Are Women at Greater Risk of Post-Concussion Syndrome?

Every year, hundreds of thousands of Australians suffer a knock to the head that can turn their lives upside down. So why aren’t we taking concussions more seriously? Here, journalist Ani Fischer shares the realities of her life post-concussion. I always sensed Monday mornings were hazardous to my health, and now I have proof: the alarm announcing the start of a new working week signalled the beginning of my dramatic unravelling. Woken by the thunderous thwack of my head hurtling through the wall, followed by the thud-thud-clonk of my body bouncing down the stairs, my daughter found me on the kitchen floor, dazed and confused, plucking gyprock splinters from under my jaw. Words refused to form through the nausea, but I registered that something was very wrong by the shards of tooth on my tongue and the panic on my little girl’s face as she took in the blood and rapid swelling. I’d missed the first step on the staircase curve, slamming headfirst through the plasterboard before careening down the full flight. My face resembled a battered tomato, swollen and split, but the worst was yet to come. The first few weeks post-concussion The days and weeks that followed are a blur. My brain felt like jelly, wobbling with every turn of my head. Daylight was torture, and car trips impossible, movement triggering a nausea-inducing dizziness that made it hard to stay upright. That seemed acceptable, all things considered. It felt miraculous to have only broken skin, teeth and a finger, but one thing did irk – words failed me. Names for things and people were stuck in that jelly-like sludge, and all attempts to drag them forth or put them in their rightful order were exhausting. “We liken it to taking a jet to the supermarket instead of just walking the two blocks. You’ll still get there, but the amount of energy used is much higher,” says Dr Sarah Hellewell, a Senior Research Fellow in Neurotrauma at Curtin University and Perron Institute who is researching concussion biomarkers. “It takes so much out of you.” Concussion is the most common brain injury in Australia with 170,000 cases clocked every year, mostly through falls, car or bike accidents and assaults (only 20 per cent are sports related). That figure is “just the tip of the iceberg as it’s only counting those who get a formal diagnosis,” according to Dr Hellewell. Most people recover within a month, but a significant minority – up to an estimated 25 per cent – suffer ongoing symptoms several months, even years, later. “Thousands of people live with post-concussion symptoms, and we’re doing nothing to help. That’s shocking.” Finding help post concussion Help, I can concur, isn’t easy to find. “Doctors haven’t been taught how to manage concussion symptoms because up to 80 per cent of people get better by themselves. So that is the working theory they go with,” says Jennie Ponsford, an award-winning professor of neuropsychology at Monash University and director of the Monash-Epworth Rehabilitation Research Centre. At the forefront of the brain injury and rehabilitation field, she advocates for a multi-disciplinary treatment (doctor, physiotherapist and psychologist) as the standard protocol. “Most GPs tell people to rest when what they should do is seek treatment for neck issues and take a gradual approach to increasing activity within their limits,” says Professor Ponsford. The first doctor I saw did indeed suggest rest. On follow-up, the second offered little more than a curt reprimand to watch my step. On the third visit, almost four weeks post-accident, I asked why my brain still felt like a wad of goo. Perhaps, the GP suggested, I should try anxiety medication. Had my words come out wrong? I felt exhausted, not anxious, and rest clearly wasn’t helping. “An invisible injury” “Concussion is an invisible injury, which often makes it more difficult for people to get help,” says Dr Hellewell. “Only you know what is normal for you, and it can be difficult to articulate.” It’s also hard to fathom just how much a smack to the head can impact everyday life – because it can affect any (or all) of the areas related to the autonomic nervous system (which controls cerebral blood flow, heart rate and breathing), it can disturb everything from heart rate to sleep, sight, sound and movement. “The reality is that people have a weird mix of symptoms,” says Professor Ponsford, adding that concussion is a complex condition not just affecting the brain, but also the neck and vestibular system. “The coordination of the eyes can be affected, so looking at a screen or visual scanning becomes really stressful. “No one really understands the reasons for sensory sensitivities, such as noise intolerance and bright light.” Human brains contain billions of neurons that form trillions of connections to each other, so there’s a lot to learn. “It’s only in the last 20 years that we have been paying attention to concussion,” says Dr Hellewell. “Before tha,t we thought only people with severe brain injury have poor recovery. We now know that’s not the case.” Post-concussion recovery Researchers have also learned this: there is no single recovery trajectory. A recent New Zealand study found that 49.8 per cent of people with post-concussion syndrome still had at least one symptom 12 months later. “If you have seen one concussion, you have only seen one concussion,” says Dr Hellewell. “Two people who are the same height, weight and gender and that have the same injury won’t recover the same way.” That lack of certainty is testing for everyone. I left the medical practice that day with a sense of shame that I wasn’t doing better, but determined to find someone who could tell me how to improve the head slush, dizziness and nausea. Fortunately, “Dr Google” led me to The Concussion Centre, where my treatment for whiplash immediately began. “Whiplash can occur without concussion, but concussion will always have a whiplash component,” says Jack Giles, Senior Physiotherapist at The Concussion Centre, whose expertise changed the course of my recovery. It’s one of the few clinics in Australia with a Multi-Cervical Unit, a quirky-looking machine that locks your head into a brace and speeds up the task of neck strengthening exercises. My neck went from supporting 200g to comfortably holding the weight of my head (around 5kg) in a matter of weeks, alleviating the slushy brain sensation. A higher risk for women “We know from the research that, structurally, women have a lower biomechanical threshold and so are exposed to greater head and neck acceleration during impact,” says Jack. “They have almost twice the concussion risk of men and often have worse outcomes from prolonged symptoms.” According to Dr Hellewell, women may also have smaller axons and fewer microtubules – the structural scaffolding of the brain – and research is yet to determine whether hormonal differences may impact recovery too. For both sexes, early intervention and exercise are key. Studies show that pushing to 80 per cent of the maximum heart rate (but below the point where symptoms are exacerbated) speeds up recovery. “Concussion treatment is a process of habituation with gradual exposure to things that provoke symptoms so the body can adapt.” Jack explains that we should, “Think of it as a cup of water. It has a certain capacity, and you want to get it just about full but not overflowing. That is a hard thing to do.” Slow and steady It can be a frustratingly lengthy process. Physical therapies and eye and balance exercises were crucial for my recovery, but Jack offered something equally powerful: hope and a plan. The treatment acknowledged that my symptoms were real and not uncommon. It also set realistic expectations. Full recovery would take months of effort, but it was possible. I felt a renewed energy to wade through the fatigue and forgetfulness that had reduced my life to a solitary kind of lockdown. In the months that followed, I still felt slow and tired and frequently a little unintelligent, but also determined to make my neurons forge a path back to “normal”. And they did. “Concussion can completely take over your life,” says Professor Ponsford. “The most powerful thing for patients is feeling they know what to expect. Tolerating a certain level of imperfection, knowing you can’t do everything you could do for a while is key, but so is validation from the community. “Most people have real cognitive difficulties and behavioural changes, but they look the same, so it can be hard for others to understand. That makes it doubly difficult.” Concussion signs and symptoms “Concussion causes the head and brain to move rapidly back and forth, altering the shape of the brain tissue and stretching cells,” says The Concussion Centre’s Jack Giles. “This leads to an initial burst of overactivity in the brain, which then causes an energy deficit. Kind of like your brain doing a 100m sprint and then collapsing.” Concussion symptoms include: Headache or migraine Dizziness Nausea or vomiting Balance problems Changes in vision Sensitivity to light or noise Difficulty thinking clearly and concentrating Poor memory Sleeping more or less than usual Trouble falling or staying asleep Feeling more anxious, emotional or irritable What to do if you whack your head: Seek urgent medical attention. You may need a CT scan to check for a fracture or brain bleed. Consult a qualified physiotherapist for whiplash treatment. Many studies have shown that swift treatment can lessen the impact of persistent symptoms. Unfortunately, public rehabilitation services are scarce so patients usually fund their own recovery. A smart watch is a useful way to track your heart rate and concurrent symptoms during exercise. Seek additional support from a neurologist, psychologist or behavioural optometrist if required. This information is general in nature. For individual health conditions and concerns, consult a health professional.