Wednesday, January 25, 2012

On Concussions, From An Expert

I usually say that there's at least person of every profession who reads DQ, but I didn't realize how handy that would be when dealing with Eli's post-concussion recovery. In this case, the reader is a practicing neuropsychologist in Canada, and he offered to answer any questions I might have. His responses were so clear and helpful that I'm going to share them with you, in case you or anyone in your family has to go through this in the future.

My first question was sent the day that Eli threw up at school, asking if we should be following the same "step" approach with his school activities that we were with his physical activities. I wasn't comfortable sending him back to school unless he was able to do homework at home without getting a headache. I also asked him if perhaps the tennis we'd played the day before had caused some kind of delayed onset symptoms. His response:
My advice would be to follow the directions given by those who are already helping, using the rule of thumb: "start low and go slow". Small amounts of physical activity in brief intervals should be OK, but often the indicators that its "too much" are delayed, so you don't even get that immediate feedback about when its time to stop. Pacing, means using the clock rather than symptoms as a means of rebuilding stamina (stopping when you still feel OK, and before you get those bad symptoms of having already overdone it). And the fatigue you described is to be expected. Cognitive fatigue has to do with that feel of sleepiness and exhaustion that comes from mental effort. This too should be carefully paced as this stamina is slowly rebuilt. He needs time to recover, and the one thing that almost no one ever tells you when dealing with this stuff is that it takes longer than you think. You break an arm, put a cast on it, and 6 to 8 weeks later, you're good to go, especially as a kid. Brains are not the same. It will be a longer haul than you think (and want). It will get better, but in your haste to normalize, minimize, put this behind you, etc. don't push too hard or sweep this under the rug.

Maybe going back to school so fast is a little bit much. He does not seem to be ready from what you've said. Headaches are to be expected. Vomiting means "way too much". Helping him build back up to it in bits is the ticket, much as you suggested as an option for the near term. The school is, I'm sure, very supportive, but they just aren't set up to accomodate the kind of "work a bit, rest a bit" pattern he needs right now. Even passive TV watching can sometimes be overwhelming, and might not be "restful" enough for a brain that has a compromised ability to filter out unnecessary sensory information. Ask him if lights, movement, sounds, too many people talking at once, too much mental activity (such as problem solving), even just being in a crowded hallway bothers him. The brain does an amazing job of suppressing loads and loads of sensory information impacting our various senses, but that we "don't need" at the moment. When that gets compromised, suddenly everything has more of an impact on us than we want it to, and sensitivity becomes an issue.

I get really nervous when I hear you consider letting him play hockey again. I would put that and any other contact type sports on hold for a good long while. The problem with concusions is that, even if a full recovery is made....they kind of add up over the lifespan. Especially if they happen in relatively rapid succession (and rapid here means within months of one another). In close succession cases, they do worse than add up, they are much more than additive; the second one has a MUCH more pronounced effect on cognitive abilities (working memory, processing speed, attention, concentration, etc.). Regardless: he is going to be vulnerable to more pronounced effects on his cognitive abilities if a future head injury/concussion occurs, so managing risk is going to become something for you all to consider carefully. Of course, you can't wrap yourself in bubble wrap on top of five layers of cotton and live in the basement. That's not what I mean. I just want to encourage you to all think about how much is a reasonable risk for the few things we actually can control in our lives that might effect brain health. Helmets? For SURE! Risk being slammed headfirst into the boards in some future hockey game full tilt scamble gone awry? Not worth it in my books, but that is up to you.

Most importantly, inform yourselves. Look up and read about mild traumatic brain injury and all the other terms used to describe concussion. Go and learn about the metabolic cascade that occurs in the brain following mild traumatic brain injury, learn about symptoms, the various cognitive effects, cognitive fatigue, recovery expectations, tips and tricks to optimize recovery (everything from diet, sleep regimen, activity level, etc.), and how to slowly pace and rebuild stamina, and regain normal daily life. Ask questions. Take it seriously. Monitor signs and symptoms closely. Be patient.

It's worth noting that his response was more conservative than what I was hearing from anyone here, which I appreciated.

A few days later, I asked him if it was in the "normal" range of recovery to have his abilities be so fully recovered before his ability to read, write, or do math. Here's what he had to day:
Mental effort (thinking hard about something, problem-solving, focusing attention) uses integrated activity from many different cognitive systems, or put more simply, requires a wide range of structures in different regions of the brain to work together. If they aren't in sync or if the' connections' in the 'lines of communication are loose' (to use an inadequate metaphor), then this process can be very inefficient, and require more 'work' to reach the desire end point. He was hit on the side of the head, right? Was it in front of the ear, above it, or behind the ear? Right side or left? [note: it was just in front of the left ear] It may not be terribly important, but you might want to look up coup/contre-coup type injuries. The brain is a soft thing inside a hard thing. Think of it as having the consistency of a bucket of lard, or a bowl of jello. If you bang on one side of the bowl with a utensil, you can see the waves propagate and reflect back and forth. The brain is fantastically complex, so those mechanical waves can disrupt some of that complex organization, or functioning abit. Sometimes the force of the impact is enough to create a kind of sloshing back and forth of the brain against the inside walls of the skull: first on the side of the impact, as the kinetic force is transferred from the skull to the brain, and then the opposite side, and the brain "bounces back" against the other side, often sort of bruising the two sides from the point of impact. Even without gross imaging evidence for contusions, there is a massive depolarization of neurons followed by an intracellular "energy crisis" gobbling up ATP, straining mitochondria, and all the organelles inside those cells, as all those ion pumps in the cell walls work like crazy to try to re-establish the ion gradient across the neuonal membrane.

That was maybe too much info, but my point is that the gross motor stuff (his physical actvity stamina) and the areas required to use a console controller foe games in conjunction with well-learned visual-motor activities might be fine, but those heavily cross-(brain)-zone integration tasks, like arithmetic, or reading, still not as over-learned and second nature (meaning effortful) in a 10 year old as they are in older folks like you and me, are much harder work for him to integrate right now. Stick with the "start low and go slow" model across all activities as you rebuild that stamina, and it will be fine. Don't expect every different aspect of his functional abilities to recover at equal paces; they all use the brain in different ways, so the loading may vary. Be patient. 3 to 6 month recovery time is normal. He has a young healthy brain, and has loads of redundancy and cortical reserve to repurpose for all the things that are abit tough on him right now. Plus some of the things that are hardest for him right now were skills that were in the process of being learned and practiced, so it is to be expected that those "less expert" areas of the brain seem the weakest at first. It really will be fine.

Much thanks to this reader for the excellent and detailed information about concussions.

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