On a cold fall day, two field hockey teams began to warm up for one of the last games of the season. Players began to stretch, practice passing, and do warm up drills. One team was shooting on the goalie, and the other began to run a few laps around the perimeter of the field. As the team was running, one player suddenly stopped short and tied her shoe, but the player behind her was caught off guard. The two crashed into each other. Brushing it off as a harmless run in, the two went back to warming up. The game began and was played normally, except that the player who tripped over the girl tying her shoes felt sluggish and was not playing like usual. Time would soon reveal that she had a concussion1.
The girl in the story above was me. In my junior year of high school, I got a concussion that turned my world upside down. I suffered from headaches, fatigue, sensitivity to light, and an inability to focus. Even the simplest task became daunting. I was affected academically, socially, and emotionally, and although I was lucky because my concussion was relatively minor, I still felt the its effects for a long time to follow. The recovery process put me behind in school and while I tried to catch up, it was difficult to learn. I struggled to grasp concepts and draw connections as quickly as I could before. My symptoms eventually subsided and I could live my life again.
I am not a unique case and often the effects of concussions are much more severe and lasting. That same year, two other girls on my team also suffered from concussions. One teammate had to be hospitalized overnight. Another soccer and lacrosse player at my school, Kristin Sutton, had so many concussions that she was no longer allowed to play contact sports. In an interview with Sutton, she discussed how multiple concussions affected her life. Sutton stated, "My grades declined substantially...I was less social because being around people hurt my head like hell. The first one [concussion] lasted for about three months, the second three weeks. All I was told to do was rest, but that just left me frustrated." Sutton's story and my own represent just two of the many concussions that occurred at my high school alone. In fact, our injuries make up only two cases out of the 3.8 million athletes that sustained concussions that same year in the U.S. ("Concussion and Sports"). To make matters worse, this number has doubled in the past decade ("Statistics"). The sheer numbers alone illustrate how widespread this injury has become, showing how important it is to protect our brains.
Concussions directly affect our most vital and complex organ: our brain. Even though it is fragile, weighs three pounds, and is composed of soft tissue, the brain is our body’s control center. It is made up of 100 billion neurons that send and receive information throughout the brain and body. Signals are primarily transmitted through the axon, the tail end of the neuron (“Fascinating Facts”). When a person gets a concussion, the brain slams against the skull. This impact causes axonal shearing where the axons stretch or tear, resulting in either impaired or complete loss of signal transmission. This shearing causes the release of neurotransmitters that in turn kill off healthy neurons in the brain (Concussion/Traumatic Brain Injury (TBI)). The sudden impact also causes rotational movement that results in a coup and contrecoup injury, or bruising at the point of collision and directly across from it that can lead to long term brain damage (Smayda). The research behind the exact science of what happens when a concussion occurs is imperative to better understanding the injury and methods of treatment—it also explains the wide range of symptoms.
Concussion victims suffer a slew of symptoms that vary based on the extent and area of the trauma. Contrary to popular belief, only 5-10% of traumatic brain injuries cause loss of consciousness or amnesia. In addition, 47% of people who have a concussion do not initially feel symptoms. A study by the Sports Concussion Institute found that athletes with concussions most commonly feel headaches (85%) and dizziness (70%-80%) (“Concussion Facts”). Other symptoms include, but are not limited to, memory loss, vestibular problems, headaches, sensitivity to light, and blurry vision (“Concussion Signs”). Due to the wide range of symptoms of a concussion, it is difficult to determine the degree of the injury.
There is currently no definitive test to diagnose concussions, due to the nature of the injury. Sean McCoy in “The Worst Part About Recovering from a Concussion” from The Atlantic quotes Dr. Robert Siman, a researcher and professor of neurosurgery at the University of Pennsylvania, who remarks that “doctors continue to rely on…indirect measures of brain function to determine the extent and severity of a concussion.” Aside from patient feedback and symptom observations, the only concrete “evidence” that doctors have to understand the extent of the injury and estimated recovery time are imaging and cognitive tests.
Imaging tests show doctors physical disturbances the injury may have caused. The common imaging tests are the magnetic resonance imaging test (MRI), or computerized tomography (CT) scans. An MRI scan uses a magnet with a strong magnetic field to create a detailed picture of the body on a computer. A CT scan uses x-rays to develop a picture of the body on the computer (“Understanding Brain”). However, a study published in the Clinical EEG and Neuroscience journal found that these machines do not always pick up on brain abnormalities (“The Usefulness of Quantitative”). While imaging tests are providing doctors with a glimpse into the damage of a concussion, the technology is lacking and is not always effective in identifying the extent of the trauma.
Cognitive testing, on the other hand, focuses on gauging and assessing the patients’ symptoms and cognition. It is a preventative test typically for someone who is at risk for a concussion, like contact sport athletes. The baseline test is taken before the concussion risk activity begins. This test quantifies memory, symptoms, and reaction time through a series of problem solving and memorization exercises. The program then compiles this data into a score (“ImPACT Test”). Then, if users eventually have a concussion, they will retake the test and their score will indicate symptoms and severity. However, like imaging testing, this method of “measuring” concussions also has its flaws. In 2007, researchers tested the accuracy of the commonly used ImPACT test by comparing the baseline scores of athletes to their scores 40 to 50 days later. None of these students sustained a concussion within this time frame, yet their later scores significantly differed from their baseline scores (“Researchers Question”). While imaging and cognitive testing give doctors some insight into concussions, there are still problems. But even when the diagnosis is made, all concussion victims receive the same prescription: rest.
Rest is the first line of defense when dealing with concussions. Like with any injury, there needs to be time for healing and recovery. In order to “rest” the brain, it is recommended that concussion patients abstain from any activity that would stimulate their minds or bodies. The patients must refrain from exercising, learning, using technology and even thinking. In their article “Continuing Medical Education and Disclosures” from the journal Hepatology, Roger Härtl, M.D., researcher in the Department of Neurological Surgery at Weill-Cornell College of Medicine, and Kenneth Perrine, Ph.D., a clinical neuropsychologist from New York-Presbyterian, conclude that during and after a concussion there is a critical period of recovery and how one recovers during this period is crucial. This information is essential because it indicates that there is brain damage during a concussion that is reversible, but only with the right treatment at the right time. Naomi J. Brown, MD, a doctor of sports medicine at the Children’s Hospital of Philadelphia, is at the forefront of this research. The study, “Post-concussion Cognitive Rest: How Much Time Is Enough Time?” published in Medscape found that concussives who had more cognitive rest healed faster than those with more activity, likely preventing permanent brain damage. Thus, this growing research suggests physical and cognitive rest is necessary to heal a concussion.
Yet, how much rest is enough? An average concussion should heal within approximately two weeks to a month (“HealthDay”). But what happens after this time frame passes and the concussion is still around? Sadly, 15% of the people who have had a concussion, even if they rest, do not get better after a year (“Concussion Facts”). The medical community tells these people to live with their symptoms because they are told they are never going to get better.
Clark Elliott, an artificial intelligence professor at DePaul University, faced this difficult diagnosis after a minor car crash left him with a concussion (Elliott 19). Elliott writes about his eight-year struggle and path to his neuroplasticitic recovery with his concussion in The Ghost in My Brain: How a Concussion Stole My Life. Due to the extent of his injury, Elliott faced many typical symptoms of a concussion but to a much greater degree (Elliott XV). Every time he tried to focus or perform a task he would feel extreme nausea and confusion. He recalls being unable to make decisions, initiate actions, visualize, or compare—he could not even articulate what was wrong with him (Elliott 119). His old life became a distant fond memory and his new life boiled down to just getting by: “As long as I did not have to think and could avoid certain tasks and there were no demands on my balance system, I was more or less functional” (Elliott 234). Elliott lived with this debilitating condition for eight years. Even after visiting countless doctors and searching for a cure, there was no treatment in sight.
That was until Elliott met Donalee Markus by chance through a mutual acquaintance (Elliott 201). Markus, a Ph.D graduate from Northwestern and founder of the Design for Strong Minds (DSM) program, has done extensive research in traumatic brain injuries in adults and has helped hundreds of concussives recover (Markus). The basis for her DSM program stemmed from her work in 2007 when Markus published a study in Physical Medicine and Rehabilitation Clinics. Markus developed a rehabilitation system that uses puzzles and the DSM mediation technique. The program is designed to target and strengthen the weaker functioning and damaged parts of the brain through directed brain activity for certain periods of time. This system successfully creates new connections within the brain that allow patients to return their injured brain to their “normal” state (Markus). The theory behind why Markus’s DSM puzzle sets and mediation practice work is rooted in neuroplasticity.
Neuroplasticity is a relatively newly accepted idea in the scientific community that the brain is “plastic” or changeable. Norman Doidge, MD, psychiatrist, psychoanalyst, and researcher, explains the ideology of neuroplasticity and its scientific basis in his book, The Brain that Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science. Doidge explains that it was previously thought that the brain was rigid and fixed. Therefore, the medical community believed that “people who were born with brain or mental limitations, or who sustained brain damage, would be limited or damaged for life” (Doidge 2007, xviii) However, there is increasing evidence that this is not the case. Doidge has documented numerous incidents where “without operations or medications, patients have made use of the brain's hitherto unknown ability to change…patients who had what were thought to be incurable brain problems” (xvii). According to this theory, the brain has the ability to reorganize and rewire itself by forming new neural connections. For long term concussion patients, this means that there is hope for recovery.
Elliott’s first session with Markus consisted of countless tests and analysis. Elliot was asked to describe his current symptoms and past treatment attempts. The most shocking test result was when Markus asked Elliott to rewrite a complex geometric line drawing (Elliott 207). As Elliot began to draw: Within a minute I began to lose normal control over my muscles…Over the course of the next five minutes, my symptoms steadily declined…I hunched over the paper with my head twisted sideways, about six inches from the table…The paper got bunched and wrinkled as my left hand, holding it, became increasingly contorted…[Markus’s] assistant was on the verge of calling 911. (Elliott 207-08) Elliot’s vivid description about how copying a drawing evoked such a violent and extreme reaction is telling. It clarifies just how much he truly suffered and how desperately he needed treatment. Even Markus, a professional in the field, was taken aback by the severity of his injury. From that test, Markus determined that Elliott had an “unworkable cognitive load,” meaning that a significant amount of energy and effort was required for Elliott to think (Elliott 206). The session continued with a variety of tests. At the end of the meeting, Markus was able to pinpoint Elliott’s deficits: balance, vision, hearing, visual/spatial patterns and relationships (Elliott 211, 227-29). While using these tests to diagnose a concussion may seem unorthodox, it is a highly precise and accurate method of diagnosing the damage a concussion has caused, whereas more traditional methods only indicate if a person has a concussion.
Markus’s detailed assessment of Elliott’s symptoms allowed her to tailor the program to fit Elliott’s specific needs. Markus used her DSM problem sets to target Elliott’s weaker brain functions and forced his brain to rewire pathways. His personalized problem sets began with a focus on two-dimensional shapes. Elliott’s task was to perform many connect the dots problems. While this may sound simple and mundane, those suffering from such an extensive traumatic brain injury need to train the brain from a childlike beginning. When Elliott mastered simple two dimensional shapes, he progressed to more complex three dimensional shapes and drawings. As the problem sets increased in difficulty, the instructions became vaguer thus promoting higher level thinking. The systematic approach ensured that his damaged brain was correctly learning how to function. As Elliott began to finish up the problem sets it was clear that Markus’s neuroplastic methodology was working; Elliott was getting better. Markus was successfully using neuroplasticity, on a small scale, to heal Elliott and, on a larger scale, to change the way long term concussions are treated.
While Elliott was working on altering his current brain pathways with the problem sets, Markus recognized that Elliott was having trouble with his vision and balance (Elliott 227). She referred Elliott to Doctor Deborah Zelinsky, a neuro-optometric rehabilitation specialist (Elliott 212). Zelinsky’s work focused on the relationship between those with traumatic brain injuries and their retinal signal processing, spatial orientation, motor planning, and motor control. In 2007 and 2010, she published two studies that had major findings. First, Zelinsky found that there is critical information from the body’s visual systems that can be imperative in evaluating and treating patients with traumatic brain injuries. This is key information for doctors because it shows there is another method of diagnosis that may be more accurate than the current methods. Second, Zelinsky discovered that traumatic brain injuries impact connections within the brain, thus leading to these numerous problems. These findings are crucial because it provides proof that in a concussive’s brain connections are broken, so focusing on rewiring the connections in the brain is the correct method of treatment. As in the case of Markus, Zelinsky’s treatment methods are rooted in neuroplasticity, the knowledge that, with the proper methods, the brain is changeable and can rewire itself.
Zelinsky assessed Elliott’s condition by manipulating light through his retina to access the brain. Zelinsky then used light to emphasize and increase the use of certain pathways. Using this form of light therapy, Elliott’s healthy tissue relearned how to properly function through habituation (Elliott 248-250). Zelinsky also designed glasses for Elliott that were not used for sight but, rather, to change how his brain saw the world. These lenses were structured as prisms that are thicker towards the center and thinner towards the end (Elliott 251). This directed light to certain parts of Elliott’s retina. With the assistance of these glasses, he was able to walk without balance problems for the first time in eight years (Elliott 226). After some modifications, Zelinsky found the correct combination that allowed Elliott to regain normalcy (Elliott 215). Although Elliott still wears these glasses to this day, his overall success speaks to the extraordinary potential of neuroplasticity and its applications for long-term concussion treatment.
Growing research in the field indicates that both Markus and Zelinsky are on the correct path of treatment. Anita Saltmarche, a nurse and researcher from the Ontario laser company, came to similar conclusions as Zelinsky about using light therapy to heal traumatic brain injuries (Doidge 2015, 128). Saltmarche is currently researching the potential of this treatment and how it works on a cellular level in an ongoing study with other researchers from Harvard, MIT, and Boston University (Doidge 2015, 129). She also used light therapy to treat a patient that suffered a concussion after a minor car accident. Like Elliott, this woman suffered for seven years before successfully being healed by this method. Saltmarche’s approach to light treatment was to shine red and infrared range LED lights at the woman’s head. Immediately after the first treatment, the woman saw some relief in her symptoms. As her treatments continued, her symptoms decreased. While this treatment is working, it must be continuous. If it stops, her symptoms come back. Saltmarche is continuing to revise her technique in order to make the woman completely symptom and treatment free (Doidge 2015, 129). Saltmarche’s method also requires that her patients undergo some type of continuous treatment like Zelinsky treating Elliott, but Saltmarche’s initial success is another testament to the possibilities in this field.
Elliott witnessed first-hand how neuroplasticity can drastically change one’s life. After eight years of enduring the drastic negative effects of a grueling concussion, in less than two weeks Elliott felt a major change. The results were remarkable. Elliott, someone who was diagnosed as untreatable, was practically healed. By targeting his weaker areas using habitual practice and light therapy, Markus and Zelinsky had retaught his otherwise “permanently” damaged brain. Elliott noted that his “plastic brain was performing its magic” (Elliott 263). The professor who endured eight long years of debilitating function regained control of his mind.
Concussions are endemic in our society: a traumatic brain injury that is seen across all ages, demographics, and cultures. The current route of treatment for concussions is to rest until the symptoms reside. This method works for some concussives, but at a certain point the current protocol of treatment becomes ineffective; rest can only do so much. For those with long term brain injuries that do not get better, there is growing evidence in the field of ophthalmology, neuroscience and rehabilitation that supports the idea that having short and directed brain activity and light therapy during recovery can help the injured heal faster, and with less lasting damage. Considering the growing frequency of this injury, the drastic rehabilitation Elliot underwent, and the potential for further research and development, the possibilities for alternative treatments is exciting. With the research that is to come, I am confident that neuroplasticity holds the key for profound changes in how we respond to long term concussions.
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