What is a TBI?
TBI is a Traumatic Brain Injury. These injuries can range in severity from mild to life threatening. A concussion is currently considered a mild TBI induced by an injury to the head or the body that causes temporary changes in brain function. Notably, the term TBI in all the information provided is used interchangeably with the term 'Concussion'.
Our understanding of brain injuries, and how individuals recover, especially those with multiple concussions is evolving. Therefore, it is important to seek medical help for concussions as soon as possible. A critical fact to remember about TBI is that these injuries are often not outwardly visible, making it difficult for those involved in the care and recovery of the individual to recognize the extent of the injury. Using an analogy might help when considering the recovery process for TBI. When a person sprains an ankle, the ankle swells and is painful. It is difficult to stand or walk on the ankle. It can take several weeks for the ankle to recover. If the person with the injured ankle continues to run on the ankle, it takes longer for the ankle to recover, and further damage might be done. Likewise, if an injured brain is overused before it can recover, healing may be prolonged and the brain may be exposed to further, sometimes irreparably.
Thus, in order to understand the significant impact of TBI's it may help to be better informed about the basic facts of TBI.
The Injury Process:
When a brain is injured, there is a decrease in blood flow to the brain, a release of chemicals which can injure brain cells, and depleted glucose in brain cells. We do not know how this process differs amongst different individuals, yet the brain is vulnerable at this time to further injury. You would not run on a sprained ankle that is painful and healing, and likewise you should not overuse a brain that is injured and healing.
Symptoms of TBI are classified into 4 domains:
Headache, confusion, disorientation, staring, appears dazed and / or stunned, light sensitivity, blurred vision, double vision, nausea, dizziness, ringing in the ears, balance problems, noise sensitivity, incoordination, slurred speech, neck pain, loss of consciousness.
Concentration and/or memory difficulty, feeling mentally ‘foggy, groggy, and/or hazy’, forgetfulness, slowed processing of basic information and/or answering questions.
Sadness, nervousness, unusually angry and/or irritable.
Sleep / Energy
Mental fatigue, drowsiness, sleeping too much or too little, difficulty initiating and/or maintaining sleep.
Treatment of TBI:
There are no shortcuts to treating individuals with TBI. Our school district in concert with the 'Concussion Task Force' has developed a treatment program which adheres to National and International standards of current clinical care for individuals with mild TBI (concussions).
The basis for the treatment protocol is derived from the thoughtful work of the REAP program developed by Dr. Karen McAvoy, PsyD | Director, Center for Concussion, Rocky Mountain Youth Sports Medicine, Centennial, Colorado.
Important components of the REAP program include:
R - Remove/Reduce physical and cognitive, or mental demands (avoiding activities that could either lead to another hit to the head such as sports, skateboarding, skiing, bicycling, etc. and / or increase heart rate and blood pressure which can compromise brain healing)
E - Educate the student athlete, families, educators, coaches and medical professionals on all of the potential symptoms
A - Adjust/Accommodate for the student athlete academically (neurocognitive or brain rest, which involves avoiding activities that work your brain overtime during healing such as school work, reading, watching television or a computer screen, using cell phones, etc.)
P - Pace the student athlete back to learning, activity, and play
Individuals often feel significant 'external pressure' to return to activity before they are ready to do so. Expectaions of parents, friends, teachers and coaches are often driven by the fact that symptoms are 'invisible' which creates an inherent difficulty to judge the severity of the TBI. The individual often seems 'normal' and onlookers cannot estimate the severity of the problem. Referring back to the ankle sprain analogy, if an individual is limping, onlookers have an objective sense of the problem, which is lacking in those with TBI.
Although it is important to rest the brain to facilitate optimal healing, recent research has shoen that 'strict rest' and 'social isolation' during the early phases of the recovery process can actually be detrimental to an individuals mindset and prolong symptom duration. Too much 'lying around' and 'being away from friends' is ill advised. It is highly recommended that individuals chalk out a carefully balanced plan for rest in consultation with their health care provider who is well versed in understanding the various nuances of good concusion management.
Recovery time can vary between individuals and is based on various factors including a prior history of TBI, strict adherance to the treatment plan, and social and genetic factors. In general, most individuals recover within 3-4 weeks and can safely return to a graduated return-to-play or activity protocol FOLLOWING adequate documentation from their school counselor showing that they are functioning at their 'academic baseline' ('return-to-learn'). Persistent TBI symptoms indicate that an individual needs a longer recovery period and 'PATIENCE WITHOUT EXPECTATION' for arbitrary return-to-play timelines can be exceedingly stressful and detrimental to meaningful healing.
Getting back to usual activities:
The most expoeditious path to recovery is 'PATIENCE'. Compliance with your health care provider's recommendations will help you immensely. 'RUSHING' the recovery process does not help your brain do its job! Akin to the fact that you cannot run on a sprained ankle, you cannot expect to ask your brain to function during recovery.
During the initial phases following a TBI, avoidance of activities that stimulate the brain such as reading, video games, screen time, prolonged social interactions and regular academic activities. No doubt, these recommendations are tough to adhere to in the modern world with our dependence on a plethora of audio-visual devices linked to numerous social media which seems to be the core of our ability to communicate with others. And while these recommendations may be intuitively boring, remember your brain is suffering as a consequence to decrease in blood flow, a release of chemicals which have injured brain cells, and depleted glucose in brain cells. Asking your brain to perform with these deficits is almost unfair to the brain which is trying its best to recover.
Typically, after your symptoms improve, you should be able to return to school and mental activities such as reading, using social media, and other light mental tasks. General guidelines dictate that return to school should be encouraged after you can tolerate 30 to 45 minutes of concentration (such as reading) without increasing the severity of symptoms. However, academic adjustments at school are critical to meaningful, timely recovery. You will need help from your teachers to limit course load, shortened class days, provide time for scheduled breaks, and postpone tests.
After your health care provider has determined that your clinical examination is normal, you do not need any academic adjustments, your neurocognitive status is normal, AND that you do not have any TBI symptoms OR are using any medications to treat TBI symptoms, you will be cleared for a graduated 4 stage return-to-play or activity program (as per Zurich Guidelines).
If TBI symptoms recur during any stage of the 4 stages graduated return-to-play or activity program (as per Zurich Guidelines), you will be advised to return to the previous stage.
It is important to realize that although reserach is ongoing, current medical data has not demonstrated any tangible benefit from the use of medications to enhance speed of recovery from TBI. Yet, certain medications may be advised to help reduce symptoms such as headache, nausea, dizziness, or insomina. It is recommended that you consult with your health care provider prior to using any medications.
THE TAKE HOME MESSAGE:
Most individuals eventually resume normal activities.
TBI is often an 'invisible injury', which may preclude 'patient understanding' from parents, friends, teachers and coaches.
However, you owe it to yourself to be patient, to follow the advice of your health care provider, and stay positive. Because at the end of the day, no matter whether you play sports in school, college or professionally, your brain will sustain your existence - mentally, socially, financially for life!
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(**This section was developed with the assistance of R. Gregory Doyle, M.D.)
Some of the information on this website was adapted and used with permission from the Center for Concussion, Rocky Mountain Hospital for Children.