Knocked into consciousness

A good knock on the head can teach you more than you ever wanted to know about brain injuries. A friend of mine learned that lesson the hard way.

Several weeks ago, while bodyboarding, he went after an enormous wave that sent him tumbling. The facial lacerations and broken nose he sustained were the least of his troubles. The force of the wave also slammed his head into the sand, and the impact caused a concussion that produced far more frightening and lasting problems. In the days and weeks after his accident, it became impossible for him to work for more than two or three hours at a time. He experienced difficulty concentrating, tired quickly and had trouble sleeping.

He couldn’t figure out why he wasn’t feeling 100% and began to fear that the injury might have caused permanent damage, although a CT scan of his brain had been perfectly normal, and the doctors who treated him had said that he’d be fine. In fact, the constellation of symptoms he was experiencing is quite common after suffering a head injury, so common that it has been given a name -- post-concussive syndrome.

By official estimates, each year 1.5 million people in the United States suffer traumatic brain injuries, those caused by a blow or jolt to the head. Most of these incidents are simple concussions, relatively minor injuries characterized by a brief period of amnesia with or without loss of consciousness. But brain injury experts think that this figure is far too low. “The majority of people with minor brain injuries never seek medical care,” says Dr. Rick Adams, medical director of the neurorehabilitation program at Long Beach Memorial Medical Center. “The real number is probably closer to 2.5 to 3 million.”

Although most people never show any outward signs of a problem after being injured, others suffer profound -- and often prolonged -- symptoms. Some, such as headaches, fatigue and dizziness, affect people physically. Others impact the way people think and feel. After a minor brain injury, people often complain of difficulty concentrating or focusing; they report that they feel slowed down or mentally “foggy” and have trouble remembering things. Some people become depressed or emotionally labile; others describe feeling nervous or irritable.

Until recently, post-concussive syndrome was viewed with skepticism by the medical community. The precise cause of these symptoms couldn’t be pinpointed, and the veracity of these complaints was often questioned. “In the past, it would be written off that these patients have significant psychosocial issues,” Adams says.

Although the cause of post-concussive syndrome remains unclear, the medical community is finally acknowledging that the symptoms are real. In June, the Centers for Disease Control and Prevention released updated information to help physicians improve the diagnosis and treatment of minor traumatic brain injuries. The CDC materials emphasize the fact that complete recovery from even a relatively minor brain injury frequently takes several months; they also stress the importance of recognizing and managing post-concussive complaints.

As with minor injuries to other parts of the body, most people make a full recovery after sustaining a concussion. “After six months, 80% of these individuals will have full resolution of their symptoms,” says Adams. “At one year, it’s closer to 90%.” People who have suffered a prior concussion appear to be more likely to have a protracted recovery than those who have never had one before; those with a history of headaches, mood disorders, anxiety or sleep difficulties may also experience recovery delays.

To improve the likelihood of a speedy and complete recovery, it’s essential to identify problems early on. “The sooner interventions take place, the better the outcome,” Adams says.

Those suffering symptoms for more than several days after a head injury should be see a physician who has experience in brain injuries. Neuropsychological tests can provide objective data about how well the brain is functioning. Among other things, they can be used to measure a person’s ability to reason and solve problems, understand and express language and concentrate. They can also test memory and emotional states. When cognitive problems are identified, occupational therapists can devise and implement strategies to compensate for the deficits and help improve functioning. A person who is having difficulty organizing tasks might benefit from learning to break them down into more manageable steps; someone struggling to remember things may need calendars and reminder notes.

Early intervention also helps minimize psychological reactions that some people can have in response to post-concussive symptoms. Many patients with lingering problems, for example, begin to doubt that they will ever fully recover. The worry and fear this elicits appear to exacerbate their symptoms and can trigger a vicious cycle. Simple reassurance goes a long way in preventing this type of downward spiral.

One of the most important components of recovery is rest. Many people are eager to quickly resume their full slate of activities -- sometimes simply to prove to themselves and others that they are well. However, exertion -- both physical and cognitive -- is likely to only highlight disabilities and impede recovery.

Until people have fully recovered, they may need to take on less responsibility or work a shortened day; students may require a reduction in their course work or additional time to complete assignments. At home, parents who are full-time caregivers may need other family members to take over some of their responsibilities. As symptoms improve, a gradual and careful return to regular, daily activities is recommended.

One of the most important aspects of brain injury care is education. People need to understand that recovery from a minor brain injury is not immediate. Lingering symptoms need to be acknowledged as a normal part of the healing process.

As for my friend, it’s been a month since his accident, and things are looking up. Although he’s not yet 100%, he feels he’s 95% of the way there. He’s learned his lesson about head injuries and reinforced a few life lessons to boot.

His accident reminded him that life is not about chasing the biggest wave; it’s about enjoying the ride.

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Dr. Valerie Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. She can be reached at themd@att.net. The MD appears the first Monday of the month.

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Signs of a concussion

A simple bump or bruise probably doesn’t merit a doctor’s visit, but obvious signs of a concussion do, especially if there is any loss of consciousness -- no matter how brief. A feeling of being dazed, confusion and amnesia -- the inability to remember events before or after the injury -- are also indications that medical evaluation is warranted. Bleeding inside the brain can develop in a small percentage of people after even a minor injury. If signs of bleeding develop, immediate medical attention is necessary. Danger signs include:

* Headaches that worsen

* Repeated vomiting

* Seizures

* Weakness, numbness or decreased coordination

* Slurred speech

* Confusion, restlessness or agitation

* Extreme drowsiness

In children, signs of a serious problem can be subtle. A child who cries excessively and can’t be consoled should be evaluated by a physician, as should a child who refuses to nurse or eat.

-- Valerie Ulene