Post concussion head trauma vulnerability
 

Hi everyone,
This is the first time posting a "thread" as well as the first time I've ever been part of an on-line forum, let alone any forum for that matter. I'm a family physician in Canada, and like most Canadians, enjoy playing hockey. Unfortunately, in 2006, I suffered a concussion during a hockey game which resulted in a prolonged recovery. After about a year, I was finally able to tolerate and enjoy sports again without inducing a headache. As you can imagine, I was forbidden by my wife to lace up my skates again (no argument).

In retrospect, I now realize I made 2 errors in recovery (wish I knew then what I know now). First, I quickly returned to work without much cognitive rest and pushed my way through long clinic hours. Second, I lifted a heavy article on day 2 post mTBI which quickly brought significant and instant head pain.

What has now become a permanent disability is an inability to strain or lift articles more than ~10 lbs without feeling a discomfort in my head. This discomfort eventually becomes pain if I persist with the strain or lift. The more intense the pain, the longer it takes to dissipate. With new head trauma (such as loghtly bumping my head on a shelf, running in my squash opponent....ie sudden deceleration), this intolerance to strain is magnified for a few weeks. Eventually it settles back to a baseline but never goes away. Essentially I am extremely sensitive to any increase in intra-cranial pressure(ICP) (physical strain--->increase venous pressure--->increase ICP. The problem is that it is now taking less force to temporarily magnify this phenomenon. I've recently had a second MRI specifically to rule out a head trauma induced Chiari-type CSF obstruction. Thankfully everything was normal. I've consulted local "concussion specialists" who can only come up with theories of meningeal hypersensitivity post injury with the consideration for medication dampen the pain during effort (which I'm reluctant to do).

The other phenomenon that now follows any head bump (and I mean just a bump), is a decline in cognitive stamina that slowly improves over 2-3 weeks. It's difficult to cancel patients who have been waiting so long to see you. So, against better judgement, I often will push myself cognitively through a days work. I now can appreciate that these changes (following repeat minor injuries) are both structural (at a cellular level) but also biochemichal (increased neuron vulnerabilty and cell dysfunction). What puzzles me is why the worsening trend over time.

Once I'm 3-4 weeks past a "head bump", I feel cognitively great again. I'm able to enjoy aerobic sports that don't increase venous pressure much or for long. In other words, I have no problems tolerating an increase in arterial pressure when I'm "well" (I can ride my bike but just can't lift it!).

I wonder if anyone else has been experiencing similar post-concussive symptoms and whether investigations have shed any light.

Canadoc,

Welcome to NeuroTalk. I wonder if you have some neck involvement causing the head pressure. Often, when we try to lift something, we will tighten the upper back and neck muscles. This can alter blood flow. I have had to learn good lifting mechanics and with such, I have little to no limitations. Often, just taking a breath and releasing it in a relaxing way is enough to allow me to lift without tensing my neck.

You may also have unresolved upper neck injuries that quickly react to any strain. The whiplash often accompanying a concussion can set up a cascade of injuries and structural imbalances.

Regarding your long days seeing patients. Many of us have had to master the skill of "Stopping to Think." This is a sort of clearing the mind of distractions and shutting out the audio and visual stimulations enough to get cognitive focus. I find a brief moment with my eyes closed can be a big help.

There are lots of good people here so feel free to share with us.

My best to you.

Thanks Mark, I also found exhaling during a lift helpful. Keeps venous pressure from rising too high. Think I'm going to enjoy this forum stuff!

Hi Canadoc, I read your post and can definitely relate to your symptoms. I suffered a slip and fall on ice 3 years ago, and still live with pressure/discomfort in my head when lifting objects/over exertion/ or any type of stress. I am a part time personal trainer, so it has made my job challenging and frustrating, at times. Most of my clients usually pick up the weights.

If I really overdo it, the symptoms last longer, with more discomfort in my head, as well as pressure in my ears, and sometimes burning in the back of my head. It almost feels like my brain is torqued in my head . Sometimes, it knocks my Atlas out as well. I usually ice my neck and head, when the symptoms increase.

Overall, I am a bit better. I can tolerate picking up more weight. But not holding it for a long time. I used to work out in a gym, lifting weights, but I can no longer do that. Maybe someday, but not now. I used to bike, and do other cardio exercise. But have been very limited in that as well, without it bringing on symptoms. In the past year, it has improved however. I can ride my stationary bike for up to 30 mins, with minimal symptoms, that don't last as long as they used to. But I can't exercise anything like I used to. If I push too much, I just set myself back. So I continue to take baby steps. Are you able to run/bike etc, for long periods, without head symptoms ???

I have been seeing an Atlas Orthogonal chiro for 2 years now. In addition to the concussion, I have an atlas subluxation. My Atlas has become more stable over the 2 years, but it still comes out. She believes the soft tissue in my neck is still healing, in addition to my head. Have you had your neck checked out ??? It may be worth it to seek out an upper cervical chiropractic specialist.

I've tried acupuncture, couldn't handle vestibular therapy, and I am very sensitive to any drugs that my dr and other neurologists have prescribed. I am on a good supplement regime. In addition to my chiro, I see a cranial sacral therapist and a myofascial therapist. Both give me relief.

I'm seeing my neurologist for a follow up next week. I haven't had an MRI in 2 1/2 years, so my chiro suggested that he order an upright MRI to rule out/check for any Chiari malformation from the trauma. I think it's a good idea. All else I've been told is that there's inflammation that causes my symptoms.

All we can do is accept our current situations, and live life as fully as we can. I try to do that everyday, while continuing to heal.
I don't post much to this forum, but have found it very helpful.

Thank you for your post !

Thanks for your post Keepin' the Faith07. Boy, sounds like we've been walking the same road. I see a fair number of concussions in my practice including complex mTBI. Still haven't come across anyone like me. I've consulted with local concussion specialists (one of which sits on a national "think tank" committee for mTBI recommendations). He thought that the exertional head pain was from a meningeal hypersensitivity to normal increases in intra-cranial pressure. His advice was to pre-medicate with anti-inflammatories before a work-out. Another MD, who actually did his fellowship in the States focusing on mTBIs, suggested a second MRI to rule out the infamous Chiari malformations which presents typically with exertional headaches. Fortunately (I think), mine was normal. He suggested getting an opinion from MD in Buffalo who dealt with more atypical cases.

I like your "cervical spine theory" to which I never gave much thought. I often ask my wife to massage the upper posterior part of neck which provides an unusual head sensation but yet oddly comforting. What goes against a purely cervical issue is a lingering cognitive haze I experience after an excessive strain. That suggest to me a intra-cranial source. But at this point, nothing is for certain. Like you say, part of coping is accepting what life sends your way. My spiritual journey has also taken on new importance.

I'd enjoy keeping in touch with you but will let you decide if that's of any interest. I'm not very familiar with this site but I think you can request me as a friend (like in Facebook). Good luck with your MRI.

Sorry to hear you are suffering, and for so long! I am sure my exercise has changed forever. I don't lift weights anymore - hurts the brain and neck. Climbing stairs is a challenge - not for the heart but for the head. Very weird and sad. I was extremely active in sports and loved getting my heart rate up! Squash, cycling, cross-country skiing, etc.

I did go to Buffalo for an assessment, if that is what you were being referred to (University of Buffalo Sports Clinic). They told me that I was at the stage where exercise would not make my concussion worse...and exercising at a sub-optimal level would be beneficial. You can find their research online and in medical journals. Dr. Leddy is one of the researchers.

I wonder if it would be useful for you? Not sure.

Did you injure your neck as well? (Sorry if you have already written that!).

Out of curiosity (because so many of us have had such bad experiences with some doctors who don't have a clue, or are patently wrong about concussion, how do you find your colleagues? Do you share your insights with them? It is the kind of injury that one cannot imagine until it happens. So hard to describe to others.
Hope you keep healing.

Hey Canadoc,

Welcome to the thread. I am an Information Technology student who has fought with the woes of PCS. I still have some residue symptoms, but I am pretty much recovered.

My injury left me with Occipital Neuralgia and amplified mental disorders. I have had Anxiety, and ADHD which was amplified after my knock to the head, and ever since was forced to stay on my meds by my medical team.

Having anxiety and my brain not filtering properly were my two biggest woes in the beginning, along with my nerves going nuts after a smack to the back of the head injury. Dizziness stayed for months, until March 2013. 98% recovered in April 2013.

I couldn't even dream of lifting anything, even now to be honest. I am pretty much afraid of straining my neck since the accident.

Its been a while since my recovery and I still follow my Vitamin Regimen from Mark since December 2012. It does help. When I don't take them, I notice a huge difference in my mood and energy. I feel fatigued without it, and my focus especially from my ADHD goes down the drain. It would end up with me taking three naps a day, not even kidding.

I actually recommend you go to the stickie at the top for Mark's Vitamin Thread, I used it in the past, and have modified/added some of my own vitamins to this regimen. I use a Stress-B complex, instead of a regular B-50. And a Magnesium Malate, instead of regular magnesium due to its nerve healing properties. Potassium Citrate for my tension headaches.

You are getting better, no doubt about it from the sound of your post, but take it easy with the lifting. I would ask for help until you think you are ready to lift.


Best Wishes,

Consider

Thanks for the input Mokey and Consider. As you eluded to in your comments, many primary care physicians remain less informed about PCS. Part of the challenge in primary care is trying to stay up to date with a rapidly expanding medical field. I'd have to quit my day job to do that. I spend a good part of my day dealing with chronic diseases (diabetes, heart disease, mental health issues, etc) as do many of my primary care colleagues. It only seems reasonable that one would dedicate more reading time to these areas. As such, family docs likely familiarize themselves with the most likely presentation of head injuries which is the simple concussion. They recognize the symptoms, institute the new recommendations of physical and cognitive rest and most of their patients are better in a few weeks. That would be a reasonable expectation for the average family doc. When it comes to the complex concussion, I think you have to search the MDs who have a special interest in this area because the landscape of mTBI and PCS knowledge is growing rapidly and your average GP and even neurologist may not be up to date. That said, there may be plenty of new theories to explain the symptoms we experience. However we are still far behind in solutions. Many of the recommendations we follow our expert opinions (which doesn't mean they are wrong) but they aren't necessarily based on randomized trials but rather "best evidence to date". And that continues to evolve. If something is working for you, keep with it. Science may catch up with you and confirm that you were doing the right thing after all! MDs also must be mindful of the fact that patients often stumble upon treatments that are later shown to be scientifically sound. Always nice to deal with a doc that listens as well. Because of my personal encounter with PCS, I've done a lot of reading around this area but I certainly wouldn't consider myself an expert. I complain about not being able to strain or lift weights. I get down on myself when I struggle cognitively through a work week after "bumping my head". I am however humbled when I read the many stories in this forum of people struggling to get through a simple day at home. The sharing of stories has opened my eyes to the importance of emotional support we all need. What is worse that a broken brain is a broken spirit as well. Stay as well as you can. Cheers, Canadoc

Hi Canadoc! I'm not a doctor, but I do play one when I diagnose myself on the Internets :)

Are you sure your intolerance to weightlifting isn't just the plain old symptom exacerbation many of us experience with high heart rates? You mentioned you were able to get back to sport without inducing headaches, but did you/do you go to the point of very high heart rate or anaerobic exertion? Maybe you can tolerate a certain heart rate but not higher and lifting sends that heart rate spike/ pressure up.

I haven't posted here yet, just lurked since my concussion November 2013 but the way you describe your post-lifting mental state is VERY similar to what happens to me when I tried to exercise and get my heart rate up. I was healing, slowly, from my original accident and actually got to the point at two months where I felt basically no symptoms at rest but if I tried to exercise I got a brain fog feeling, blurry vision, dizziness, etc. Depending on how much I did, it would last half a day or a day or so.

Then two weeks ago I lightly tapped my forehead into a small tree. I know, it sounds bad, but it was honestly lighter than the taps we've already probably done pre-PCS, like hitting into a car door or something. It didn't even hurt. But I'm still in a mild relapse of symptoms. I refuse to consider it a rein jury because that's just way too depressing and I'm not nowhere as bad as I was after my original concussion. I'm choosing to think of it as a setback in my healing.

I go to U of Buffalo this Monday to see Dr. Leddy and his team. Before my tree tap setback I had started their protocol on my own and was progressing nicely, from twenty minutes at a heart rate of 120s up to 140s over three weeks, with no return of symptoms. Stupid tree!:mad:

Anyway, just out of curiosity, what would happen if you slowly monitored your heart rate until you go to your max heart rate...would any of those same symptoms that happen after lifting/ exertion come back? Might be worth your time to try it out.

Good luck!!

Thanks for taking the time to post me a note. I also recently stumbled on this site and find it terrific to be able to share stories. I seem to have two distinct consequences to my mTBI when it comes to exercise (by the way, I'm also a sports junky and still am.....it's just morphed in to a different form).

The first is what you've experienced with the tree bump. It usually takes me 2-3 weeks to slowly climb the "heart rate" ladder but I always eventually get there. Once "there", I can tolerate rates up to 160 bpm. In other words there is eventually no limitation from a purely cardio perspective.

The second problem I have (which has never really improved) is an inability to tolerate higher levels of resistance in the exercise (such as weight training, high resistance to pedaling, etc). When I push the limit, I develop i head pain which lingers for a while. If I "really" push the limit, I feel cognitively hazy for a while. I can provoke this pain without raising my heart rate or moving my neck (for example squeezing something tightly). When I bump my head, the tolerated "strain threshold" decreases for a few weeks much like the heart rate issue. However even after I'm finally able to tolerate higher heart rates, I never fully improve on the other stuff. I continue to hunt for explanations regarding the physiological changes induced by the mTBI. I too will be interested in hearing how things went with Dr Leddy. Keep us posted.