A perfect day in the bay
Nellie was out on the bay in a small sail boat with her two friends when Wham! the boom of the sail swung out and struck her, jettisoning her into the water. She felt embarrassed more than hurt. The 12 year-old quickly clambered back onto the boat, her cheeks burning.
"I'm fine," she said to her concerned friends, "c'mon, let's go!"
The girls were racing four other boats on a hot summer Thursday afternoon. When the day was over and her parents picked her up from the marina, Nellie was bursting with excitement over their win. She forgot all about her accident except every now and then, she unconsciously rubbed the back of her head where the boom made contact. It felt sore.
Nellie slept like a baby that night, utterly exhausted and wolfed down her breakfast the next morning, ravenous. Around lunch time, she began to develop a headache, slight at first, then picking up speed. Her mother gave her some Tylenol and told her to drink plenty of water, suspecting that Nellie had been out too long in the hot sun the day before. She also seemed very irritable, which was unusual for Nellie.
By that evening, Nellie's head was throbbing so much that she skipped dinner and went to bed instead. By Saturday morning, her headache was no better and her parents became concerned. Nellie, ever the tomboy, was not one to complain about pain, and certainly not one to skip meals.
"I don't understand this," her mother said, "you have been out in the bay on hotter days before. It must be all the excitement of the race."
It was then that Nellie remembered about the boom. She told her incredulous parents.
“How,” her mother exclaimed, “do you just forget to tell us something like this?!”
They rushed her to the local ER, where the doctor examined her and diagnosed a concussion.
What is a concussion?
The brain, with the consistency and texture of uncooked liver or firm gelatin, floats in a bath of cerebrospinal fluid, suspended there by strong membranes anchoring it to our very thick skulls. We are all truly hard headed, even when we are amiable.
COOL FACT : Your brain, which weighs just about 3.3 lbs in air, weighs only about 0.1 lbs when cushioned by this fluid!
In other words, Nellie’s brain, and yours, is well-protected within our hard skull-helmets, tethered by strong and fibrous membranes and floating in the shock absorbing cushion of cerebrospinal fluid. However, a strong enough impact, or even a lighter impact at just the right angle (like a dodgeball to the head, a hit against a soccer pole or a sail boom), can jostle the brain forcefully within the skull.
"I thought you had to pass out to have a concussion?" Nellie's mother asked the doctor.
"No," the young ER doctor replied. "You can have a concussion even when you are completely aware and awake."
"And just passing out doesn't mean you have a more severe injury than someone who doesn't,” she continued, "although, usually this is true."
The ER doctor was right. There are approximately 1.3 million concussions per year in the US. Concussions cause brain injury in obvious and in subtle ways. As jarring as this process sounds, most of us who have the misfortune of a concussion may suffer from symptoms such as headache, dizziness and nausea which generally resolve in a few hours to a few days.
The Anatomy of a Concussion
Two things happened when Nellie's skull came into contact with the sailboat boom. One, her brain moved within the skull in a direction opposite to the force of the blow, causing some mostly microscopic damage. Two, her top heavy brain hemispheres twisted against the willowy stalk of her brain stem, creating a torque type injury. Because the brain stem houses the cells which keep us alert and spray up and out into the brain, like slender stalks of a giant bouquet, the twisting leads to loss of consciousness. Also, small and generally transient changes occur within some nerve cells, disrupting the normal functioning of those cells and the neural networks they are a part of.
This is why in boxing, the punch that reliably produces a total knock out is a powerful jab to the side of the jaw from below, the torque moving the brain relative to the brain, causing the opponent to pass out cold for the count. In Nellie's case, the angle of impact was such that there was little twisting and so she did not pass out. Thank goodness, because as you will recall, she was knocked into the bay.
So Nellie went home, her parents reassured that she did not have a problem requiring emergency intervention.
FACT: Teenage girls who play soccer and volleyball are twice as likely to suffer from concussions as teenage boys who play the same sports. However, the sports with the highest rates of concussion are American Football and Australian Rugby, two games that are exclusively male.
By Monday, with her headache slightly better, Nellie went off to school. But at midday, the school nurse telephoned her mother. Nellie was sobbing with pain from a severe headache. Her mother picked her up and took her home to rest.
On Tuesday, she stayed home all day, but when she tried to watch television, she felt sick. As the day wore on, Nellie found that whenever she got up or turned her head, she felt dizzy, “like I was off balance… the walls moved a little.” This feeling made her nauseous and her headache worse.
Nellie develops Post Concussive Syndrome
Wednesday morning, she developed pain in her neck, and so her mother called their pediatrician. He had Nellie come in right away. After an examination, he felt Nellie was suffering from Post Concussive Syndrome (PCS).
Only a small percentage (4-10%) of people who have had a concussion will have persistent symptoms lasting longer than a day or two and even fewer with symptoms lasting weeks to months, the so-called PCS. Nellie was among this small percentage. Most of us who get bonked on our heads will have symptoms that resolve in a few hours to a few days, at the most.
While anyone is susceptible to PCS, trends indicate that teenage girls are particularly vulnerable, even though the highest rates of concussions are among male toddlers and adolescents.
Additionally, teens who place a lot of stress on themselves to excel in school are at an elevated risk for PCS. Some studies have noted personality traits such as anxiety and the need for achievement in these patients. Nellie, for example, was a straight-A student and worried incessantly about how she was going to catch up with her school work while she was sick.
However, even the Dude in The Big Lebowski, laid back, mellow and with zero ambition, can still develop PCS. In other words, while certain characteristics may exacerbate the symptoms of PCS, it is an equal-opportunity condition.
Symptoms and treatment of Post Concussive Syndrome
A month after that fateful Thursday on the bay, Nellie was still having headaches. She was taking several over-the-counter pills like Motrin and Advil to help and although her teachers at school were understanding, she continued to have severe daily pain, from mid-morning into evening. Even though she wasn't given much homework, she was debilitated by fatigue every evening.
Her pediatrician decided to refer Nellie to a neurologist. When Nellie arrived at my office, she had full-blown PCS. While there are many different components to PCS, including cognitive loss, I am going to focus on two that affected Nellie and significantly compromised her function: headaches and dizziness.
Headaches after Concussion in Post Concussive Syndrome
Let's take headaches first – 30-90% of those with PCS suffer from headaches, making it the most common symptom. There are many reasons for headaches after concussion. Headaches that are not associated with bleeding into the brain are generally due to spasm of the neck and jaw muscles and local damage and inflammation in the area of these muscles. These headaches can, on rare occasions, persist for over a year.
Managing headaches is a significant part of treating PCS in my practice, particularly among high school kids, because of another major issue: pixelated screens. Like most teenagers, Nellie was spending quite a bit of time in front of various LCD screens, which significantly contributed to her headaches.
Those little pixels that create the words you’re reading right now are constantly flickering at about 30Hz, indiscernible to the naked eye. This invisible strobe-like effect strains the muscles controlling our eyes as they attempt to keep up with the motion of the words, giving way to pesky and sometimes intense headaches. In a patient with PCS, who is likely suffering from whiplash and tender head and neck muscles to begin with, this extra muscle strain can be particularly incapacitating.
Adding injury to injury, by limiting the way people navigate texts, screens may impair comprehension. In a study of Norwegian 10th-graders with similar reading ability, half of the students read from texts on paper while the other half read them from pdf files on 15” LCD screens. On reading comprehension tests administered afterward, students who read on paper performed better than those who read the same text on screen.
"The ease with which you can find out the beginning, end, and everything in between and the constant connection to your path, your progress in the text... makes it less taxing cognitively, so you have more free capacity for comprehension," notes Anne Mangen, this study's author.
Surveys support her observation, indicating that screens and e-readers interfere with our need for serendipity and control. Apparently, we enjoy of flipping back to previous paper book pages when a sentence jogs a memory, scanning ahead on a whim, writing margin notes and deforming our paper in all manners.
As a result, this is what I told Nellie:
- No screens of any kind including: movie screens, computer screens and phone screens (The last needs to be emphasized with teens. A patient of mine, Elliot, continued to complain of headaches and fatigue despite staying away from screens. Turns out, he had continued using his telephone LCD screen, as this “was just my phone!”)
- No texting/ reading while in cars
- At least eight hours of sleep at night, particularly important for teenagers who often make do with far less. This was a hard sell.
"Why?" Nellie wanted to know. "Why is sleep so important?"
"Because," I explained to the skeptical preteen, "sleep relaxes your tired eyes. It helps you remember what you learn in school. It completely relaxes your sore muscles."
Sleep was a hard sell but Nellie agreed to try it, "for two weeks, max!"
- Reduced to no homework during the early PCS period, which Nellie's school had already instituted.
- More time during tests for a limited time is needed for a very small number of patients. In Nellie's case, I recommended one month. I am very sparing in this type of recommendation as I believe that speedier recovery from PCS is aided by returning to norms as soon as advisable.
- I prescribed a simple non-narcotic prophylactic medication for Nellie's daily headache.
Vertigo and Dizziness
Nellie’s body in space a thing of elegance, a constantly choreographed and exquisitely timed dance between her eyes and the vestibular organs in her ears. If there is a disconnect between her eyes telling her she is moving and her ears telling her she is stationery - common when in the back seat of a car looking out at scenery speed by- she gets dizzy enough to vomit. Some people are more prone to this and Nellie’s parents had gotten into the habit of strapping her into the middle back car seat even when she was a small child, sandwiched between her two brothers. This kept her looking ahead, a simple trick to overcome this disconnect. Ballerinas call a similar trick “pointing,” which prevents them from tumbling over during their graceful pirouettes.
Unfortunately for patients with PCS, these tricks won’t work because the vertigo in PCS is from a mechanism that is different from the simple disconnect in stimulus input in the above mentioned situations. To understand the source of Nellie's PCS dizziness, it’s helpful to understand how her brain uses her vestibular organs detect motion.
Nellie's brain detects motion from three little C shaped tubular canals in each ear, carved into the thicker bony parts her skull, like labyrinths. These canals are placed, just like in high school geometry, perpendicular to each other along the x, y and z axes so that all computations of spatial dimensions can be accounted for. These three canals, deep inside each ear (six in total) are all filled with a viscous fluid that moves slowly when we move. The movement of this fluid sways these hair cells with their large calcium carbonate crystals heads, adding weight and gravitas to the sway of the hairs — think of sunflowers swaying in the wind. This allows Nellie, even with her eyes closed, to know if she is upside-down or right-side up. When she played ‘Ring Around the Roses’ as a little girl, she gave the fluid, and thus the hair cells, momentum. When she and her friends stopped suddenly, they got dizzy and collapsed in a laughing heap to the floor. This was because of the continued sensation of movement when there is none, as the fluid in the little girls' ears stays in motion just a little while longer.
With head injury, these crystals in Nellie's semicircular canals got knocked off and went rogue, rattling around, so the slightest movement, like moving her head from left to right while reading, created a feeling of "dizziness." As if this weren't enough, her eyes, with the fastest muscles in her body, tried to compensate and Nellie began to get eye strain and headaches, particularly after a day at school looking at pixelated screens. Dizziness is reported by 50% of patients making it the second most common symptom. Nellie, in fact, had been suffering with vertigo for nearly a month when she came to my office.
When Nellie's inner ear and her eyes didn’t quite coordinate, her neck muscles stiffened up to try to keep her head steady. Her stiff neck worsened her headache. Also, the increased eye strain from the poor vestibular system increased Nellie's fatigue which worsened headaches, her symptoms heightening as the day wore on. Her vertigo worsens her eye strain which worsens her headache and her neck muscle spasm which increases fatigue which worsens her eye strain.... It’s a vicious cycle, and Nellie needed help to break out of it.
Nellie undergoes the Epley Procedure for Vertigo
Help arrived in the form of the elegantly simple Epley procedure, developed by Dr. John Epley in 1980. Through a series of precise head movements, this office procedure moves the crystals to an area of the labyrinth with no neural sensors, safely corralled and rogue no longer. Magically effective, the Epley takes only a few minutes and has an 80-100% success rate after a single treatment.
Nellie enjoyed the Epley and hearing about the mechanics of it.
“Crystals in my ear!” she exclaimed. “Awesome!”
After the procedure, Nellie felt immediately much better.
“Things don’t move a little when I do any more,” she said, amazed.
Over the following month, with her vertigo gone and her headaches improving daily, Nellie was feeling like her old self again. Now all that’s left is to convince both a nervous Nellie and her parents that she is safe to go sailing again.
It’s important to remember that PCS is rare and that the symptoms, though scary and a detriment to daily life, will resolve in most cases with time and the right treatment.
Note: For the sake of brevity I have addressed only two of the many symptoms after concussion in this article. Forgive me for the omission of other, equally significant symptoms, particularly cognitive loss.
Acknowledgment: Thanks to Dana Abrassart, MS, who helped with the research and editing of this article.
Mangen, A, Walgermo B, Bronnick K. Reading linear texts on paper versus computer screen: Effects on reading comprehension. Int J Edu Res. 2013;58:61-68
Hall R, Hall R, Chapman M. Definition, diagnosis, and forensic implications of postconcussional syndrome. Psychosomatics. 2005;46(3):195-202
Giza C, Kutcher J, Ashwal S et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports. Neurology. 2013;80(24):2250-7
Garden K, Sullivan K, Lange R. The relationship between personality characteristics and postconcussion symptoms in a nonclinical sample. Neuropsychology. 2010;24(2):168-75
Babcock L, Byczkowski T, Wade S et al. Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents requires further detailed study. JAMA Neurol. 2013;70(3):636-7
Chrisman S, Rivara F, Schiff M et al. Risk factors for concussive symptoms 1 week or longer in high school athletes. Brain Injury. 2013;27(1):1-9
Epley, JM (1980). "New dimensions of benign paroxysmal positional vertigo". Otolaryngology and head and neck surgery 88 (5): 599–605