Recovering from Post-Concussion Syndrome:  A Guide for Patients

                                   PHYSICAL

EMOTIONAL                                                  COGNITIVE

WHAT IS POST-CONCUSSION SYNDROME?

People who have been involved in motor vehicle crashes, falls, or other injuries involving a blow to the head sometimes develop post-concussion syndrome.  A syndrome is a medical term used when a person is experiencing symptoms in a variety of areas.  Post-concussion syndrome occurs when a patient is experiencing physical injuries, emotional distress, and thinking difficulties following a concussion or physically traumatic event.   These symptoms interact with each other, resulting in a person experiencing problems which are much more impactful to them than if they were experiencing only individual symptoms.  In other words, as a person’s physical injuries become more pronounced and fail to go away, that condition results in a person experiencing increased emotional distress and increased difficulty in thinking clearly.  Think about it, if you experience a headache that won’t go away, after just a few weeks you will surely begin to feel more irritable, have less patience, begin worrying that something might be seriously wrong with you, and start to have problems concentrating, paying attention, and occasionally forgetting some things. 

Similarly, if because of an injury you are unable to work, you may begin worrying quite a bit about financial issues, your ability to pay your bills, whether you are going to be fired from your job, and whether you are going to continue to be able to meet your responsibilities to your family. With all of these worries, you may experience an increased feeling of tension in your back, shoulders, and neck, you may experience an increase in your headaches, and you may begin to have difficulty sleeping because of all the worries running around in your head. Additionally, all of these worries and concerns may cause you to have difficulty paying attention, concentrating, or thinking clearly. 

Finally, a concussion can cause your thinking to be temporarily altered.  If you begin to pay more attention to this alteration in your thinking, that may lead to increased worry about your health and your future, and the effects of a concussion can cause some increased physical difficulties such as balance difficulties, dizziness, nausea, or ringing in the ears (See Figure 1).

As you can see, difficulties in one area can cause an increase in problems in the other two areas.  The result can be a vicious cycle of problems feeding on themselves and resulting in problems which last a long time unless treated.  Effective treatment for post-concussion syndrome involves intervention in all three areas at the same time.  By doing so the cycle is broken, and you begin to feel better faster.  Before talking more about treatment, let’s look at each one of the symptom areas in more detail.

 PHYSICAL INJURIES

 The results of a car accident, fall, or other injury often involves chronic headaches, neck pain, back pain, numbness or tingling in the hands or feet, ringing in the ears, balance difficulties, dizziness, and disturbed sleep.  Headaches are the most common symptom complaint of people who are suffering from post-concussion syndrome.  The important thing to remember is that headaches are very rarely caused by a brain injury.   The majority of all headaches are due to muscle tension.  As your muscles become tighter, they squeeze the vessels which send blood to the head, resulting in headaches.  One of the most effective treatments for chronic headaches is to learn relaxation techniques.  When you learn how to relax yourself, your muscles loosen, resulting in the blood flow to your head being increased and your headache going away.  Although it is possible that headaches are the result of something wrong with your brain, this is a very rare condition and is usually accompanied by a number of other symptoms.  Your neuropsychologist or your physician have likely already evaluated you for these other symptoms and determined that they do not exist.  In all cases, however, if you experience very severe headaches which don’t go away, even after you have practiced your relaxation techniques, you should go to an emergency room to get checked out.  Again, however, this is a very rare condition and almost never happens to people involved in minor injury accidents.

 Headaches can also be caused by muscle tension in your shoulders and neck.  The muscles tightness inflames the nerve cells in your shoulders and neck.  Those nerve cells look like trees which have branches that extend into other areas of your body, including your head.  If you are receiving massage therapy or some other type of physical therapy, that treatment is designed to reduce the inflammation of those nerves which, with time, will make your headaches diminish.  Finally, headaches can be caused by an injury to your temporal mandibular joint.  This joint is the hinge which is located just in front of your ear which allows your jaw to move up and down.  Sometimes in minor accidents this joint can be injured, resulting in you experiencing headaches.   There are specific treatments for temporal mandibular joint dysfunction and if those treatments are effective, your headaches will likely be reduced.

 Back pain, neck pain, shoulder pain, and a general feeling of physical discomfort are all the common effects of a minor injury accident.  With time, and treatment, these injuries do go away and you begin to feel better.  You may be receiving physical therapy treatment, chiropractic care, massage therapy, acupuncture, Pilates Treatment, or orthopedic manipulations, all designed to reduce your physical pain symptoms.  It is important that you give feedback to your therapist or doctor about how that treatment is working.  Be an active participant in your health care and be sure to clearly tell your treating provider what is working and what is not working.  The more active and involved you are in your treatment, the faster you will get better.

 Finally, sleep disturbance is one of the most complicating and destructive factors you may be experiencing.  If you are having difficulty falling asleep and/or are experiencing problems staying asleep throughout the night this will have a profound effect upon your ability to function during the day.  People with sleep disturbances often report problems with memory and concentration and feel irritable, stressed, and fatigued. You may be experiencing nightmares or disturbing dreams about feeling out of control, being chased, or being in danger.  Your sleeping difficulties may be caused by physical discomfort but are more likely the result of worry, stress, anxiety, and depression. 

 There are two effective treatments for sleep disturbance.  The quickest solution is to take some medication specifically designed to reduce your level of tension, to control your racing thoughts, and to help you feel relaxed.  This medication often has an additional benefit of reducing your headache pain.  These types of medication are called sedating antidepressants.  They are non-addicting and are prescribed in a very low dose for a short period of time. There are also herbs and natural remedies which you may take to improve your sleep if you do not wish to take prescribed medication.  Your neuropsychologist or physician can discuss these treatments with you.

 The other very effective treatment for sleep disturbance is to learn relaxation techniques.  Your psychologist can teach you very effective techniques which can help reduce your anxiety and worry, stop your racing thoughts, and help you feel more relaxed.  By learning how to take control of your mind, your body, and your life in this manner you will be able to reduce your stress and sleep more soundly.

EMOTIONAL DISTRESS

 People who have experienced Post-Concussion Syndrome often complain of a variety of emotional distresses which have the effect of causing them profound difficulty in their everyday life.  Apart from simply not feeling well physically and being in pain much of the time, they often experience additional worries such as these:

feeling unsafe in the world                                                 feeling vulnerable

believing the world is unpredictable                                     expecting harm

health concerns                                                                concerns about their job

worries about financial responsibilities                                 feelings of frustration and irritability

feelings of guilt                                                               depression

feeling emotionally vulnerable                                            becoming easily overwhelmed

driving anxiety or nervousness

All of these symptoms are very common following an unexpected traumatic event and/or a minor concussion injury and almost all resolve completely with time.   There are a number of things you can do, however, to make these symptoms go away more quickly.

?                     First, recognize that these symptoms are natural and that they do frequently occur to  patients involved in similar injuries.

  ?                     Second, resolve to do something about these symptoms.  It is important to not  simply let these feelings and thoughts ruminate inside your head without discussing them with someone else.  Thoughts can make us depressed.  Thinking that things are terrible or will not get better only makes things worse.  Oftentimes, bad situations are not actually as bad as they may seem at first but become so as we think about them more and more.  Such thoughts become statements which we tell ourselves and which make us feel worse.  If you find yourself thinking depressing thoughts, stop.  Simply telling yourself to not think those thoughts and to think of a pleasant thought can be very effective in helping you feel better. 

 ?                     Third, replacing the distressing thoughts with more positive statements can be very helpful to you.

 Worrying about your health and your ongoing symptoms can be very stressful.  For many people, this may be the first time that you have been “ill” for longer than a few weeks.  Normally in our life we are sick for a few days and then we get better.  If you are continuing to experience the effects of your injury after 3 weeks or more, this can become very distressing to you and can lead you to worry a great deal about your general health and whether you will ever get better.  Rest assured, you will get better and your symptoms will go away, but the recovery period is frequently much longer than you may expecting.  It is important that you tell yourself that you are in the middle of your recovery phase and that, with time, you will return to normal.  Worrying and wondering whether you will ever get back to normal can often result in a delay to your recovery.   Such worry causes you to feel more stress and, therefore, more muscle tension and headaches.  Working to reduce that stress and tension by maintaining a positive outlook about your recovery is crucial to you getting better faster. 

TIP      Be sure to remind yourself that you will get better but that such injuries sometimes take a long time to recover.

This may also be the first time that you have ever been hurt as badly as you have been as a result of this accident.  If the injury occurred without warning (such as being rear-ended in a car while stopped in traffic), this can be extremely traumatizing to you and may lead you to feeling more vulnerable and insecure about your personal safety, as if you or your family could be injured without warning at any moment.  Such thoughts are a very normal reaction following such an injury, but it is important to recognize those thoughts as being natural but not realistic.  Just because you have been in an accident and been injured does not mean you are now more susceptible to being injured a second time in another accident.  In fact, most often, this will be the only time you will ever be so injured in your life.  But these feelings of vulnerability and a loss of personal safety that you may be experiencing can be extremely disruptive to you and can cause you to lose sleep and not be able to focus your attention as well as you did previously.  It may almost feel as if you are a Knight of the Roundtable who is going out to defend the kingdom without wearing your suit of armor to protect you.   Such a situation could certainly cause a person to be very focused upon watching out where the first attack will come from and not paying attention to the more mundane day-to-day activities such as what you were supposed to pick up from the grocery store on your way home from work after fighting dragons all day.  Try to visualize for yourself putting your suit of armor back on and creating for yourself a method of protection and reestablished personal safety.

TIP       Tell yourself that you are safe, your family is safe, and that you will get better and once more be the strong person that you were before your injury.

 Driving Fears

 If your injury was caused by your involvement in an automobile accident, you may be experiencing some anxiety while driving in a car, especially in situations similar to the circumstances related to the accident.  This is a normal reaction and will go away with time.  It is important that you remind yourself of this fact.  It is also important that you work to reduce the anxiety you feel when you drive or ride as a passenger in a vehicle.  Do so by consciously telling yourself to relax.  Focus on your breathing by taking slow, deep breaths in through your nose and out through your mouth whenever you feel anxious.  Be sure to review the various relaxation techniques outlined in the back of this manual and practice them as often as you can.  They only work if you practice them on a daily basis and if you use them when you begin to feel anxious.  You might try relaxing yourself before getting into your car to drive, or by taking deep breaths while you are driving.  It is also often helpful to tell yourself that these feelings are common following such accident and that, given time, they will go away.  If you begin to have thoughts about getting in another accident, tell yourself “Stop!” and force yourself to think about something more pleasant.

 COGNITIVE DIFFICULTIES

 As you have seen, a large percentage of your thinking difficulties can be related to your ongoing pain, sleep problems, and your emotional distress.  These conditions often result in significant problems with your ability to pay attention and concentrate, remember things, remember words that you want to say, organize your thoughts, or think rapidly.  A concussion can also result in you experiencing some thinking problems, but the effects of concussions almost always go away completely with time.  In fact, research has found that approximately 85% of people who experience significant concussions experience a complete resolution of their thinking problems within 3-6 months after their injury.   It is very likely that any lingering effects you have experienced as a result of a concussion will also go away.

 Concussions occur when you receive a significant blow to the head or when you experience a significant whiplash type injury causing you to be momentarily dazed, dizzy, or confused.  You may have even lost consciousness for a few seconds.  Many people who suffer such injuries never go to the hospital to seek medical care because the injury seems minor at first.  Oftentimes, the cognitive problems take a few weeks or even a month to become noticed.  This is frequently due to the fact that the thinking problems begin only after the person has experienced a long period of chronic pain, sleep problems, and emotional distress.  Resolving your difficulties in those areas often results in the cessation of the thinking problems you are experiencing.

 The brain is made up of thousands and thousands of long, thin nerve fibers.  If your head is hit hard enough, some of these nerves can be torn or broken.  Oftentimes, this damage cannot be seen on CT or MRI scans because the damage is so minor.  Fortunately, however, you have many other thousands of nerve cells which are not damaged as a result of the injury and which attempt to take over the work of the damaged nerve cells.  During the first few months after the injury, the brain works to heal itself just like your body works to heal a bruise on your arm.  After three or four months, or as long as six months, most of the healing has been completed.  This recovery often coincides, fortunately, with the physical healing that has taken place in your body and with the resolution of any emotional distress you have experienced.  Therefore, by the time six months have passed since your accident you should be feeling very close to BACK TO NORMAL.

 If your brain is bruised seriously enough, there may be some swelling that can take awhile longer to return to normal.  One way to tell if a concussion is serious is to determine the amount of time the patient was unconscious after the injury.  If you were not knocked out at all, or if you were unconscious for only a few seconds, then the injury is most likely very minor or mild.  Even though you may have some symptoms, there is probably very little injury to the brain itself, and complete recovery is expected.  Most people who have a concussion fall into this category. 

 The longer you were unconscious, the longer the recovery period usually takes.  If you were knocked out for more than an hour but less than a day, your injuries may be more serious, and full recovery will probably take awhile longer.  People who have been unconscious for longer than a day have suffered a significant injury to their brain.  Although many patients make a good recovery even after such serious injuries, symptoms can often last for a long time.  Sometimes those symptoms can be permanent.  Nevertheless, rehabilitation is often very helpful in limiting the effects of such injuries.

 The most common symptoms that people experience following concussions are very similar to those identified by people who have never hit their head but who are just living their normal lives.  Experiencing thinking type problems is very common for many people as a result of simply the everyday stresses which occur in normal life.  Here is another important thing to remember.  Research has found that people who have had a concussion have a tendency to overestimate their level of pre-injury thinking ability.  They believe that they never made any thinking type mistakes and that they had perfect memory.  What they fail to realize and remember is that before their accident they were actually experiencing minor and insignificant memory and concentration difficulties which they never even noticed.   But then, after an accident when they experience some minor thinking difficulty they tend to believe that that difficulty is much worse than is actually true.

              TIP       Be sure to maintain a realistic sense of how you are functioning now compared to how you were functioning before your injury.  Try not to mislabel normal thinking mistakes as evidence of brain injury.  

Certainly, having a concussion, going to an emergency room, being in pain, not sleeping, having to work with attorneys and insurance companies, and going to many doctors appointments adds a great deal of stress to your everyday life.  Such stress will often produce a significant decrease in your thinking ability, making you feel as if your brain is not functioning at all well.  Such a decrease, however, does not necessarily mean you have a brain injury.  Rather, you should understand that these symptoms are the naturally expected result of all of the things that have happened to you and all of the changes in your life as a result of your injury.   It is important to remember that these symptoms will also go away with time. 

 Obviously, if you worry that you have something seriously wrong with your brain, this will add to your stress and can result in a further decrease in your thinking ability.  If you have concerns or symptoms that simply will not go away, be sure to consult with your neuropsychologist or neurologist. They can check you out to confirm that your symptoms are not serious and that your brain is functioning adequately.

 SUMMARY

 As you have seen, post-concussion syndrome is a combination of physical, emotional, and cognitive symptoms which can all combine to cause a person to begin functioning at a much lower level than they were before their injury.  Simultaneous treatment in all three areas is the most effective way to reduce the symptoms of post-concussion syndrome and to help you return to normal as soon as possible.  Becoming aware of post-concussion syndrome, maintaining good sleep habits, adopting a positive mental attitude, and limiting the number of activities in which you become involved on a daily basis are some of the most effective ways of returning to normal as fast as possible.   Most patients will be back to normal within 3-6 months without any special treatment.  Following the guidelines in this manual will speed your recovery.

 Some of the most effective things you can do to improve your thinking abilities are listed below.

?                     Limiting your activities means not volunteering for any extra jobs or responsibilities, temporarily turning over some responsibilities to other people, getting enough rest, and limiting the number of hours you work every day.

?                     Use your notebook and Daytimer to write down all information that you need to remember.

?                     Carry a small notepad with you wherever you go and write down all new information. 

?                     Wear a watch which beeps every hour and which can remind you to check you Daytimer on the hour.

?                     Ask people to repeat or explain things more simply whenever necessary.  

?                     Be sure to schedule rest breaks during the day.

?                     When you return home from work in the evening, go straight to your bedroom and spend 20 minutes resting with your eyes closed and without any distractions.  Do not read a magazine, watch TV, open the mail, pet the dog, talk to your spouse, listen to your messages on your answering machine, or fold the laundry.  Simply lie down and rest after having worked a long day. After 20 minutes or so you feel much more refreshed and can then meet the demands of the rest of your day.