Understanding Post-Concussion Syndrome: The Interrelationship Between the Neurologic and the Psychiatric
Seth Fischer, a fourth-year medical student at the University of California/Davis School of Medicine, was riding his bike near the campus in 2015 when an accident resulted in a concussion. While not uncommon among active young people, the bike accident would shed valuable light on a subject that continues to vex physicians: post-concussion syndrome.
Dr. Elizabeth Sandel, Paradigm Medical Director, recounted Seth's story during a webinar on the topic. In an interview with Seth, she learned that his post-concussion symptoms lasted at least a year after the accident, and that Seth — as a future doctor — had a unique perspective on his recovery.
“I asked him how his injury and recovery changed his view of concussions as a physician in training. He said that the convoluted nature of these injuries is something the medical profession doesn't understand, and is hard for the patient to elaborate on. For him, recovery was a slow slog.”
Dr. Sandel said that Seth's case, like many other post-concussion situations, is typical in that a lot of these patients aren't getting an early education about their condition, nor are they being followed throughout the post-concussion period. They're left to figure out for themselves the process of recovery.
“I think the more early education and reassurance we can provide, and the targeted treatments, will reduce symptoms in the acute and long term, and decrease recovery time,” she added.
Dr. Sandel recounted how early in her career concussions were simply classified as “minimal brain injuries” or “minor brain injuries.” Now they're simply called “mild brain injuries.”
None of the terms, however, really describe exactly what the patient is experiencing. They are simply part of the Glasgow Coma Scale that was developed in the 1970s and 1980s. The mild brain injuries were in contrast to the moderate and severe injuries that the scale quantified.
“There's been more recent work on trying to really define these mild injuries,” Dr. Sandel said. “One is a period of loss of consciousness that's less than 30 minutes. The other and most important is post-traumatic amnesia, a memory problem that can typically last a day or less.”
She references the sports world where there's been a lot research into defining concussions and guidelines for measuring them, including the SCAT-5 and ImPACT tests. These define concussion as a direct blow to the head, face, neck or elsewhere in the body — not necessarily just to the head.
“This is a recognition that it's really an acceleration-deceleration event, an inertial event that causes the brain to move within the skull,” Dr. Sandel said.
Defining the symptoms of post-concussion syndrome is still in flux, she says. These might include headache, dizziness, fatigue, irritability, difficulty concentrating, memory problems, insomnia and reduced tolerance to stress. “Anyone who has at least three of these symptoms at four weeks constitutes post-concussion syndrome. But many patients will have all eight.”
Dr. Sandel says symptom management is key, with each symptom deserving targeted treatment and tracking of recovery. Another valuable tool is neuropsychological evaluation, which is a great way to really identify what's going on cognitively and psychologically.
“Ultimately, though, what's really important is to get to know the patient, their relationship to what happened and their past medical history,” she says. “But the big question remains, and must be answered — what is the interrelationship between the neurologic and the psychiatric? Most of the patients with post-concussion syndrome have a mix, and they deserve to be treated for both.”
Seth Fischer couldn't agree more. “You see the patient, you get the report, but you don't understand what the patient's really going through.”
For more from Dr. Sandel and her extensive concussion research, you can follow her blog.
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