Heidi really doesn't remember how she made it through school during the first ten days after her concussion playing hockey. On the final day of classes before exams, the dean - who had considerable experience with concussed students - finally did the right thing: she excused Heidi from exams on medical grounds, with her grades for the term based on her work to date.
On February 26, 2010, almost a week before spring break was scheduled to begin, I brought Heidi back home to New Jersey. It was then that I alerted Dr. S., Heidi's sports physician at a noted Connecticut sports medicine clinic, to Heidi's concussion. We agreed that he would evaluate her the following week, during a previously scheduled check-up for a nagging back injury.
Accidents happen, even on detours
One would have thought Heidi would be safe away from school, but it was not to be. First, she slipped on black ice and fell on her back, which aggravated her pre-existing back injury. To make matters worse, on the way back to Connecticut to see her sports doctor, we got into an accident: our SUV was side-swiped on the Interstate, and Heidi hit the side of her head in the ensuing multi-vehicle spin-out (the crash didn't deploy her side airbag). Dr. S. could only shake his head at our tale of woe and agree, after a physical examination and hearing her describe her symptoms, that she indeed had suffered a severe concussion.
There was no point in having Heidi take a post-concussion neurocognitive test at that point to compare to her baseline because it was clear on clinical exam, almost three weeks after injury, that she had not recovered sufficiently to return to class, much less the hockey rink. The doctor reviewed the rest protocol with us, and prescribed pain medication for her severe headaches - something he typically didn't do for a concussion - in the form of a half-dose of Toradol (a potent migraine/post-op NSAID) for daytime and Percocet at night. He asked us to return at the end of spring break, about three weeks away. Surely, I thought, Heidi would be much better by then.
No maps to guide us
At home in Princeton, finally, without the distractions of school, Heidi began to comprehend the severity of her injury. She was experiencing almost every single symptom listed on the SCAT2 form, and then some:
- problems concentrating;
- memory problems, both retrograde (i.e. recall of pre-concussion events) and anterograde amnesia (forming new memories, such as phone numbers, vocabulary, or physics formulas)(the presence of which indicated, in Heidi's case, a longer recovery);
- sensitivity to light and noise, and taste;
- fatigue and sleep issues; and
- irritability and emotional volatility.
Games, puzzles, and letters
Meanwhile, Heidi slept long and often during the day, but her night sleep was still not sound (typical concussion insomnia can be very provocative for parents, who by this time might be plenty irritable themselves.)
During this first month post-concussion, Heidi's distress stemmed mostly from the physical symptoms. I did a lot of research to explore therapies to encourage the healing of a traumatized brain. When Heidi was awake, I kept her company and we played games, adapted from some of the concepts of stroke rehabilitation therapy, including:
- memory games to sharpen recall: starting out with easy ones, designed for pre-schoolers, and slowly increasing the number of pairs in the grid until Heidi reached an 8 x 8 grid (32 pairs);
- jigsaw puzzles, starting with 100-piece simple image puzzles and graduating to puzzles with 300 pieces (although Heidi later told me that, while she liked the puzzles, I pushed her into harder puzzles too quickly, which made her head hurt);
- learning exercises using an alphabet board with letters in random order and in various colors, which I switched around each day (both in order and color). I would give Heidi a word to spell, and she would look at the board, figure out what color the letter was that day, and say the color, not the letter. So, for example, if C was white, and A was purple, and T was green, and I asked her to spell CAT, she would answer white-purple-green. We would do this exercise many times a day, three words at a time, working up from four letters to eight letters over time. Using colors and shapes engaged different parts of her brain than used for language processing.
Based on the location of the injury in her brain, we also listened to quiet, very evenly rhythmic, music, such as Baroque, waltzes or marches. (A different injury location might benefit from nature sounds). Heidi found listening to music and trying to play her harp therapeutic, too.
We also watched really old movies and selected TV shows, Because the editing of most new shows is very fast, some shows were not compatible with cognitive rest. Reruns of old sitcoms, or even slow-paced contemporary TV (think "Monk" or "Psych," i.e., "live action", not animation) are much easier on cognitive processes. Heidi also stayed away from the computer.
In addition, Heidi continued to see her chiropractic neurologist, Dr. Vincent Kiechlin (Dr. K). Chiropractic, now considered a branch of mainstream medicine, is best known, of course, for the adjustments DCs do of the vertebra of the neck and back to correct misalignments (subluxation) which irritate the spinal nerves, reducing muscle strength and setting off spasms, or other painful symptoms.
Chiropractic neurology was developed by Dr. Ted Carrick and is a much more recent sub-specialty focusing specifically on brain function. A CN evaluation is able to identify areas of the brain that injured or damaged. Its therapies promote new connections into damaged areas in order to improve brain function. The ability of the brain to form new connections is called "neuroplasticity".
The CN view of concussion suggests that, following the injury, symptoms linger due to the swelling of neurons in the damaged area of the brain, causing dysfunction of those neurons and possibly the death of connections. The goal of CN is to identify the damaged areas using simple, yet sophisticated, diagnostic techniques which explore brain function.
One of the tests a chiropractic neurologist uses involves the use of a blue-and-white-striped cloth ribbon (in some cases a red and white stripe) called a optokinectic nystagmus strip, which the CN moves horizontally in front of the patient's eyes to check how smoothly she can track the stripes as they go by (see photo below). This gives the CN information about processing activities in various centers of the brain (using the eyes as a window on brain processing is a core approach of chiropractic neurology).
Another test of eye movement used by CNs is called videonystagmography or VNG, in which the patient wears a pair of black goggles equipped with a camera that transmits live video of one eye to a monitor, enlarging and recording the information about brain processing provided by the eye movement. The chiropractic neurologist watches to see how the patient's eye responds to the way he moves her body and can replay the video for the patient so she can see how her own eye responds. Here are photographs of Heidi wearing the goggles, and of the monitor showing her eye.
New connections (neuroplasticity) are encouraged through various stimulations appropriate for the specific area of the brain injury. One specific brain area often damaged in a concussion is the vestibular system. Injury to the vestibular system may cause dizziness and/or dysfunction of the brain's vascular (blood flow) system, among other symptoms. When the blood flow is impacted, reduced oxygen and glucose to the brain can slow down the recovery.
CN employs a deep toolbox of non-invasive sensory experiences to gently stimulate (or calm) targeted areas of the brain or nervous systems to reduce neurologic imbalance and improve function and productivity. This toolbox includes selective environmental stimuli, such as very simple, non-strenuous, visual exercises; the use of specific colors and patterns of target lights, and other sensory therapies. Coincidentally, we had been taking Heidi to see Dr. K since she was 13 months old, related to her disability, so we have an ample bank of positive experience with CN as an aid to recovery from many conditions, and have referred many others to him, if the fit seems right. The CN also suggested getting into a pool and floating, or taking frequent baths, to lighten the load on the vestibular system, especially for her dizziness.
[NOTE: One technique often employed as a first therapy for dizziness is the Epley maneuver (or canalith repositioning maneuver) used to treat benign paroxysmal positional vertigo (BPPV). It is often performed by a doctor, chiropractor, or a physical therapist, after confirmation of a diagnosis of BPPV using the Dix-Hallpike. Canaliths are little crystals resting on a membranous cushion in your cochlea. Gravity pulls on them, and they tell you how your body is oriented in space. Sometimes they get mispositioned, causing dizziness and/or nausea. BPPV was not Heidi's problem; the Epley maneuver Dr. K tried left her feeling worse. Other CN therapies were very helpful, but the dizziness was eventually helped more by craniosacral therapy (CST), described below. We did not see an ENT or neurotologist for the dizziness.]
Part Three of the series "Unmarked Detour."
For more in the series, click here.
For a page listing related video segments featuring Dorothy Bedford, click here.
Dorothy Bedford is a mother of three from Princeton, New Jersey.
Posted January 26, 2012