Concussion thoughts

I was going to say I have become an expert in concussion – but that would be stretching it a bit. But if you get a concussion, and it involves being off work for nine months, you do get more interested.  How the hell did it happen?  The short answer is I don’t know. I woke up in St Luke’s Hospital, just north of Central Park. People were cutting my clothes off. I was in no pain, and immediately realised I’d had some kind of accident. The nurse asked me my name – managed that – my age – managed that – and then the year.  Hmmm. Was it 2011? Like a good boy not wanting to get it wrong, I chose not to answer.

I heard her say I had “come down hard on a corner” and that’s mostly what I know. I was probably cycling down the loop road, past the Lasker Pool at the top of the Park. My bike must have slid over – rapidly – my shoulder and elbow were grazed – and the main impact was on my right forehead – my helmet was cracked and slightly crushed at that point. (The helmet being cracked is good – it’s supposed to do that – to distribute the impact.) I got my medical records later. No one else was involved. I was on a corner. I was unconscious for up to a minute. I can’t remember anything from five minutes before the accident to thirty minutes after – although apparently I was conversing with people, although in a strange, persistent way. (This kind of amnesia is common as well – yes, strange that you can’t remember BEFORE the accident – but as I said, not unusual.)

I saw this video from the Tour de France – while this cyclist is on the level, notice how his back wheel slides out on the road marking – and notice how he hits his right forehead. I must have done something similar:

Things I’ve learned: a helmet is really important but can’t stop a concussion. The helmet can help prevent a more serious brain injury (see information below) but since concussion is a result of the brutal deceleration caused by a head meeting concrete, it can’t prevent this – effectively your brain hits the inside of your skull.

The main symptom has been fatigue and limited energy. My PT, who has extensive experience working with brain-injured Iraq vets, says that fatigue is the most commonly reported symptom.

Theories: the medical specialist who sees me at NYU Langone (which recently created a special concussion centre – he’s an internationally recognized expert) believes that the rest of the brain may have to work harder to compensate for the damaged area of the brain. Since the brain takes up about 20% of the body’s energy supplies, that could be linked with fatigue. Theory two, from the University of Buffalo – glucose delivery to the brain is diminished because blood vessels become constricted after a concussion. Their theory – being applied in practice but not yet proven – is that improving blood circulation through controlled exercise can help.

For some people – like me – recovery is glacial. If you’re over 40 it’s likely to be slower.

Moral conclusions: I almost certainly wasn’t “doing anything wrong”. I was cycling normally – as I have done hundreds of times in the park – and just got unlucky – presumably slid on a road marking, gravel, sand, oil, whatever. Just unlucky. Yes the cliché – it can happen to anyone at any time.

Useful information – helmets DO make a big difference in protecting you (even though they can’t protect you from everything). And evidence from studies – see the one on legislation at bottom – suggests that requiring helmets doesn’t mean that people will switch away from cycling – and, even if it did “encourage” people to be more reckless (not that there’s any evidence that it does) overall, helmets reduce death and injury.

Excellent bicycle helmet safety website.

Studies:

Statistics from the most recent study by Robert S. Thompson, MD, Frederick P. Rivara, MD, M.P.H., and Diane C. Thompson, MS

Helmets for preventing head and facial injuries in bicyclists

Main results:

We found no randomized controlled trials, but five well conducted case-control studies met our inclusion criteria. Helmets provide a 66 to 88% reduction in the risk of head, brain and severe brain injury for all ages of bicyclists. Helmets provide equal levels of protection for crashes involving motor vehicles (69%) and crashes from all other causes (68%). Injuries to the upper and mid facial areas are reduced 65%.

Authors’ conclusions
Helmets reduce bicycle-related head and facial injuries for bicyclists of all ages involved in all types of crashes, including those involving motor vehicles. Our response to comments from critics are presented in the Feedback section.

Plain Language Summary
Wearing a helmet dramatically reduces the risk of head and facial injuries for bicyclists involved in a crash, even if it involves a motor vehicle.

Cycling is a healthy and popular activity for people of all ages. Crashes involving bicyclists are, however, common and often involve motor vehicles. Head injuries are responsible for around three-quarters of deaths among bicyclists involved in crashes. Facial injuries are also common. The review found that wearing a helmet reduced the risk of head or brain injury by approximately two-thirds or more, regardless of whether the crash involved a motor vehicle. Injuries to the mid and upper face were also markedly reduced, although helmets did not prevent lower facial injuries.

Statistics from a study titled The Effect of Bicycle Helmet Legislation on Bicycling Fatalities by Darren Grant and Stephen M. Rutner.

Abstract:
“A number of states passed legislation in the 1990s requiring youths to wear helmets when riding bicycles. The effect of this legislation on bicycling fatalities is examined using data from the Fatality Analysis Reporting System. A panel analysis is used to account for unobservable, time-invariant factors that may correlate with the incidence of laws across states. A control-group methodology is used to control for time-varying unobservable factors that may correlate with the implementation of laws within states. Timing issues are also explored. A helmet law reduces fatalities by about 15% in the long run, less in the short run. There is no evidence of spillover effects (to adults) or substitution effects (youths choosing other methods of transportation) associated with implementation of a helmet law. Through 2000 existing helmet laws have saved 130 lives. If all states had adopted helmet laws in 1975, more than 1,500 lives would have been saved.”

Added note:

I think with a head injury it’s sometimes hard for others to understand what’s going on – especially if there are no visible wounds – no cast, sling or bandages etc One of the aspects of this that’s important to emphasise is that this is a physical problem – not a psychological one. What is additionally somewhat confusing is that the physical injury is in the head.  It’s in these circumstances that phrases like “in the mind” and “mind over matter” become rather misleading. Yes, it is in the mind in the sense that what happened affected my head and the brain inside it – and the mind emerges from the activities of the brain. But the phrase “in the mind” implies a psychological phenomenon – which it is not, in this case. It’s a physical injury with physical repercussions – in this case fatigue, and often, though now lessening, a feeling of floatiness (not dizziness as in a spinning sensation, but a general floaty feeling – plus also a feeling of strain and heaviness in the head at times). And the phrase “mind over matter” neglects the fact that, in an important sense, the mind IS matter – in that it is derived from the physical brain.  Yes, psychology plays a role in recovery – and I’m working with a neuro-psychologist at NYU – but most of the work is to make sure I am sufficiently active, that I monitor my activity carefully, and that, by doing that, I can gradually increase my activity until I’m ready to return to work. A part of that work is focusing on the positive – that’s not unimportant, but essentially I’m trying to create the conditions in which the physical healing in my brain can take place – that is the core of this. Yes, it’s possible that I could become depressed and inactive – which wouldn’t help my recovery, but in practice I haven’t been depressed – if anything I’ve been overly optimistic, which has led me to try to do too much. Of course, at times I’ve become frustrated and demoralized, but as my psychologist points out, that is entirely normal – in fact it would be abnormal if I didn’t have any emotional reaction to my situation. But to repeat, the core driver of all this is physical.