Post Concussion Syndrome – Diagnosing and Treating for All Risk Factors

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Posted on 4th January 2010 by Gordon Johnson in Uncategorized

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I said this last week on my Justice and American Politics blog,
In the days after a concussion, the brain is trying mightily to rewire itself to deal with the new challenges. That rewiring is not always positive. Add panic or emotional distress and the plasticity that we all hope will avoid negative consequences, can rewire the brain in the wrong ways. I call this “negative plasticity” and I believe it is one of the strongest arguments for better and more thorough diagnosis and follow-up for concussion.
To answer that question one must first define the term “plasticity.” I found a great definition of it at:

Brain plasticity refers to the brain’s lifelong capacity for physical and functional change; it is this capacity that enables experience to induce learning throughout life. Research in this field has demonstrated that the adult brain continuously adapts to disproportionately represent relevant sensory stimuli and behavioral outputs with well coordinated populations of neurons. This adaptation is achieved by engaging competitive processes in brain networks that refine the selective representations of sensory inputs or motor actions, typically resulting in increased strengths of cortical resources devoted to, and enhanced representational fidelity of, the learned stimulus or behavior.

In severe brain injury lingo, plasticity is the capacity of one part of brain to take on the function of a part of the brain which is damaged. But as the brain has the capacity to rewire itself in positive ways, so can it in negative ways.

As long as I have been doing Post Concussion Syndrome cases, I have been asking myself this question: Why is there this significant subset of people who have such bad results from an injury that the majority of people have apparent full recoveries, within days if not hours? This small minority of people that fall into the symptomatic category have been referred to most often as either the “miserable minority” (Ron Ruff, neuropsychologist) or as suffering from the Persistent Post Concussive Syndrome. “PPCS” (Michael Alexander, M.D. , Neurology, 1995). That “miserable minority” of people consistently make up between 5 and 15% of those who suffer a concussion or mild traumatic brain injury. What explains this divergent outcome for this PPCS group?

I believe there are a number of issues. First, some of them have far more than a “simple concussion.” This portion have fairly serious brain injuries but because the symptoms of those concussions occurred when they were not being monitored by medical professionals, the severity of the brain injury is grossly underrated.

Second, some of them have other neurological injuries, which again, went misdiagnosed. The most common among this group are those with vestibular disorders. See Symptoms of dizziness, balance and vertigo can put significant demands upon the brains attentional resources and account for many of the cognitive and emotional complaints associated with the post concussion syndrome. In my career, I have found nearly a 50% incidence of vestibular disorder among my clients.

Third, there may be an artery dissection that happened contemporaneously with the head injury or as a result of treatment for the head injury, particularly from a chiropractor. Artery dissections can cause a stroke, with resultant moderate to severe brain damage.

Fourth, the brain injured person may be emotionally more vulnerable than the 85 to 90% of those who have good recoveries. This is likely the most significant factor and is the area where my term of “negative plasticity” comes into play. While the evidence of this particular component of concussion pathology is incomplete, I believe that as we learn more about the limbic system and the axonal connections between it and the lower frontal lobes, the emotional component of concussion recovery will become a huge field of discovery and potentially treatment.

What is the reason this is important in a week when a football coach gets fired for locking an athlete with a concussion up in a dark place? There is a major overlap between PTSD and the post concussion syndrome. After all, both are “all in the head”. “All in the head” means it is in the brain. There is not a bright line of demarcation between emotional injury and organic or “hard wire” injury in the brain. In all likelihood, there is no line at all. If you damage a person’s emotional center, regardless of whether you do so by direct trauma or via emotional rewiring, the hard wiring change is the same.

Concussion survivors need the best treatment, not just to protect them from repeat trauma’s, but also to protect the vulnerable brain from negative rewiring. A concussion in its infancy can become a life long disability if the vulnerable brain is neglected or abused. We worry about “shaken baby syndrome”. We should also worry about the neglected emotional state of all brains that are injured.