Friday, June 09, 2006
Mild Head Injuries
Mild head injuries and chiropractic
Zielinski, Robert J
Count to 15. When you reach 15, another person in the United States will have sustained a head injury. Each year, an estimated 2 million people will suffer a head injury and about 500,000 to 750,000 will be severe enough to be hospitalized. These accident victims will be classified as having a moderate to severe brain injury. However, approximately 85 percent of accident victims will sustain a "mild head injury" or concussion and will not be hospitalized. These accident patients will typically seek treatment for the physical consequences of their accidents in the offices of chiropractors, neurologists, and/or orthopedic doctors. Although these patients generally seek relief from physical pain, i.e., neck, back, and muscle, they may also be suffering the consequences of a closed head injury. An accident victim who has sustained a mild closed head injury may show no noticeable signs of physical damage to the head area, but he or she may be suffering from a traumatic brain injury. It is also necessary to realize that the term "mild brain injury" is a misnomer since any insult to the brain can have significant and devastating effects on cognitive functioning.
An accident victim may have had an automobile accident, a fall, a sports accident, or any other serious event. This can cause trauma to the muscles, bones, ligaments, blood vessels, nerves in the neck, back, and head, and to the brain. A traumatic brain injury can be defined as:
* direct impact of the brain upon the skull caused by an object striking the skull (such as a baseball bat striking the skull)
* the skull striking an object ( such as the head hitting the windshield in a car) the brain undergoing movement in the skull without direct impact to the head (such as a whiplash).
If the brain is damaged at the point of contact, it is considered a coup injury. If the damage is on the opposite side of the brain, it is known as a contrecoup injury.
The mild head injury without visible signs is often overlooked by physicians because the patient looks and acts "normal." In reality, a mild closed head injury may not show structural brain damage on a CAT scan or MRI and the accident patient may or may not have lost consciousness, or only report feeling "dazed" after the accident.
In a mild head injury, there may be no direct blow to the head. Instead, the head may be violently shaken back and forth, as in a rear-end collision. An injury may result to the brain because the brain ricochets inside the skull during the impact of the accident. The bouncing of the brain first against one part of the skull, and then against another, can produce bruises and/or swelling in different parts of the brain. Additionally, a shearing or tearing may occur, especially in the temporal and frontal areas of the brain, because of the skull's bony structure. The shearing and tearing happen on a microscopic level and, for the most part, are not apparent on common medical tests, such as an MRI or CAT scans. It should be noted that even if an MRI or CAT scan is negative, this does not mean that the brain is not compromised. These tests do not assess how the brain processes incoming and outgoing information. They assess only brain structure. In other words, these medical tests do not assess the "brain in action"-cognitive tasks that involve thought, memory, reading, and so on.
When a patient who has been in an accident comes to your office because of neck/back pain, you must be aware that in any accident, the brain may also be compromised. The patient may show only subtle signs of compromised brain functioning, and without an alert recognition of possible problems, the patient is shortchanged in terms of a treatment plan.
By the time the accident victim shows up in your office, he or she may have the following cognitive and personality consequences (beyond the physical problems for which the patient is seeking relief):
Cognitive Deficits
short attention span
short-term memory problems
problem-solving deficits
difficulty in understanding abstract concepts
inability to perform one- or two-step commands simultaneously
problems in reading comprehension or in performing math problems
mispronouncing words
word-finding difficulties
Personality Changes
depression
emotional instability
apathy and lessened motivation
lowered Frustration tolerance
fatigue
increased aggression
If these symptoms do not improve from one to three months after the head trauma, they may become permanent. An appropriate referral to a psychologist, neuropsychologist, or neurologist is absolutely necessary.
Behaviorally, an accident victim with a mild head injury can get confused about performing simple daily tasks, such as remembering telephone numbers, names, and faces, and in carrying out the common tasks of daily life. While pre-injury learning and memory typically remain unaffected, learning new material and procedures can be devastating since so much mental energy is needed to cognitively function that the tasks become overwhelming.
Additionally, in a mild head injury, it is typical that mental confusion occurs in over-stimulating environments, such as grocery stores, malls, restaurants, or large crowds. Learning new material is exhausting for this patient. Performing several tasks at the same time is equally taxing--such as cooking a meal. Concentrating on doing paper work is daunting. This exhaustion occurs because of the necessary additional effort on the part of the patient to pay attention to the task at hand; additionally, it usually becomes worse as the day wears on. The exhaustion is not only mental but also physical. Usually, a rest period is needed in late afternoon or early evening to help the patient recharge his or her "batteries." Along with the mental and physical exhaustion come emotional stress and a reduced ability to control the temper. Thus, the patient may become extremely frustrated, angry, and depressed and experience significant self doubt.
These deficits become even more devastating if the patient has been told that the MRI or CAT scan was negative. Patients wonder if they are "going crazy 11 since they think they should feel normal if their test results come up negative. These accident victims are "put into a box," i.e., victims know that "something is wrong," but they are told that they should not be experiencing cognitive consequences from their accident. Many times patients suffer in silence, afraid to pit their own experiences against their medical tests. The typical result is a depression in which patients doubt their own cognitive weakness experiences. This self-doubt is overwhelming in terms of emotional functioning.
Patients with a mad head injury tend to deny their cognitive problems and try to cover up their weaknesses. Few patients want to admit memory lapses, cognitive confusion, reading comprehension problems, or other related cognitive tasks. They want to avoid losing a job. Or they want to appear "normal" in daily life.
For the treating chiropractor, careful observation and active listening to the patient's verbalizations are necessary to detect if subtle consequences of the mild head trauma are present. For instance, does the patient forget simple instructions during your treatment, ask you to repeat what you have said, have problems verbally expressing thoughts, stumble over words, need to be directed over and over to perform a task, have difficulty discriminating left from right, or seem to be depressed or unduly anxious?
Questions can be directed to the patient, such as:
How is your memory?
Do you have problems remembering what you read?
Do you get distracted easily?
Is your thinking confused?
Do you forget what has been told to you?
Do you have trouble performing daily tasks?
Do you have problems following directions?
Has there been a change in your personality since the accident?
These, among other variables, can suggest that the patient is suffering from the consequences of a mad head injury. Since many patients, however, will try to deny "problems," each response will need to be validated by behavior observed by the treating physician. Other methods of inquiry could include questionnaires relating to the consequences of a mad head injury, as well as computerized screening assessments of the patient.
The first tragedy of an accident victim may be a mild traumatic brain injury. The second tragedy is if a treating physician does not recognize the devastating cognitive and emotional consequences of a brain injury, which may mean that a proper referral to those professionals with expertise in working with head-injured patients is not made.
The author would like to state that this article is not intended to be an exhaustive examination of mild traumatic head injuries. It is merely a starting point for those who are interested in the topic.
Reference and Reading List
1. Filskov S & BoIl T. (Eds.) Handbook ofClinical Neuropsychology. 1981. New York: Wiley and Sons.
2. Levin H, Eidenberg H, e3 Benton A. (Eads.) Mild Head Injury.1989. New York: Oxford University Pres.
3. Levin H., Benton A, e3 Grossman R (Eds.) Neurobehavioral Consequences of Closed Head Injury. 1982. New York: Oxford University Pres.
4 Lezak L. Neuropsychological Assessment.1995; New York: Oxford University Press.
5: Long C & Ross L. (Eds.) Handbook of Head Trauma: Acute Care to Recovery 1992. New York: Plenum Press.
6. Parker R Traumatic Brain Injury and Neuropsychological Impairment. 1990. New York: Springer- Verlag.
7. Taylor R. Distinguishing Psychological from Organic Disorders. 1981. New York: Springer Publishing.
8. Szymanski H & Linn R. "A review of the post concussion syndrome. "International J. Psychiatry in Medicine. Vol. 22 (4), pp. 357-375:1992.
9. Reitan R & Wolfson D. Traumatic Brain Injury. Pol e3 Vol. 2. 1986. Tucson: Neuropsychological Press.
Zielinski, Robert J
Count to 15. When you reach 15, another person in the United States will have sustained a head injury. Each year, an estimated 2 million people will suffer a head injury and about 500,000 to 750,000 will be severe enough to be hospitalized. These accident victims will be classified as having a moderate to severe brain injury. However, approximately 85 percent of accident victims will sustain a "mild head injury" or concussion and will not be hospitalized. These accident patients will typically seek treatment for the physical consequences of their accidents in the offices of chiropractors, neurologists, and/or orthopedic doctors. Although these patients generally seek relief from physical pain, i.e., neck, back, and muscle, they may also be suffering the consequences of a closed head injury. An accident victim who has sustained a mild closed head injury may show no noticeable signs of physical damage to the head area, but he or she may be suffering from a traumatic brain injury. It is also necessary to realize that the term "mild brain injury" is a misnomer since any insult to the brain can have significant and devastating effects on cognitive functioning.
An accident victim may have had an automobile accident, a fall, a sports accident, or any other serious event. This can cause trauma to the muscles, bones, ligaments, blood vessels, nerves in the neck, back, and head, and to the brain. A traumatic brain injury can be defined as:
* direct impact of the brain upon the skull caused by an object striking the skull (such as a baseball bat striking the skull)
* the skull striking an object ( such as the head hitting the windshield in a car) the brain undergoing movement in the skull without direct impact to the head (such as a whiplash).
If the brain is damaged at the point of contact, it is considered a coup injury. If the damage is on the opposite side of the brain, it is known as a contrecoup injury.
The mild head injury without visible signs is often overlooked by physicians because the patient looks and acts "normal." In reality, a mild closed head injury may not show structural brain damage on a CAT scan or MRI and the accident patient may or may not have lost consciousness, or only report feeling "dazed" after the accident.
In a mild head injury, there may be no direct blow to the head. Instead, the head may be violently shaken back and forth, as in a rear-end collision. An injury may result to the brain because the brain ricochets inside the skull during the impact of the accident. The bouncing of the brain first against one part of the skull, and then against another, can produce bruises and/or swelling in different parts of the brain. Additionally, a shearing or tearing may occur, especially in the temporal and frontal areas of the brain, because of the skull's bony structure. The shearing and tearing happen on a microscopic level and, for the most part, are not apparent on common medical tests, such as an MRI or CAT scans. It should be noted that even if an MRI or CAT scan is negative, this does not mean that the brain is not compromised. These tests do not assess how the brain processes incoming and outgoing information. They assess only brain structure. In other words, these medical tests do not assess the "brain in action"-cognitive tasks that involve thought, memory, reading, and so on.
When a patient who has been in an accident comes to your office because of neck/back pain, you must be aware that in any accident, the brain may also be compromised. The patient may show only subtle signs of compromised brain functioning, and without an alert recognition of possible problems, the patient is shortchanged in terms of a treatment plan.
By the time the accident victim shows up in your office, he or she may have the following cognitive and personality consequences (beyond the physical problems for which the patient is seeking relief):
Cognitive Deficits
short attention span
short-term memory problems
problem-solving deficits
difficulty in understanding abstract concepts
inability to perform one- or two-step commands simultaneously
problems in reading comprehension or in performing math problems
mispronouncing words
word-finding difficulties
Personality Changes
depression
emotional instability
apathy and lessened motivation
lowered Frustration tolerance
fatigue
increased aggression
If these symptoms do not improve from one to three months after the head trauma, they may become permanent. An appropriate referral to a psychologist, neuropsychologist, or neurologist is absolutely necessary.
Behaviorally, an accident victim with a mild head injury can get confused about performing simple daily tasks, such as remembering telephone numbers, names, and faces, and in carrying out the common tasks of daily life. While pre-injury learning and memory typically remain unaffected, learning new material and procedures can be devastating since so much mental energy is needed to cognitively function that the tasks become overwhelming.
Additionally, in a mild head injury, it is typical that mental confusion occurs in over-stimulating environments, such as grocery stores, malls, restaurants, or large crowds. Learning new material is exhausting for this patient. Performing several tasks at the same time is equally taxing--such as cooking a meal. Concentrating on doing paper work is daunting. This exhaustion occurs because of the necessary additional effort on the part of the patient to pay attention to the task at hand; additionally, it usually becomes worse as the day wears on. The exhaustion is not only mental but also physical. Usually, a rest period is needed in late afternoon or early evening to help the patient recharge his or her "batteries." Along with the mental and physical exhaustion come emotional stress and a reduced ability to control the temper. Thus, the patient may become extremely frustrated, angry, and depressed and experience significant self doubt.
These deficits become even more devastating if the patient has been told that the MRI or CAT scan was negative. Patients wonder if they are "going crazy 11 since they think they should feel normal if their test results come up negative. These accident victims are "put into a box," i.e., victims know that "something is wrong," but they are told that they should not be experiencing cognitive consequences from their accident. Many times patients suffer in silence, afraid to pit their own experiences against their medical tests. The typical result is a depression in which patients doubt their own cognitive weakness experiences. This self-doubt is overwhelming in terms of emotional functioning.
Patients with a mad head injury tend to deny their cognitive problems and try to cover up their weaknesses. Few patients want to admit memory lapses, cognitive confusion, reading comprehension problems, or other related cognitive tasks. They want to avoid losing a job. Or they want to appear "normal" in daily life.
For the treating chiropractor, careful observation and active listening to the patient's verbalizations are necessary to detect if subtle consequences of the mild head trauma are present. For instance, does the patient forget simple instructions during your treatment, ask you to repeat what you have said, have problems verbally expressing thoughts, stumble over words, need to be directed over and over to perform a task, have difficulty discriminating left from right, or seem to be depressed or unduly anxious?
Questions can be directed to the patient, such as:
How is your memory?
Do you have problems remembering what you read?
Do you get distracted easily?
Is your thinking confused?
Do you forget what has been told to you?
Do you have trouble performing daily tasks?
Do you have problems following directions?
Has there been a change in your personality since the accident?
These, among other variables, can suggest that the patient is suffering from the consequences of a mad head injury. Since many patients, however, will try to deny "problems," each response will need to be validated by behavior observed by the treating physician. Other methods of inquiry could include questionnaires relating to the consequences of a mad head injury, as well as computerized screening assessments of the patient.
The first tragedy of an accident victim may be a mild traumatic brain injury. The second tragedy is if a treating physician does not recognize the devastating cognitive and emotional consequences of a brain injury, which may mean that a proper referral to those professionals with expertise in working with head-injured patients is not made.
The author would like to state that this article is not intended to be an exhaustive examination of mild traumatic head injuries. It is merely a starting point for those who are interested in the topic.
Reference and Reading List
1. Filskov S & BoIl T. (Eds.) Handbook ofClinical Neuropsychology. 1981. New York: Wiley and Sons.
2. Levin H, Eidenberg H, e3 Benton A. (Eads.) Mild Head Injury.1989. New York: Oxford University Pres.
3. Levin H., Benton A, e3 Grossman R (Eds.) Neurobehavioral Consequences of Closed Head Injury. 1982. New York: Oxford University Pres.
4 Lezak L. Neuropsychological Assessment.1995; New York: Oxford University Press.
5: Long C & Ross L. (Eds.) Handbook of Head Trauma: Acute Care to Recovery 1992. New York: Plenum Press.
6. Parker R Traumatic Brain Injury and Neuropsychological Impairment. 1990. New York: Springer- Verlag.
7. Taylor R. Distinguishing Psychological from Organic Disorders. 1981. New York: Springer Publishing.
8. Szymanski H & Linn R. "A review of the post concussion syndrome. "International J. Psychiatry in Medicine. Vol. 22 (4), pp. 357-375:1992.
9. Reitan R & Wolfson D. Traumatic Brain Injury. Pol e3 Vol. 2. 1986. Tucson: Neuropsychological Press.
