Читать книгу Concussion - Kester J Nedd DO - Страница 12

CHAPTER 6

What really happens during a concussion?

A TIME CAPSULE is perhaps the best way to define what transpires following a concussion. All of a sudden, a person goes from functioning as what one can call normal to losing control. How long does this last?

Table # 3 -- Paula Durben (Case # 2) – A cheerleader

Immediate Period
Impact	She landed on her head after performing a summersault.
Immediate knowledge	She recalled her head hitting against the concrete in the most brutal way and thinking to herself, “I am dead.”
LOC	No
Anterograde amnesia	She had no recollection of the events that transpired for the next 5 minutes except for what she was later informed of by her friends.
The most common early symptoms	The next thing she knew was that she woke up with everything in her visual field dark and was hyperventilating with the most excruciating headache. This was followed by blurred vision, the inability to stand up, and a sensation of dizziness and spinning (vertigo), followed by nausea.
Sensory integration issues	While she could hear people speaking around her, she was not able to completely understand what they were saying.
Cognitive and neurobehavioral issues	Around that time, she noted difficulties focusing and concentrating and recalled feeling fearful and out of control.
PTA – Time between impact and her ability to form new memories and to realize her person	Paula was unable to recall all the events as they had transpired but had a patchy recollection until she was in the ambulance on her way to the hospital. After being hit, she was in a state of altered consciousness where she was not totally aware of what was going on around her. In less than an hour, she realized that she was not the same person.
Retrograde amnesia	She had no recollection of what she was doing for at least one hour before the impact.

Two of the most important features of her condition were cognitive-behavioral and balance issues during the early stages, which are common adverse effects reported after concussions (Dougan 2014). This was accompanied by some of the most common symptoms, including headaches and dizziness with noted dysfunction of the vestibular system, which was responsible for the early imbalance that Paula experienced.

Fortunately, most injured athlete’s cognitive deficits and the associated balance symptoms together with the accompanying experience recover within 2 weeks after injury (Williams 2015, McCrea 2015, Nelson 2016). Those who generally continue to experience the negative effects of cerebral concussion beyond 30 days have a story to tell.

Table # 4 -- Paula’s symptoms lasted for about 30 days from the injury, and her symptoms dissipated thereafter.

Up to day 2	Symptoms of dizziness, vertigo, headache, excessive sleep, fatigue, and hypervigilance; aggravation noted with light, noise, and motion.
Week 1–2	Symptoms improved over time but now with difficulties falling asleep and with racing thoughts. She was not able to return to work or school. She had trouble focusing, paying attention, and multi-tasking. She was not able to use computers, iPads, or tolerate smart boards in class.
Week 3–4	She returned to school and work but was still symptomatic to a much lesser degree. She needed special accommodations to complete her classwork and perform on her job.
Week 4	By day 30, she was symptom-free and able to perform all of her activities without limitations.

Paula: 7 years later …

She was working and performing well at her job, as well as attending college. The last time I saw her was a few months after her injury. I had lost track of Paula, assuming all was going well when I happened to see her as a patient again 7 years later. During her visit, she said to me, “Till this day since the concussion, I have not felt like myself.”

While she has not been able to pinpoint a specific symptom, she was aware that something was not quite right. So, what about the fact that seven years earlier, she had been released to play competitive sports and was given a clean bill of health?

I decided to do a full battery of neuropsychological testing on her.

Table # 5 – Paula – seven years later

Neuropsychological testing	• Excellent memory• Easily distracted with a poor attention span• Deficits in executive functions
Moral of the story	Even though a person may think they have fully recovered from a TBI/concussion, watch out! There may be silent situations that go unrecognized and then manifest later in life.
Impact of attention deficit and trouble in executive function	• The issues of attention deficit and deficits in some of her executive functions that went unrecognized for years caused Paula major setbacks in her life and relationships.• She developed chronic depression and anxiety.• She lost her university scholarship, as she could not maintain her grades, and had to transfer to a community college, as she had trouble at the Ivy League school that she was attending at the time of her injury.• She got involved in multiple pathological relationships.• The testing revealed that she had poor self-esteem, which was supported by her own reporting of loneliness even when people were around her. She had a constant need for the approval of others and became vulnerable to anyone who praised her.• Paula made decisions for her life that were heavily based on maintaining her ego system, and she became deathly afraid of failure.
Treatment and reconciliation	After pointing out the natural course of her concussion over the years, Paula had a clear understanding of what had gone wrong. Based on a carefully collated clinical history, we were able to identify all of the salient markers in her life that either demonstrated injury or how her brain adapted or compensated.

In Paula’s case, defining the events as they transpired before and after the injury was critical to our understanding of the natural course of the history of TBI/concussion. Efforts in the past and present to understand and follow patients with TBI/concussion were met with major challenges. Defining the existence and course of TBI and concussion remains challenging because of the more significant focus on the cluster of signs and symptoms, and less on the natural history and course. Here, the multidimensional context was not utilized precisely to define the natural course of TBI/concussion based on the hierarchical understanding of how the brain evolves following an injury. TBI/concussion is not one disease; it has many features, turns in the road, manifestations, clinical courses, and outcomes.

Paula’s clinical course following the injury based on the hierarchical nature of her injury including the recovery time, severity, stage of recovery, signs and symptoms, physiological and anatomic basis, functioning, early intervention, and recovery measures were important in determining the prognosis and when she should’ve resumed her activities.

In our business, there are few clinical studies on TBI/concussion that follow patients beyond three years and most clinics dismiss a patient after they self-report that they are symptom-free. Many of our friends, colleagues, relatives, patients, and persons out there dismiss the effects of a prior TBI or concussion, not realizing that some of the challenges faced currently may be due to a concussion.

The example of Paula’s case begs the question: What should the follow up be, if any, and when should it occur? For patients who have had concussions, dismissal from care and treatment is carried out as a standard of practice when it is determined that the signs and symptoms are abated and resolved. Clinical knowledge and experience associated with one’s ability to map out the clinical course and history of such patients stand as the most important tools or markers of injury and recovery. This can only be done by following a person longitudinally while observing their quality of life and higher cortical functions or “head” behaviors that give us an edge.

Other diagnostics and lab tests are important, but the clinician’s role is superior to any diagnostic studies. There remains significant holes or gaps in the science relating to our understanding of the natural course of a TBI/concussion based on our understanding of the hierarchical organization of the brain following an injury and during recovery. The secret sauce in the evaluation and treatment of TBI/concussion is an understanding of the natural course of the brain’s reorganization on a hierarchical basis following an injury and during recovery over time.