Family doctor

What is concussion?

We all know the typical story of someone who gets concussed - they are knocked out playing football and wake up at the side of the field dazed and confused. They are taken to the Accident Department of the local hospital and after an hour or two they are well enough to go home. They feel bad for twenty-four hours, go back to work a couple of days later, and in a month have almost forgotten the whole incident.

Unfortunately this isn't the complete picture - many people have unpleasant symptoms for several weeks after being concussed, and in a few of them the problems may last much longer.

Most people are unaware that this can happen and they may become very concerned, anxious and sometimes depressed. They may be afraid that they have 'brain damage' or that they will never get back to being normal. They may make wrong decisions about their future, and can lose the sympathy and understanding of their family and friends.

The good news is that these unpleasant symptoms don't last forever, and that if you manage them properly there should be no long-term ill effects.

Symptoms that most people have in the two weeks after concussion

Tiredness

After concussion your brain seems to have less energy. Even after a little effort you are likely to feel worn out and be unable to go on. You will want to go to bed early and sleep longer.

When you feel like this, don't be ashamed to rest or go to bed. Your brain is telling you that you need rest - listen to it. If you struggle on, you will only make yourself even more tired and less able to cope.

Poor concentration

Concentration depends on being alert, and it's the first thing to fail when you get tired. If you are tired and can't concentrate, rest. If there's something you must get done, start it when you're fresh after a sleep, and stop as soon as your attention begins to fade. If you haven't finished, have a rest and then try again.

You may find that you forget where you put your glasses or what you went to the dairy for, but that you can remember as well as ever what happened a year ago. This is partly because you're concentrating badly, but also because concussion puts the memory system out of order for a while. Don't be alarmed, it will get better. Meanwhile, concentrate when you want to remember, and make notes of theimportant things - this will not stop your memory recovering.

Irritability

Often people who have been concussed find that they are easily annoyed by things that normally wouldn't worry them. They lose their temper for nothing, snap at the family or their workmates, and perhaps get themselves into trouble because of it. This occurs because self-control, like concentrating and remembering, needs a brain that's fresh and working well.

The first thing to do is to be on the watch for it happening. If you feel your irritation is going to burst out, it's important to turn away, go out of the room, take time out. Relieve your tension by learning ways to relax - we'll mention this later - or use up your aggression by taking exercise or hitting a punch-bag.

Noise

Putting up with noise needs brain energy, and people find it difficult after they have been concussed. Children playing, a loud radio or machinery at work may be unbearable. The only remedy is to avoid the noise - ask the family to help you by turning the volume down, or get the grandparents to take the children for a day or two.

Dizziness

Concussion sometimes upsets the balance organs in the ears, and for a short while after the injury a sudden movement of your head can give you vertigo, so that the world seems to spin round you. More often people have a feeling of unreality or floating, which they describe as dizziness. Both these settle down in time, but they can be disturbing if you are not prepared for them.

Clumsiness

When you are recovering from concussion you may find that you bump into people in the street, or drop the dishes when you're drying them. Again, this is your brain reacting more slowly and being less efficient than usual. Take it as a warning that you should take special care when there could be danger, like crossing the street, and of course you shouldn't be driving your car if you are reacting slowly.

Eye problems

After concussion people often find that bright light worries them, and that it helps to wear sunglasses, even indoors. Sight is sometimes a little blurred, either because the eyes are not focusing well, or because they are not lining up correctly. Again this is the result of the brain not working as well as usual. This almost always comes right on its own, but get expert advice if it doesn't get better.

Headache

Headaches can be expected in the early stages because of the bruising from the injury. Later they are often due to tiredness and stress, when you are asking your brain to do more than it's capable of. This sort of headache can usually be relieved by resting, but it is best to prevent it by working within the limits of your fatigue. Headache pills often don't make much difference to this sort of pain. If the headache is severe and will not go away, you should see your doctor.

What to do if the symptoms don't go away

Most people will have at least some of these symptoms after they have been concussed, but they should be almost free of them by a fortnight. However, about one person in ten will take longer to recover. If your symptoms have lasted for more than two or three weeks, or are particularly severe, you should ask for professional help.

The first thing that's done is to make sure that there are no complications of the injury. Then there will be tests of concentration and memory, to serve as a guide to treatment and a baseline to measure your progress.

Once there's no doubt about the cause, you can be reassured that the symptoms will clear on their own. The problems that have to be tackled are the misery they cause while they last and the upset of family life, job and earning power that results.

How help is organised will depend on what's available where you live. Usually it will come from a team with a doctor, a psychologist, an occupational therapist and a social worker. They will talk to you and your family, and perhaps arrange meetings with other people with the same problems.

Organising help

Once everyone understands what is happening, a programme can be worked out. Often the first things to fix are money and family problems. They are important causes of anxiety and stress, and, because of irritability and poor concentration, may have not have been dealt with properly. The social worker will be able to help with this.

When concussion symptoms have not cleared in two or three weeks, most people become quite anxious and depressed, and an important part of the programme will be to help you to get over this. To begin with, you need to talk with a member of the team, either by yourself or with one of your family, who can explain the problems and how they can be tackled. Often because you will be thinking slowly, this counselling has to be gone through several times. After this it's helpful to have group discussions with others who have the same problems. When people are very anxious they will need special help, and instruction on relaxing and how to manage stress will be helpful.

A daily routine is needed

Unless the symptoms are only mild, it's best to be off work to begin with. Although you are not at work you should have a regular programme of things to do, both brain work and physical. This has to be enough to make you feel that you have achieved something, but not so much that you are tired out.

Rest

You must learn to pace yourself and rest when you are tired, and you must never get so tired that you don't feel fresh again after a night's rest.

Increase gradually

As you get better, you should slowly step up the amount you do, each time making sure that you can cope before making a change.

Get back to work by easy stages

As it becomes possible to do more and more, you can think of starting work again. It is important that the return to work is in easy stages, starting a day, perhaps three days a week, and then increasing the time at work slowly, only when it's certain that it's possible to cope and that fatigue will not build up from day to day. It may not be easy to arrange this with your employer; the ACC Case Manager may be able to help with this.

Get people to understand

It's important that others know what's happening, that the symptoms are real, and directly due to the accident. Because most people don't understand what the effects of concussion are, family, friends, workmates or employer may think that it's all been put on, that 'they could do better if they tried' or 'they just want some time off to lay about at home'.

It can be difficult to convince people. Showing them this information may help. The team will be glad to talk to your family, and the ACC Case Manager will contact your employer about your job situation.

Getting the help that you need

If you are having problems after a mild head injury, you should see your doctor to make sure that there are no complications. He or she may wish to look after you or may prefer to send you to see a neurologist or a neuro-psychologist. When a programme of treatment is arranged, it can be difficult to follow it on your own, and it may be best for you to go several times a week to the occupational therapy department or a special clinic at your local hospital, where you can get help and perhaps meet others with the same problems. The hospital's medical social work department will be able to help you to sort out financial problems and advise about the benefits you may be entitled to. The ACC is there to help you.

Special problems with mild head injury

Children, preschool and primary school

This is the time when the brain has most learning to do and a head injury that affects memory, even for a short time, can have a serious effect. Family and teachers may not realise that this can happen. If there is any suggestion that after a head injury, even a mild one, your child is not progressing as well as he should, you should get expert help.

School and university

People at secondary school and university also depend on their ability to learn, and again even a short period of incapacity at a critical time, such as the run-up to an exam, can have a serious effect. Often they and their families may not want to admit that there is a problem, but if there is a suggestion that they are having unexpected difficulty with their work, they should ask for expert advice.

Older people

As people reach middle age they are likely to be more affected by a head injury. The symptoms they have are the same, but they often need more help and more time to get over them.

People who work on their own

Homemakers and people with their own businesses can have special difficulty in managing their head injury symptoms. Often they feel that they can't afford to stop working, and so they deny that they're ill. Because they're not coping, the problems mount up and they become more and more stressed until a crisis occurs. Family and friends then need to persuade them to accept help and reduce their work load, and to get expert advice.

Sports injuries

When to play again

Concussion is quite common in some sports, and there may be pressure to play down its effects. It is dangerous to life to risk a second concussion within a few weeks of the first one. Some sports bodies, notably the Rugby Union, have strict rules about this and it is irresponsible not to follow them.

Repeated head injury

Each head injury, even mild concussion, permanently reduces the capacity of the brain by a small amount. The reserve of brain power that we all have will conceal the loss after one or two injuries, but if there are more than this the loss will start to show, by slowing of thought, poor memory and change of character. Those who have had more than one injury should think carefully before exposing themselves to repeated risks, such as those of football and boxing. A good rule is not to play again that season if you have two concussions, and to give up the sport if you have one more.

What you should remember after having a mild head injury:

• Do not drive your car or motorbike until you have made sure that your concentration is good and your reactions are quick enough.
• Do not expect to deal with alcohol in the usual way until you have fully recovered. One small drink may lay you flat.
• Do not expose yourself to the risk of another injury. Until you have recovered completely your reactions will be slow and you may be clumsy, just inviting a second accident.
• Do not think it's giving in to have a rest when you are tired. It's not a sin to have a sleep in the afternoon. Do not swear to finish the spring cleaning when you feel tired, even if it kills you. It may.
• Do start work again by easy stages. Do not let your mates or your boss pressure you to work longer than you feel you can.

Agencies that can help

ACC

ACC is there to help you. You should make a claim as soon as possible after the accident. The hospital staff will have a 'Claim for Cover' form to fill in and will show you how to do this. If you did not go to hospital your family doctor will be able to do this.

After your claim has been accepted, a 'Case Manager' will be assigned to you. Their role is to help manage your claim and recovery. They will be your personal contact at ACC and will help ensure that you receive the right treatment, compensation and rehabilitation.

You may be entitled to several different types of assistance from ACC including weekly compensation, independence allowance, transport, attendant care, housing modification, and aids and appliances. Your case manager will explain this.

The Head Injury Society

This society was started by people who had suffered head injuries, and by their families, to help others in the same situation to cope.

Get in touch with them, the hospital staff or the ACC Case Manager will be able to give you a telephone number to call, and you will be able to find out what support is available in your area. If you have any difficulty with this contact the Neurological Foundation.

The Neurological Foundation

PO Box 68 402, Newton, Auckland 1. Ph (09) 379 8470.