic functioins due to traumatic brain injury can be unsettling for familiy members and clinicians alike. The recovering subject can have wild swings of autonomic arousal such as elevated heart rate – patients sometimes chug along at 140-160 while autonomic storming.  Paroxysmal changes in blood pressure may pose significant risk, respiratory rate may become tachypnic, patients frequent are febrile and may become excessively sweaty  as a consequence of autonomic dysfunction.  Patients in our rehabilitation frequently undergo repeated blood cultures and lab studies looking for a source of infection.  Many are returned to the trauma centers for additional brain imaging studies and cardiac monitoring that takes hours and is often unneccessary.  These procedures delay recovery and add confusion to the patient and his family.
The regulation of the secondary injuries such as paroxysmal sympathetic hyperactivity is essential for patient well-being and outcome measures including returning home and re-entering the work force. The Lancet series is a well written update on current brain injury treatment and management of this serious public health threat.

 Lancet Neuology (2017) Jun;16(6):452-464. doi: 10.1016/S1474-4422(17)30118-7. Traumatic Brain Injury. Taken 12-18-2017.

What happens to the brain when concussed? See for yourself in CDC video just published

WESTBOROUGH, MA April 21, 2017  There has been a great deal of research published recently about the cumulative impact of concussion.  Every athlete who experiences a concussion has a unique trajectory toward recovery.  It is well-known that athlete’s who experience  a second or third concussion may be at risk for long-term cognitive symptoms unless they rest until the symptoms are fully resolved. It is now expected that each recovery is different and should be tailored for the presenting symptom profile and the athlete’s medical history. A combination of rest and controlled exertion seems to work best for recovery.  Balance and vestibular changes from concussion require physical therapy in the days after injury. We offer these services at Whittier Rehabilitation Hospital. In cases of second or third concussion the recovery can be very different and often prolonged.
There are dozens of You Tube videos that I have posted in these pages illustrating the brain as it becomes concussed. On my first website nearly 20 years ago I purchased a .gif program to illustrate the movement of the brain during a concussion – like the one below.  It cost me nearly $100 to download and post on my website.  Now they are available free of cost and easily posted to social media.
A concussion is a traumatic brain injury resulting from force causing energy to pass through the brain resulting in the brain shaking within the skull.  A study published in January 2016 in the Journal of Pediatrics suggests that preadolescent boys are at higher risk of concussion when playing on varsity ice hockey teams.  The study at Hasbro Children’s Hospital in Providence, RI also suggested that girls playing ice hockey who are heavier may be at greater risk for concussion.  On average, the preadolescent boys in the study took 54 days to become symptom free.
Here is a link to another very useful video produced by a Canadian physician Dr. Mike Evans. I often have families watch this 10 minute video before initiating our conversation.  The point is that the brain is seriously impacted by energy pulsating through the skull from whatever cause.  I have seen several snow boarders this winter. Spring sports usually see an uptick of concussions in lacrosse and girl’s softball.  Concussion can be expected to effect all cognitive functioning including concentration, speed of mental processing, problem solving, memory, and behavior.

Clock of the week – a man of Trump’s age

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Drawn by 70-year old male
WESTBOROUGH, MA November 10, 2016 You may be interested in the Clock of the week on this day after the presidential election of Donald J. Trump.  It was drawn by a male with obvious cognitive dysfunction.  The task is simple – draw a clock and set the hands for 11:10. In this case the patient became stuck. He asked me “how do I do it” and I replied start with the circle.  As you may notice the man drew the large circle quite well.  I thought to myself “hmm, not bad”.  Next he drew one small circle after another.  Finally he was able to approximate the minute hand only – as you can plainly see it is set juxtapose where the 2 might be.
Dementia is an insidious neurological disease that robs patients of their mental functioning – including memory, problem solving and the capacity to think with critical acumen.  The late president Ronald Reagan succumbed to dementia of the Alzheimer’s type in 2004 after a decade of declining cognitive prowess.  He was 69 when he entered the White House. It has grown more prevalent in the past decade. Neuropsychologists are uniquely qualified to manage the cognitive and behavioral changes associated with dementia. There is no cure for dementia at the present time. Exercise and mental activity are two components of maintaining a healthy mind and body into one’s old age.  My practice is filled with older patients many of whom do not believe in the adage about old age being “the golden years”.  In fact, many older patients are lonely and demoralized.  Many are afraid of what the next president may do to their healthcare, housing and social security pensions.
Let us hope that our next president will maintain his mental faculties well into old age. His somewhat unbridled behavior is not unlike that of patients suffering with some forms of dementia that negatively impacts judgment, planning and decision-making. Mr. Trump will be 70 years old when he enters the White House in January 2017.  The oldest man to ever be elected to the office of the president.

Perseveration, severation, eration, ation

WESTBOROUGH, MA October 14, 2016 What does the term ‘to perseverate’ refer to in clinical terms.  The media attached below will illustrate the concept of perseveration in its clinical presentation. The patient was asked to copy her name.  A model was presented for her by the examiner. Most people have control over behavior through a series of feedback loops that become active in the brain that allow for anticipatory awareness and behavioral prospective as a person reaches full cognitive maturity.  Patients who are recovering from right hemisphere lesions often exhibit the pattern

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Patient asked to copy her name – Frances

of repetition without regard for how appropriate the pattern may be in respect to the task demand. You can see that the patient draws what appear to be tee pee shaped figures and two horizontal lines – perhaps a modified upper case A.  Meanwhile, she repeated the figure until she ran out of paper at the bottom margin.  In blogs already published I have mentioned the term perseveration and made an effort to illustrate its unusual presentation. One can see in the feature image a circular pattern of zeros as a patient attempted the clock drawing.  The patient got stuck making the number 0.  In the recent blog on this topic, I posted a video for the readers use that shows one case of perseveration in an older patient drawing circles over and over.

 

The term refers to the pattern of repeated motor movement in spite of the indication (or feedback) that the response is no longer needed or is inappropriate.  As you can see by this drawing the individual continued to make the same pattern over and over without regard for the task I had assigned – copy your name.

Treatment from serious stroke require months of cognitive rehabilitation in addition to physical and occupational therapy.  patients must be taught to recognize their cognitive vulnerability to errors like this.  As recovery is made most patients establish improved self-monitoring to compensate for their weaknesses. But some fail to re-establish the feedback loops and awareness that allow them to live in the world with the immediate awareness that once is enough and it is okay to stop.

What is post-concussion syndrome?

“The syndrome consists of musculoskeletal pain, headaches, sensitivity to sound and light, sleep disturbance, changes in memory and balance, anxiety and depression. The emotional impact of this leaves patients feeling alone and frustrated” Sefton, 2016

The likelihood of getting a concussion while playing sports is between 10-30 percent of high school and college athletes.  As many as 29 percent of these injured players may go on to experience post-concussion syndrome. It is important for team physicians, trainers, and primary care doctors to understand and treat people with lingering symptoms of concussion.

brain_pictureIn a blog post published in September it is noted that concussion is an invisible injury and recovery takes time – generally 2-3 weeks. The consequence to individual athletes or others recovering from car crash, falls, and any brain trauma can be debilitating and effect a few bodily systems. The emotional stress of lingering symptoms should not be underestimated. Whether it is a professional, elite student athlete or a salesman injured in a car crash there is an experience of stigma associated with the invisible injury of concussion. The emotional impact of this marginalizes patients often leaving them feeling alone and frustrated.

A multidisciplinary approach is best that allows for restoration of physical activity and acknowledgement of both physical and emotional symptoms. Pain management is a useful intervention including aquatics.  My approach to treatment includes biofeedback, education and psychotherapy.  This helps reduce the autonomic effects of acute stress and the inflammatory impact on the fight/flight response – including blood pressure, sleep, and rate of breathing.

Sefton, M. What is PCS: and why do I care? Blog post: https://concussionassessment.wordpress.com/2016/09/30/what-is-pcs-and-why-do-i-care/. Taken October 1, 2016.

What is PCS? And why do I care?

ART1WESTBOROUGH, MA  September 28, 2016 Postconcussion Syndrome is a complex disorder that can stymie many physicians because of the abundance of both physical and emotional symptoms. There are about 3-25 percent of patients who are diagnosed with concussion that go on to have a longer duration of symptoms – sometimes a year or more . That is quite a discrepancy in the prevalence of cases.
The PCS cases with whom I have worked having prolonged symptoms from concussion often experience both physical and emotional symptoms that can be debilitating. “Post-concussion syndrome is a complex disorder in which various symptoms — such as headaches, light and sound sensitivity and dizziness — last for weeks and sometimes months after the injury that caused the concussion.” (Mayo Clinic)  If someone you know suffers from PCS the effects to a family system can be dramatic especially when the head of household can no longer go to work.  Whether it is a professional, elite student athlete or a salesman injured in a car crash there is an experience of stigma associated with the invisible injury of concussion. The emotional impact of this marginalizes patients often leaving them feeling alone and frustrated.
Sometimes vague physical symptoms create an overwhelming emotional response that comes from the lingering resentment patients feel when seeing doctors who seem unable to understand their needs. Sometimes the outward appearance of lingering concussion may appear to be solely a psychiatric condition rather than someone who is recovering from a brain injury. Some physicians unfairly believe prolonged symptoms may be linked to ongoing litigation.
In a blog published in December 2015, Concussion and PCS was discussed in some detail.  “Like concussion, it is an invisible injury that renders many people unable to work. Headaches, neck pain, fatigue, visual changes, irritability, sensitivity to sound and light, depression, and poor sleep hygiene were common” (Sefton, 2015).  The long-term impact negatively impacts both physical and emotional functioning by slowly increasing autonomic activation and impact sleep, appetite, and emotional well-being.
When I am working with someone who has been symptomatic for months or more it is quite apparent how frustrated they can become. It is important for the patient to feel they are believed in the story they are telling. Their symptoms are real and in many cases life changing.  I realize that they have never received the proper education from experts to understand their concussion and its potential recovery course.  Someone with prolonged PCS can be difficult to work with because symptoms can be refractory to traditional therapy. The last thing they may want is to sit with a neuropsychologist and retrace their steps all the way back to the beginning of their symptoms or personal injury. A multidisciplinary approach is best for all involved and should include physical exertion that does not exacerbate existing symptoms (Makdissi, et al, 2016).
Meanwhile, there is a growing body of literature that links prolonged symptoms of concussion to major life stress that can imprint psychologically – like PTSD when the timing is right.
References
Mayo Clinic Website, http://www.mayoclinic.org/diseases-conditions/post-concussion-syndrome/basics/definition/con-20032705. Taken September 28, 2016
Sefton, M. Concussion: physician’s once espoused a link to unresolved litigation. Blog post: https://wordpress.com/stats/insights/concussionassessment.wordpress.com Taken October 1, 2016.
Makdissi, et al. The difficult concussion patient. Br J Sports Med. 2013 Apr;47(5):308-13. doi: 10.1136/bjsports-2013-092255 Taken October 1, 2016