Nellie Develops Post Concussive Syndrome (PCS)
Nellie is a 12-year-old girl who was hit by a sailboat boom five days ago. She did not pass out, but has headaches, fatigue, dizziness and nausea. Read more about her injury in the blog post "Anatomy of a Concussion."
Wednesday morning, she developed pain in her neck, and so her mother called their pediatrician. He had Nellie come in right away. After an examination, he felt Nellie was suffering from Post Concussive Syndrome (PCS).
What Is Post Concussive Syndrome?
Only a small percentage (4-10 percent) of people who have had a concussion will have persistent symptoms lasting longer than a day or two and even fewer with symptoms lasting weeks to months, the so-called PCS (1). Nellie was among this small percentage. Most of us who get bonked on our heads will have symptoms that resolve in a few hours to a few days, at the most.
While anyone is susceptible to PCS, trends indicate that teenage girls are particularly vulnerable, even though the highest rates of concussions are among male toddlers and adolescents (2, 3).
Additionally, teens who place a lot of stress on themselves to excel in school are at an elevated risk for PCS. Some studies have noted personality traits such as anxiety and the need for achievement in these patients (2). Nellie, for example, was a straight-A student and worried incessantly about how she was going to catch up with her school work while she was sick.
However, even the Dude in The Big Lebowski, laid back, mellow and with zero ambition, can still develop PCS. In other words, while certain characteristics may exacerbate the symptoms of PCS, it is an equal opportunity condition.
Symptoms and Treatment of Post Concussive Syndrome
A month after that fateful Thursday on the bay, Nellie was still having headaches. She was taking several over-the-counter pills like Motrin and Advil to help, and although her teachers at school were understanding, she continued to have severe daily pain from mid-morning into evening. Even though she wasn't given much homework, she was debilitated by fatigue every evening.
Her pediatrician decided to refer Nellie to a neurologist. When Nellie arrived at my office, she had full blown PCS. While there are many different components to PCS, including cognitive loss, I am going to focus on two that affected Nellie and significantly compromised her function: headaches and dizziness.
Headaches After Concussion in Post Concussive Syndrome
Let's take headaches first -- 30-90 percent of those with PCS suffer from headaches, making it the most common symptom (4). There are many reasons for headaches after concussion. Headaches that are not associated with bleeding into the brain are generally due to spasm of the neck and jaw muscles and local damage and inflammation in the area of these muscles. These headaches can, on rare occasions, persist for over a year.
LCD Screens and Post Concussive Headaches
Managing headaches is a significant part of treating PCS in my practice, particularly among high school kids, because of another major issue: pixelated screens. Like most teenagers, Nellie was spending quite a bit of time in front of various LCD screens, which significantly contributed to her headaches.
Those little pixels that create the words you're reading right now are constantly flickering at about 30Hz, indiscernible to the naked eye. This invisible strobe-like effect strains the muscles controlling our eyes as they attempt to keep up with the motion of the words, giving way to pesky and sometimes intense headaches. In a patient with PCS, who is likely suffering from whiplash and tender head and neck muscles to begin with, this extra muscle strain can be particularly incapacitating.
Adding injury to injury, by limiting the way people navigate texts, screens may impair comprehension. In a study of Norwegian 10th graders with similar reading ability, half of the students read from texts on paper while the other half read them from pdf files on 15" LCD screens (5). On reading comprehension tests administered afterward, students who read on paper performed better than those who read the same text on screen.
"The ease with which you can find out the beginning, end, and everything in between and the constant connection to your path, your progress in the text ... makes it less taxing cognitively, so you have more free capacity for comprehension," notes Anne Mangen, this study's author.
Surveys support her observation, indicating that screens and e-readers interfere with our need for serendipity and control. Apparently, we enjoy of flipping back to previous paper book pages when a sentence jogs a memory, scanning ahead on a whim, writing margin notes and deforming our paper in all manners.
As a result, this is what I told Nellie:
- No screens of any kind, including: movie screens, computer screens and phone screens. The last needs to be emphasized with teens. A patient of mine, Elliot, continued to complain of headaches and fatigue despite staying away from screens. Turns out, he had continued using his telephone LCD screen, as this "was just my phone!"
- No texting/reading while in cars.
- At least eight hours of sleep at night, particularly important for teenagers who often make do with far less.
"Why?" Nellie wanted to know. "Why is sleep so important?"
"Because," I explained to the skeptical preteen, "sleep relaxes your tired eyes. It helps you remember what you learn in school. It completely relaxes your sore muscles."
Sleep was a hard sell, but Nellie agreed to try it, "for two weeks, max!"
- Reduced to no homework during the early PCS period, which Nellie's school had already instituted.
- More time during tests for a limited time is needed for a very small number of patients. In
Nellie's case, I recommended one month. I am very sparing in this type of recommendation as I believe that speedier recovery from PCS is aided by returning to norms as soon as advisable.
- I prescribed a simple non-narcotic prophylactic medication for Nellie's daily headache.
Now, it was time to take care of the other major issue: Nellie's complaint of dizziness. If her dizziness was not addressed, for reasons you will soon see, Nellie's headaches would persist. In the next blog post, I address the cause and treatment of this problem.
NB: All identifying information has been changed to protect patient identites.
Selected References:
(1) Chrisman S, Rivara F, Schiff M et al. Risk factors for concussive symptoms 1 week or longer in high school athletes. Brain Injury. 2013;27(1):1-9
(2) Garden K, Sullivan K, Lange R. The relationship between personality characteristics and postconcussion symptoms in a nonclinical sample. Neuropsychology. 2010;24(2):168-75
(3) Giza C, Kutcher J, Ashwal S et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports. Neurology. 2013;80(24):2250-7
(4) Hall R, Hall R, Chapman M. Definition, diagnosis, and forensic implications of postconcussional syndrome. Psychosomatics. 2005;46(3):195-202
(5) Mangen, A, Walgermo B, Bronnick K. Reading linear texts on paper versus computer screen: Effects on reading comprehension. Int J Educational Res. 2013;58:61-68
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