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Patrick was 42 years old. He was being seen for neck and back pain after experiencing a motor vehicle accident the week prior. He was 10 minutes late for his new appointment and took an additional 10 minutes to fill out the paperwork he was supposed to have filled out prior to arriving. To say that I was initially concerned about having enough time to see him was an understatement. As I started the interview, I noticed he was having trouble answering the questions, seemed to have to pause and asked his wife for the questions to be repeated. When asking his wife if this was normal for him, she said no, and she added that although her husband was normally very independent, they had gotten lost on the way to the appointment. She thought it might have to do with stress over the accident, or medications. At this point I became highly suspicious that something more than neck and back issues was going on.

A New Diagnosis

Patrick, his wife, the medical personnel in the emergency department (ED) and his primary care provider (PCP) all failed to recognize that Patrick had become one of the 1.4 million Americans who suffer a head injury every year.¹ In this case he had a mild traumatic brain injury (mTBI), otherwise known as a concussion. Many individuals with a concussion who receive medical attention do not have a TBI diagnosis recorded, especially when there are multiple injuries.²

Patrick recalls driving to the grocery store and seeing a vehicle pull out to his left. The next memory is of his vehicle spinning and coming to a stop in the opposite direction he was heading. His airbags did not deploy. He does not think he had any loss of consciousness but did feel he was dazed and confused for several seconds. He was helped out by a passer-by as he seemed to be just sitting in the vehicle. He did develop an immediate headache and felt dizzy, but attributed this to his neck pain which occurred at the time of the accident.

Since this accident, Patrick was having difficulty falling and staying asleep, had difficulty with completing his work as an accountant and felt more irritable with his children. These were all new symptoms since the accident. Patrick was initially evaluated at the local ED, had x-rays of his neck for whiplash, was given pain medication and was told to follow up with his provider in 3-7 days. Patrick did call his PCP, who gave him a referral to see a neurologist. Neither the ED nor his PCP asked about a possible head injury associated with his neck pain. Like most patients who have a concussion, he looked normal and had no lacerations or bruises to his head. Patrick only complained about neck and back pain in the ED. If a computed tomography (CT) of the head had been done on Patrick, it probably would have been negative, as most are.³

Patrick did not have any outward signs of injury, so he assumed there was no damage. He knew he was having trouble, as did his wife, but neither could identify what it was. Because he was dazed right after the event and was having ongoing memory, headache, sleep and mode changes it was determined that he, in fact, had suffered a concussion during the car accident.

Is Concussion Common?

This situation is very common. By reassuring patients that they have suffered a concussion, that they will get better and that there are treatments that may help, you actually start the healing process.⁴

According to statistics by the Centers for Disease Control (CDC), of the 1.4 million who sustain a head injury, 75% of these are considered to be mTBI or a concussion.⁵ The leading causes are falls (28%), motor-vehicle crashes (20%), struck by or against events (19%) and assaults (11%).⁶ Blasts are the number one cause of TBI for our active duty service members in a war zone.⁷ In addition, consequences can be long term. According to the CDC there are at least 5.3 million Americans who have long-term or lifelong difficulties with activities of daily living after a concussion.⁸ Lastly, looking at the cost of direct medical care and indirect medical costs such as lost productivity, it was estimated at $60 billion in the United States in 2000.⁹

In order to diagnose a head injury as an mTBI or concussion, the injury must meet certain parameters. The American College of Rehabilitation Medicine established the criteria for mTBI: "a physiological disruption of brain function as a result of a traumatic event as manifested by at least one of the following: alteration of mental state, loss of consciousness (LOC), loss of memory or focal neurological deficit, that may or may not be transient, but where the severity of the injury does not exceed the following: post-traumatic amnesia (PTA) for greater than 24 hours, after the first 30 minutes Glasgow Coma Score (GCS) 13-15, and loss of consciousness is less than 30 minutes."¹⁰ In addition, CT imaging of the brain is negative. The patient does not need to have lost consciousness.

Common symptoms include headache, sensitivity to noise or light, nausea and vomiting, dizziness, balance difficulties, memory and/or concentration difficulties, mood changes, sleep disturbances. These should be new or different symptoms. Some individuals may experience an exacerbation of current symptoms, such as more intense headaches that are no longer responding to medication.

Also, brain imaging is usually completely normal.³ Education starts the healing process and most individuals will heal within 1-3 months and function as they had before.¹¹ A small percentage may have ongoing difficulties, such as memory issues, and will require memory aids. Repeated concussions increase the chance of long-term difficulties such as memory problems, mood changes and increased risk of Parkinson's or Alzheimer's.¹²