MTBI
Car Accident Injury: Post Concussion Syndrome
Post-Concussion Syndrome
A Craniocerebral Car Accident Injury
A traumatic brain injury often occurs due to the sudden acceleration/deceleration of the brain within the skull (whiplash from car accident). A rotational force makes matters far worse as it rapidly twists the brain. This commonly occurs in a rear-end car crash when the driver’s head is turned left or right. Motor vehicle injuries tend to cause focal contusions (bruises) with potential bleeding of brain tissue with associated damage to nerve fibers and junctions throughout the brain.
A concussion is an alteration of mental status due to biomechnical forces affecting the brain. A concussion may or may not cause loss of consciousness. In motor vehicle accidents, concussion can occur without an actual blow to the head. Instead, concussion occurs when the vehicle starts or stops suddenly. Fewer than 10 percent of concussions result in a loss of consciousness. Axonal shear is the primary pathologic feature of traumatic brain injury in all levels of severity. This is exactly the mechanism of injury to be expected when a driver is involved in a rear end collision where they are surprised and this outcome is increased when the drivers head is turned.
The literature indicates that it is common for symptoms from auto related injuries to emerge slowly over a long period of time. You cannot tell the extend of the damage you’ve received for several weeks after the initial car crash. This is the reason many insurance companies attempt to settle cases quickly, before you have had time to realize how bad your injuries really are.
Does Whiplash Result in Brain Injury?
Despite appearing normal, many patients experience persistent effects following the concussion that considerably impact their daily functions. They often encounter marked psychological difficulties when their cognitive dysfunctions continue to exist.
In recent years many neuro-psychiatrists have warned the general doctors to be considerate and informative towards the patients and if necessary refer them to appropriate specialists.
Post-concussion syndrome refers to the emergence and variable persistence of a group of symptoms following head injury, particularly mild head injuries. A person with a concussion is a person who has traumatically induced physiological disruption of brain function as manifested by any period loss of consciousness, any loss memory, any alteration in mental state( disorientation and confusion), and any neurological deficits.
It’s important to realize that no actual blow or fall need be suffered by the head to cause moderate or even severe brain damage. It is the change in velocity —— either acceleration or deceleration —— with a rotational rater than solely axial element, that leads to damage: the surface of the head need never contact any hard object or surface.
In most head injuries —— notably traffic accidents and falls —— there is marked deceleration of the moving head on contact with a fixed surface, the initial sudden change in velocity is applied to the scalp and skull, the latter then transmitting the change to the brain via the anatomical suspensory system within the cranium. This system is slightly flexible and consists of the falx and tentorium, which divide the cranial cavity into three major compartments; these contain the two cerebral hemispheres, the cerebellum and the brainstem.
When violent relative movements take place between the brain and the dura forming the partitions of the cranium, the cerebral tissue can become damaged against both the sharp edges and the flat surface of these membranes. When the head is moving and is suddenly arrested the skull will decelerate first and the momentum of the brain will cause it to continue in motion, against almost certainly with some rotatory component.
In either the deceleration or acceleration mode, the skull and brain cannot change their velocities simultaneously, and the brain will speed up or slow down only by virtue of the restraint provided by the dural septa and the configuration of the interior of the skull.
In a side impact collision the brain collides with the opposite side of the skull and bounces back causing damage to the nerve cells and fibers. A brain concussion is a cumulative injury. The neuropsychological assessment does not focus on the tissue damage resulting from an injury but on the functional consequences of the injury (i.e., the impaired cognitive functions secondary to damage to the brain). Post-Concussion Symptoms reflect interaction of cognitive and emotional factors.
Even a head injury that does not produce prolonged unconsciousness can result in impaired cognitive functioning. Neurological damage alone may not cause such symptoms; rather, they become more pronounced when the individual attempts to take on more and, as a result, experiences more stress. Monitoring post concussion symptoms can provide valuable information as the effect that the injury and the situation is having on the survivor at any given time.
A concussion most frequently relates to different forces which occur when the head is mobile. What happens at impact is that the head is mobile and is thrown forward, backward, or to the side. More specifically, the skull is thrown forward, but the brain tends to lag behind because of inertia. The head pivots at the neck; thus, when the head is suddenly thrown forward, the maximum effect of the inertia (or resistance) is at the point between the skull and the cortex where the forces are greatest. The brain stem is least affected since it is closest to the pivot point and moves the least distance. The effect is that the skull suddenly moves and the brain resists, causing shear forces. These shear forces are maximum at the surface of the brain (the cortex). Using this model, it is easy to see that even a mild injury (in which there is no loss of consciousness) can result in some damage to the cortex and lead to problems in cognitive functioning for a time after the accident. The likelihood of such damage is even easier to understand when you consider that the brain is specialized for transmission of information, has little internal structural support, and is dependent on the skull and other structures to support and protect it.
Symptoms from a concussion related to a car collisions may not appear for some time after the initial trauma. When the brain is jolted back and forth in the skull due to the impact of a collision bleeding and swelling of the brain can occur Even a mild concussion can result in subtle injury to the brain the affect both cognitive and musculoskeletal function.
Cognitive symptoms are known to adversely affect one’s ability to work or attend school following a car collision. Problems with attention and concentration, difficulty with both short and long term memory functions, trouble reasoning and problem solving, and reduced information processing may all be cognitive impairments that develop after a closed head injury from car collision incidents.
Patient sufferer from early symptoms of concussion including headache and dizziness. Late concussion symptoms include ligth-headedness, poor attention and concentration, easy fatigability, irritability and poor tolerance of frustration. Patient also complains of anxiety with depression and severe sleep disturbances.
A recent New England Journal of Medicine article showed that only approximately 6.3 percent of patients with documented “mild” traumatic brain injury had abnormal CT scans. Research has shown that MRIs may be effective in identifying focal trauma, but do not show the kind of “diffuse axonal injury” that can incur in acceleration/deceleration situations. Recent scientific studies have demonstrated a lack of correlation between the level of consciousness and long-term outcomes. In fact, a recent study by a group of well respected British scientists found that a significant number of victims of “mild” TBI or “post-concussion syndrome” still experience disabling symptoms a year after the accident and that disability one year later is as common after apparently mild head injuries as it is after more serious injuries.
A recent Journal of Head Trauma Rehabilitation article reports that although standard clinical EEG techniques are not effective in detecting the diffuse brain damage that can occur with a “mild” TBI, new electro-physiologic procedures like “Visual P-3 Latency” tests are being developed that are far more sensitive to the effects of mild injury. New developments in neuro-imaging are also increasingly enabling physicians to identify the consequences of mild traumatic brain injury, particularly “functional” imaging procedures such as PET scans, SPECT scans and functional MRIs. A particularly promising area of MRI technology involves “gradient echo imaging” which is said to detect the effects of the micro-shearing that can occur with diffuse axonal injury.
These promising neuro-imaging technologies still in development are not universally available, and are very expensive, but are expected to become more available and less expensive over time.
J Chiropr Med. 2005 Winter; 4(1): 32–38.
Published online 2005. doi: 10.1016/S0899-3467(07)60110-4
PMCID: PMC2647031
Chiropractic Management of a Patient with Post Traumatic Vertigo of
Complex Origin
Matthew E. Collinsa,* and Tom M. Misukanisb
aPrivate practice of chiropractic, St. Paul, MN
bPrivate neuropyschology practice, Bloomington, MN
Matthew E. Collins: Matc506@aol.com
*Submit requests for reprints to: Matthew E. Collins, DC, DACRB, 671 North Snelling Avenue, St. Paul, MN 55104, Phone: 651.646.6710, Fax: 651.646.8332 ; Email: Matc506@aol.com
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Copyright © 2005 National University of Health Sciences
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Abstract
Objective
To illustrate a case of vertigo in a patient with cervical spine injury and mild traumatic brain injury following a motor vehicle accident and present chiropractic and rehabilitative procedures used for management.
Clinical Features
A 30-year-old female had neck pain, head pain, a variety of cognitive problems, vertigo, and restricted cervical range of motion following a serious motor vehicle collision. Following several weeks of chiropractic management with positive progress the patient suddenly had worsening of the vertigo and the cognitive problems. Positional vertigo was ruled out by the emergency room doctors and a neurologist. A neuropsychological assessment indicated that mild traumatic brain injury was present.
Intervention
The patient began chiropractic treatment with both passive and active care, prior to the vertigo incident. Following the vertigo incident, treatment was modified to include 6 weeks of cervical exercises in clinic and at home. The patient reported resolution of the vertigo following the chiropractic treatment plan.
Conclusion
This case reports presents an example of vertigo that improved under chiropractic management. This case illustrates the benefits of adding mild traumatic brain injury to differential diagnoses, co-managing care with other providers, and modifying treatment when necessary. Further research is suggested to study the contribution that chiropractic management could offer to those with neurological injury.
Key Indexing Terms: Brain Injuries, Manipulation, Chiropractic, Exercise Therapy, Neuropsychology, Post-concussion Syndrome, Vertigo
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