So yesterday was the 3-week anniversary of what I fondly refer to as my brain damage episode. It was a beautiful day and I was running in a little local 10K trail race and having a blast and a great run! For the first time ever I was ahead of a rival runner who kicks my ass every year (and who also happens to be another PT in town in addition to being a lightning fast trail runner). I was sprinting way too fast down a steep technical trail trying to hold the lead when my left foot caught something—a rock, a root, who knows what–and the catch threw my weight way too far forward. Instead of just letting myself go I took 7 or 8 huge steps trying to stick the landing and, as I remember it now, I accelerated into the ground and landed on my right shoulder, but the right side of my head kept going downhill into the dirt.
Perfectly normal story—I was so ridiculously competitive trying to win a little local race that I sustained a concussion. I had been incredibly stupid and I was extremely lucky. It could have been so much worse. I could have hit a rock or a tree. What happened when my head hit the ground was that I saw a huge flash of white light but did not lose consciousness. I did feel, however, that this was a little more than one of my typical displays of klutziness and lay there for a minute. The lovely ladies whom I had been trying to beat all stopped to try to help me. I assured them that I was fine and got up, sat for a few minutes, then walked for a few minutes and eventually ran the rest of the way in. I didn’t feel great but I thought I was all right, although some people who were there now tell me that they knew something was wrong when they saw me. And this relatively mild, minor injury turned out to be something that eventually required medical attention and diagnostics and turned life upside down for a little while. Any degree of concussion is no joke.
Concussions, thank goodness, have received much more of the attention that they deserve from science and the media in the past two years, but they are still poorly understood, even by health care professionals. So let’s pause here for a moment and define this type of injury. A concussion is defined by the American Academy of Neurology as a mild traumatic brain injury (MTBI) which is characterized by a trauma-induced change in mental status, with confusion and amnesia, and with or without a brief loss of consciousness. The National Athletic Trainers’ Association refers to a concussion as “an immediate and transient impairment of neural function including alteration of consciousness, disturbance of vision, and equilibrium.”
There are several mechanisms of injury that are responsible for a concussion. The most common is the coup-contrecoup mechanism, which is an acceleration-deceleration injury. When the head hits an object, such as in a fall on the head, the brain accelerates into the inside of the skull on the side sustaining the blow, causing a contusion, or bruise, on the brain; then it rebounds backward, striking the inside of the opposite side of the skull. Both blows damage nerve fibers within the brain. Rotational injuries, seen frequently in sports such as boxing where the head sustains a blow causing a high velocity rotation, causes the brain to violently rotate on its axis, stretching and tearing nerve fibers as well as blood vessels, and then brain strikes the inside of the skull, also causing a contusion. Both mechanisms of injury can be sustained by a blow to the skull as well as a blow to the jaw or the face.
Another mechanism of injury not usually seen in orthopedics and sports medicine but that has severely affected many of our country’s brave and altruistic military personnel is a blast wave injury, in which the shock waves from an explosion cause damage to fluid-filled organs; the brain is one of these. Secondary injuries from shrapnel and heat following the explosion cause further damage. The horror of this mechanism of injury is beyond comprehension. Give me a fall on the head any day.
The pathophysiology of a concussion is that the impact to the brain along with possible shearing or tearing of nerve tissue and blood vessels stimulate the inflammation process. This sets off a cascade of events in which cells and substances migrate to the injured area and damage the sensitive tissue further, causing cell death and symptoms. Typical signs and symptoms include headache, disequilibrium or being “off balance,” drowsiness, nausea and vomiting, fatigue dizziness, numbness and/or tingling, sensitivity to light and sound, jaw pain, ringing in the ears, difficulty sleeping, feeling “foggy,” difficulty with concentration or short-term memory, and depression or mood swings. If a concussion victim appears to have rapidly progressing symptoms, significant confusion, or altered gait, he or she should be taken to the emergency room immediately in the event of a subdural hematoma (that’s bleeding between the brain and the soft tissue covering of the brain). I suspect based on my own experience, however, that there are many less common symptoms that may not be at the top of the list, but that vary from individual to individual; I would say that if there is a question of a concussion, and if you feel that something is not right, then get checked out. The only way I can describe how I felt during the first hour or two after I hit my head was that something felt off. I felt detached, as if the whole scene was unreal. More symptoms developed over the next few hours.
An interesting note about loss of consciousness with a head injury: It is 100 percent of the time an indicator of concussion. If you lost consciousness, then you sustained a concussion. Loss of consciousness, however, is thought to be a protective mechanism for the brain, and some concussion studies indicate that patients who lost consciousness after a blow to the head actually recovered faster than those who did not lose consciousness.
The tricky part of concussions comes in assessing the degree of concussion, and this is a big factor in the stories we are hearing in the news of athletes running into trouble in returning to their sport too soon. Several scales that attempt to grade concussions have been introduced in the past. They all suck. Why? There is too much variability in symptoms, in terms of the wide range of symptoms, time of onset, and degree. A much more useful tool for sports teams has been baseline testing. Uninjured athletes are tested physically and cognitively to establish a healthy baseline, against which changes in physical function and cognition can be highlighted in the event of a head injury. It also is wonderful to see that schools, including our middle and high school here in Stowe, are baseline testing children involved in contact sports. We receive much more valuable information from baseline testing if an athlete does sustain a concussion than we used to get from knowing that a concussion was a “level VI.”
The treatment for concussion is rest. This is hard for everyone. You really are just supposed to lie there. At first, and possibly for a while depending on the severity of symptoms, you are not supposed to read, watch TV, play video games, goof around on your phone, or text. And trust me, you will not even want to. I communicate with many of my clients via text, and texting made my vision blurry and felt like a metal band was tightening around my head. Avoiding cognitive as well as physical activity to rest your brain is really the same principle as acute care for an orthopedic injury—give it a rest to let it heal. The other more disturbing reason for brain rest is that physical as well as cognitive activity heats up your brain, which can increase inflammation and as already mentioned, damage nerve tissue.
But the most important, and most unnerving factor about the possibility of returning to a sport or high level activity too soon is the possibility of another concussion, with more injury and nerve tissue destruction. Concussion studies demonstrate that individuals with a history of concussion are at an increased risk of sustaining another concussion, and that the greatest predictor of a concussion in sports is a previous injury. And here I will hazard an opinion that this is so because, even if you feel great, you are still “off” for a while. I’ve always had good balance. And it’s coming back quickly, but I am having trouble with high level balance activities like standing on a BOSU. I simply fall off. And I imagine that other systems that play a role in injury prevention such as vision, reflexes, and hearing are similarly affected and may be a little slow to catch up. I’m so sorry, ladies, my mountain biking season is over for the year.
The good news is that your symptoms are accurate indicators of the level of activity you can handle. Children have delicate, developing nervous systems and to be safe should be under the care of a doctor for assistance with return to activity. We adults, however, are not quite as neuroplastic as our children, and it is hard for moms as well as business owners to take a rest. I admit that for the first few days I attempted to power through the headache, fatigue, and fogginess, taking an “ignore it and it while go away” strategy. As I told people, it didn’t feel tremendously different from how I frequently feel anyway, at the end of a long, crazy day when I am trying to get the kids settled down. By day 3 after the event I was paying for my strategy big time. My head just felt hot. I had a raging headache, metallic taste in my mouth, sensitivity to sound so bad that I would cower with my hands over my ears if the kids were too loud, and fogginess to a degree that had me concerned about my ability to drive safely. I am so thankful for my amazing friends—director of middle and high school athletics JG, who assessed me after the race and checked in with me frequently; close girlfriends nurse practitioner AW, who helped guide me through the maze of symptoms and return to activity–and OR nurse ST, who on that bad day 3 texted her neurosurgeon friend for advice on what I should do and then drove up my road, tossed me into her car, and drove me to the ER for a CT scan (which turned out OK). AND made her husband take care of my kids until Mark arrived on the scene; and great guy friend CH who showed up at the hospital to drive me home after the tests. I also am indebted to all my other wonderful, loving friends for the countless offers of help I received (and took advantage of) with respect to child care and transporting the kids to and from activities during that time; to my patients who were so understanding during the first 2 weeks—some of whom called and cancelled their appointments and insisted I use the time to rest, and some of whom were brave enough to keep their appointments and trust a concussed PT; and to the friends I train with, who helped me to not be afraid to return to activity and promised to help me protect my head. And of course I am so lucky to have Mark who, although furious at me for falling on my head, really bore the brunt of everything and everyone at home so I could rest AND handled a foggy, demented, forgetful, emotionally labile brain-damaged wife for a few weeks.
Recovery has been mercifully quick. There is a phenomenon called post-concussion syndrome, in which symptoms can linger for months or years. It is poorly understood and appears to affect women more than men, and older people more than younger people. My most heartfelt sympathy goes out to these sufferers. I cannot even imagine the thought of the symptoms going on and on, and an entire new physical therapy specialty is evolving to help these patients alleviate symptoms and restore cognitive function.
Something that almost never is mentioned but that I think deserves more attention is the musculoskeletal portion of the injury. The brain gets all the attention because it is such a vital organ but at some point, maybe around the 10-day point I began to realize I was having trouble sorting out what was neurological and what was musculoskeletal and myofascial. I was feeling OK for much of the day but after being up and around all day I would develop a painful headache with trigger points—tight bands of muscle that are sore to the touch—on my head and at the base of my skull, as well as tension in my neck and shoulders. This was around the time that it occurred to me that my fall most likely had knocked my neck and cranial bones out of their proper alignment and that it was time to not only move more, but treat myself and get some additional treatment.
One erroneous assumption in concussion management and recovery is that if you rest enough, you will one day get up and all of the symptoms will be gone and you will charge back into life. I took a concussion seminar last year which made concussion recovery sound like a straight line. What I found was that it was a little up and down, that one day would be fine and the next day not quite so fine. Confused, I looked back at my notes and saw that the straight line recovery was based on studies on professional football players! I am pretty sure they were ordered to rest and did not have to do errands, cooking, laundry, care for kids, go to work, and so on. Maybe they did. Or, as girlfriend AW pointed out, maybe they lied during the study to get back to play sooner. Anything is possible. But I did find that at the 2 to 2½ week point I did I have to do a little working through symptoms to get my brain used to processing certain types of stimuli and feel better. Flip turns in the pool were horrible the first practice that I attempted them and made the pool spin, so I eased back into those, at first flipping one out of every four turns and then increasing from there. Crowded places also were sensory overload at first, and it took a little time for my brain to get used to processing multiple inputs at once. I went to the middle school open house 48 hours after the injury, thinking I could just sit there and be passively entertained and everything would be fine. I thought I was going to die—the fluorescent lights, noise, and crowd of people were complete brain overload and I couldn’t even carry on a coherent conversation. I just allowed Mark to lead his brain damaged wife around the school and eventually out the door. I also called Ange in a panic when I went into the local grocery store in town during a peak foliage weekend and felt like my brain was imploding. I was lucky to have Natalie with me to steer me out of the store as quickly as possible. Pickup time at the elementary school also was torture for a few days, but found everyone was understanding of my rambling speech and glazed expression!
By far the most alarming symptom for me was the short term memory. Immediately after the race on September 21st, as part of her assessment Joanna gave me three unrelated words and asked me 5 minutes later to repeat them. I got it wrong. She tried it again and I got it right the second time. But that function deteriorated over the next 24 hours and lasted for a couple of weeks, which really upset me. I kept asking Mark and the kids to give me three words and I kept failing the test. (It didn’t help that nobody could agree what the words should be and would argue and shout out different words. They probably ended up making the test much higher level than it needed to be.) I also had no baseline—for all I knew I was horrible at this task to begin with. But I’ve gotten this function back in the past week and don’t need to stress about that anymore.
But it was an interesting experience. I learned that our world is a highly overstimulating place. I also found that the activities that I thought would be overstimulating, such as work, housework, and exercising where actually routine, rhythmic and calming while things that are part of daily life as a mom of three which I considered no brainer, easy activities—the runaround afterschool craziness, grocery shopping, getting out the door in the mornings, the evening routine—require tremendous amounts of multitasking and brain power and are incredibly fatiguing. It’s no wonder that parents are exhausted at the end of the day! The iPhone also is a killer, and I believe useful in small doses, but a lot of it is really not good for anyone.
For a PT, a concussion was unnerving because I am used to injuries that I can assess visually; this was entirely different at first but in the end not so different, in that frequently injuries help us to find ways to improve our lives that we had never before considered back when we were uninjured. The past three weeks helped me to see life a little differently and think about doing things like shutting my phone off completely at certain times of the day, slowing the pace a little and taking breaks, and letting some things go.
–Kathleen Doehla, M.S. P.T.