The Concussion Crisis

by Linda Carroll

  On the drive home, Angelica sat quietly in the passenger seat, stunned by the mere suggestion that she’d suffered a concussion. In her mind, concussions only happened to the football players she would cheerlead for under the lights on Friday nights. Whenever she’d see one of them staggering around after a big hit, she’d think, “Thank God I don’t play football, ’cause I’ll never be in a position where that could happen to me.”

  The next day, the Kruths met with a pediatric neurosurgeon. All it took was a five-minute neurological test to confirm Ochs’s diagnosis of severe concussion. The neurosurgeon’s instructions were firm and frightening: “Angelica shouldn’t be going to school. In fact, she shouldn’t be going anywhere for quite some time. You need to get to a concussion program.” Kruth walked out of the doctor’s office with another stack of pamphlets on brain injury. Though she finally had an answer to explain what was wrong with her daughter, she now had a million questions about what it all meant. “Oh brother, is this really going to work?” she wondered. “At least now I know she’s got a concussion. But what all does that involve? And how are we going to fix this?”

  Kruth would have to wait two weeks before she could get any answers. It was football season, and the Pitt concussion clinic was so backed up that it was impossible to schedule anything sooner. When the Kruths arrived for their Monday morning appointment, the waiting room was packed. Even so, Mark Lovell spotted the pair immediately. Angelica’s long honey-blond hair, straight and neatly draped over her shoulders, was hard to miss. The slender, fine-featured teen was staring blankly out the window as her mother furiously scribbled down the latest of her concussion questions. Both were surprised when Lovell suddenly appeared and introduced himself. As they walked to the exam room, Lovell noted how wobbly and unsteady Angelica was. Once there, he guided her to a chair, and when she’d settled in, he asked for a description of the accident.

  Angelica told him that it had happened during cheerleading practice when she was rehearsing a stunt called The Helicopter. She explained how the stunt is supposed to work. She was the “flyer,” the one who gets tossed up in the air by four teammates. She would first be hoisted up in a horizontal position, with her back parallel to the floor. Her four teammates would then hold her aloft—one grasping her shoulders, another gripping her ankles, and the other two supporting her torso from opposite sides of her body. When everyone was ready, Angelica would stiffen her body and the four teammates would then fling her up several feet in the air with a twisting motion. She would rotate 180 degrees parallel to the ground and be caught by her teammates as she came back down. Only this time, the stunt went terribly wrong. The teammate who was supposed to catch her shoulders didn’t. Angelica crashed to the ground, completely missing the mat and smashing her chin on the gym floor.

  Wincing for an instant, Lovell asked Angelica if she remembered hitting the floor. She shook her head no. In fact, she said, the rest of the story she’d had to piece together from the scraps she remembered and from what her teammates told her later. “I really didn’t know what was going on,” she said. “I wasn’t aware of what actually happened to me. I remember the trainer came and saw me, and the coaches were there. They took me to the bathroom and wiped all the blood off and gave me an ice pack. I just sat there, I guess, for a little bit, and I just went back ten minutes later. One girl told me that I went back out and did the same stunt without even hesitating. And I think I did it a couple of more times.”

  Lovell then asked her what symptoms she’d been experiencing since the accident. She told him about the unrelenting headaches so excruciating that they often kept her awake through the night. She told him about the crushing fatigue that kept her in bed all day. She told him about the dizziness, the nausea, the balance problems. She explained that she couldn’t read anymore because she couldn’t get both eyes to focus on the same spot on a page.

  Considering how debilitating her symptoms were, Lovell wasn’t surprised when Angelica bombed on her first run-through with ImPACT. Once the test results were printed out, Lovell spread them across a small conference table for Angelica and her mother to see. He explained that Angelica would have to take it easy for the next month or so. Her scores revealed that her mental processing was now slower than that of 95 percent of the kids who take the test and her memory was almost as dramatically impaired. Lovell looked at Doreen Kruth and said, “By Pennsylvania law, she’s legally handicapped.”

  Noticing the frightened look on Kruth’s face, Lovell immediately tried to reassure her. The good news, he said, is that most kids got better after a month or so of rest. For the minority who didn’t improve on their own, he could offer newly developed rehabilitation techniques, including medication and physical therapy. Kruth asked why they couldn’t start the rehab right away. “She’s not ready for that yet,” Lovell replied. “Her brain needs time to calm down. Right now, rest is the best medicine. She needs to stay home from school. She should have a quiet room with no bright lights. She shouldn’t do anything even remotely taxing to the brain. The most I’d allow her to do is watch TV.”

  After a month of rest, Angelica’s symptoms were still so severe that she could watch TV only when the sound was off. It seemed as if the most innocuous stimuli could spark a headache. Some days even the twenty-minute drive to the clinic was enough to make Angelica’s head throb so intensely that Kruth would have to turn the car around and return to their suburban Munhall home. In an effort to get the headaches under control, Lovell began experimenting with medications designed to prevent migraines.

  The drugs helped ease the headaches enough for Angelica to start working on her vision problems. At first, her vision was so impaired that if a page contained a single word, like “cat,” she could tell that there were letters but she couldn’t make out what they spelled no matter how large they were; the harder she tried to read the word, the harder her head would pound. To help her relearn to focus her eyes, therapists held a pencil inches from her nose and asked her to follow it only with her eyes as they moved it several feet away. In another exercise, she was told to stare at a word on the wall and turn her head from side to side without taking her eyes off of it.

  As her vision began to improve, Angelica was able to start working on her balance problems. For months she struggled to make it through a rudimentary obstacle course. Therapists would place a shoebox in the middle of a hallway. Sometimes she would be asked to walk around the box, sometimes she’d be asked to step over it. Often that was too much of a challenge and she’d trip. In another exercise, she would have to grab an object off a shelf. Invariably, as she reached up, she would get dizzy, lose her balance, and start to fall.

  For Angelica, the process was all the more frustrating because she had been an accomplished competitive diver before the accident. She took great pride in the exquisite sense of balance and body control she’d developed through years of practice. Now, whenever therapists asked her simply to stand with her eyes closed and arms extended, she’d start to topple over. Sometimes she’d bemoan the loss of those diving skills to her therapists: “It’s like getting a really good gift for Christmas and then having to take it back.”

  Doreen Kruth watched her daughter struggling day after day through hours of grueling therapy and saw only the subtlest signs of improvement. During the day, Kruth would sometimes be overcome by a feeling of helplessness. At night, she’d lie awake in bed for hours, staring at the ceiling, wondering whether Angelica would ever get better. She still didn’t understand exactly what had gone wrong with her daughter’s brain and how they were going to fix it. Some nights the anxiety got so intense that she would climb out of bed, find a hiding place where no one could hear her, and just let it all out. She would sob quietly and pray that everything would eventually turn out all right. When morning came, Kruth would push the doubts and fears from her mind because she knew she needed to be the cheerleader’s cheerleader.

  When Kruth took her fears to Lovell, he reassured her that Angelica would
eventually get better. “We’ve just got to hang in there,” he told Kruth. “Time heals most of these injuries, but there are some people we see, particularly kids, whose systems need to be nudged along. Sometimes people really do need that nudge.”

  Research had shown that a medication called amantadine could speed recovery in people with severe brain injuries, and Lovell wanted to try it with Angelica. A mild stimulant, the drug had been shown to speed mental processing and to sharpen concentration. For the first time in months, Angelica started to feel like her old self. Her symptoms began to abate gradually. She was still getting headaches, but she’d get more work done before one would terminate a rehab session. Words were now coming into focus, and she felt less dizzy. Six months after the accident, her ImPACT scores had improved enough for Lovell to clear her to go back to school on a limited basis.

  Kruth knew she would need to do a lot of educating before her daughter could return to Steel Valley High School. In the Pitt waiting room, she’d met many frustrated parents who told her horror stories about schools that didn’t grasp the seriousness and severity of concussions. Sometimes it was administrators who refused to make any accommodations; sometimes it was teachers who put impossible demands on kids whose brains were still foggy and slow.

  In an attempt to avoid problems like these, Kruth set up a conference with school administrators and teachers. She walked into the meeting clutching a folder stuffed with Angelica’s medical records. Laying the folder on the conference table, Kruth pulled out the first of Angelica’s ImPACT tests and said, “This is where my daughter started. With scores like these, under Pennsylvania law, she was legally handicapped.” Kruth then pulled out the most recent test and said, “Here’s where she is now. As you can see, she’s still not at one hundred percent and that’s where we need to get her. Now I know that’s a pretty tall order, but we are very determined people.”

  Kruth left the meeting with a sheet of paper detailing a plan for her daughter’s transition back to school. To ease back in, Angelica would be allowed to attend school for half days. To minimize the risk of another concussion, she would be allowed to go late to classes—after hallways had emptied of other students.

  Some of her teachers got it, and would come up with their own ways to make Angelica’s job easier; if there was a book assigned to be read, for instance, they would allow her to watch the movie instead. Other teachers grumbled about the new plan and privately suggested that Angelica might be faking her symptoms to have an excuse to skip class and still get good grades.

  One time, after Angelica became dizzy from constantly looking back and forth between the blackboard and the notes she was taking, she raised her hand and asked to be excused. Clearly irritated, the teacher responded, “If you don’t want to do anything in this class, then get out. I’m not going to have somebody who sits here and complains. Kids come through my class every day with a concussion. If you don’t want to work, just get out.”

  Dealing with the doubting and disbelieving teachers was hard enough, but what distressed Angelica the most was the response of her friends and classmates. Sometimes as she was walking down the empty halls to her next class, she’d overhear students talking about her through half-closed classroom doors: “She’s just wasting our time, ’cause nothing’s even wrong with her.”

  When Angelica stopped by cheerleading practice to visit, some of her teammates just glared. They’d taken to shunning her in the lunchroom, insisting she was being melodramatic and trying to grab attention. They’d all fallen at one time or another and none had sustained a concussion. Besides, they’d seen football players bounce right back from concussions and they couldn’t understand why a cheerleader would be out of school for six months after the same type of injury.

  Angelica got even less sympathy from the football players themselves. One of them told her, “I don’t understand. I had a concussion. I was even knocked out and had to have a facemask with oxygen—and I was back the next day. What’s your problem?”

  While Angelica was struggling to make it through her half days at school, she continued with her rehab program in the afternoons. Three days a week, she’d go over to Pitt and work on her balance and coordination. She could walk on the treadmill now, but she’d have to hold on to the sides to keep from losing her balance and toppling over.

  There were days when she’d come straight home from school and just sit, staring at the walls, too exhausted to do anything after only four classes. “I’m never going to get back to where I was,” she’d tell her mother with a sigh. “I’m never even going to be able to go a full day.” Even though Kruth secretly worried the same thing, she never let on to her daughter. “You can never give up,” she’d say. “You have to go to therapy. You have to fix this. You can still get back.”

  Angelica kept at it, telling herself that even if she couldn’t make it all the way back, it would be an accomplishment to make it through a full day at school, to be able to walk up and down stairs without worrying about falling. “If I could just sit here for eight hours and just have it on the attendance record that I was here, maybe that’s what I have to settle for,” she’d think.

  Angelica was getting better, but the signs were too subtle for her to see—until the day she managed a short walk on the treadmill without holding on to the sides. The speed was set at just 1.5 mph, but she was beaming. It had been nine months since her fall and for the first time she started to think she might make it back. The pace picked up after that, with each week bringing a tiny victory. Angelica’s sense of balance returned and she was able to actually run on the treadmill.

  Thirteen months to the day after the fall, Angelica and her mother were back at the concussion clinic, meeting with Lovell. “When we first met,” he said to Angelica, “I told you that we’d know you were done when you had no symptoms at rest, no symptoms with exertion, and a good ImPACT test. Now that your symptoms are gone, I could clear you for diving if your test scores are where they should be.”

  Angelica was so confident she’d ace the test that she ventured, “What about cheerleading?”

  “If you want, you could go back to cheerleading,” he replied. “You could even be a flyer again if you want, but I don’t think that would be smart. Before we even get to that, let’s see what your test scores are like.”

  After Angelica finished the test, she rejoined her mother to wait for the results. When Lovell returned with the printouts, he was smiling and shaking his head.

  “This is amazing: you got a hundred percent on two of the sections,” he said. “That’s not even supposed to be possible. I designed the test so that nobody gets a hundred on it.”

  Angelica punched her fist in the air and hissed a barely audible “Yes!” She could barely resist the temptation to jump up and do a little victory dance.

  After letting it all sink in, Doreen Kruth turned to Lovell and asked, “Does that mean we’re done?”

  Lovell leaned back in his chair, stroked his goatee, and paused for a few seconds. “Yes,” he said, breaking into a grin, “I think you are.”

  Chapter 7

  Anatomy of a Brain Injury

  For most people who sustain a concussion, there is no way to document the damage, no way to explain the bizarre and wide-ranging symptoms they experience each day, no way to prove beyond any doubt that there’s actually an injury. Conventional brain imaging methods—MRI machines and CAT scanners—will show no indication of damage. The same is also true for many patients with severe closed-head injuries. The only way doctors can determine that something serious has happened to the concussed brain is by cataloging the patient’s deficits. Even without visible proof, specific symptoms can be linked with damage to localized regions of the brain. When a patient’s short-term memory becomes muddled, for example, doctors can assume that something has gone wrong with a deep brain region called the hippocampus.

  Figure 7.1: Architecture of the brain

  The profound discovery that brain functions were local
ized came about over the last couple of centuries as scientists studied patients with damage that was both visible and limited to a discrete area of the brain. Prior to the discovery of localization through those famous patient studies, many scientists thought that the whole brain participated in every function. Three classic case histories provide a window into some of the most common concussion symptoms.

  I

  By all rights, Phineas Gage was a dead man the instant he dropped his custom-made tamping iron down into the blast hole and accidentally ignited the gunpowder he’d just poured. The iron rod—weighing 131/4 pounds and stretching 31/2 feet from its pointed tip to its flat base 11/4 inches in diameter—blasted back upward like a missile, pierced his head just under his left cheekbone, ripped through the left frontal lobe of his brain, and burst out the top of his skull above the hairline. Gage was instantly thrown flat onto his back, and as the iron clanged to the bedrock a hundred feet behind him, the workers in his construction gang rushed through the smoke to his aid, stunned to find him convulsing and conscious. They watched in amazement as he slowly sat up and then, after a few minutes, started to speak while blood poured down his face.

  Since it was 1848 in the middle of the Vermont countryside, the workmen had to transform an oxcart into a makeshift ambulance to take their fallen foreman to the small town where they were all staying while building the railroad. Gage propped himself upright in the flatbed for the ride back to his hotel. Once there, he stood under his own steam, walked up onto the porch, and sat himself down on a chair to await medical attention. If his men were shocked by everything they’d witnessed in the half hour since the blast, the first doctor on the scene would be positively astonished.

  Before he could alight from his horse-drawn carriage, Dr. Edward Williams was struck by the gaping wound in the head of the man chatting away on the porch, the brain’s pulsations visible even from that distance. Observing the wound up close, Williams couldn’t believe the man was still breathing, much less talking and joking. The raised shards of bone atop Gage’s head reminded Williams of “an inverted funnel,” brain matter oozing up through its apex and hanging in shreds on his matted hair. Throughout the examination, Gage related details of the accident clearly and entertained questions from curious onlookers. No matter how rational and lucid Gage sounded, Williams couldn’t believe this tale. When Gage insisted that a rounded tamping iron had indeed shot through his skull, Williams shook his head in disbelief. Finally, one of Gage’s workmen offered the doctor eyewitness testimony. “Sure it was so, sir,” the man asserted in an Irish brogue, “for the bar is lying in the road below, all blood and brains.”