We need a plan for addressing concussion

Seriously. When it comes to handling concussion and mild traumatic brain injury, especially among student athletes, we desperately need a plan of action to address the injury when it happens.

Because it can — and does — happen. And it will continue to happen so long as we are doing more than sitting passively in a chair watching the game. Provided you never move from that chair, you’ll be safe… until obesity and all the health issues that accompany sedentary life catch up with you.

Personally, I’d rather run the risk of concussion.

And so would a lot of other people.

So, given that there are individuals out and about who are engaged in activities which carry a danger of head injury, how shall we address it when it happens?

I say, we come up with a plan for this. Especially among athletic trainers and other healthcare professionals and those who have been down the road of mild TBI and lived to tell about it.

People who are in a position to respond — response-Able individuals — need to step up and put some thought into not just prevention and immediate response, but also concussion recovery. Because if we just say, “You got hurt, but we really don’t know what to do to get you back on your feet. Every brain is different, so we really don’t know what to tell you, other than rest,” I will bet you any amount of money that the under-reporting and symptom concealment and unsafe return to play will continue, even escalate.

At the same time, you don’t want to set unrealistic expectations with the Plan and set people up for disabling disappointment. It’s true that every brain is different, so we have to be careful about making ‘guarantees’. There are none in life, especially with brain injury.

I think there’s definitely a fine line between providing hope and supporting health, and getting yourself into a professionally untenable position. The last thing you want, as a professional healthcare provider, is to have angry athletes and parents showing up at your doorstep shouting, “But you PROMISED my kid would be okay in three months!” I won’t even go into the lawsuit stuff.

Still and all, we need to do something. All of us, not just a select few. And outside the realm of commercial enterprise. Commerce and Concussion should never mix, but unfortunately, they increasingly do. We need to seize the moment and step up, as this concussion business is getting a lot of press – and heaven forbid we squander the opportunity to rise to the occasion.

How about this? Say, we craft a “crowd-sourced” response to concussion which draws on the collective intelligence and training and insight of experts of many kinds all over the place. And we do it for free. Online. As a community.

I envision the following Concussion Response Plan (CRP) for responding to concussion:

This would be an approach which, after a mild traumatic brain injury:

  • Leverages expertise in conditioning and protection and prevention, which comes from the Athletic Trainer camp. We need this to educate players (and others, like parents and coaches) about the source of their injury, to show them how and why their concussion happened.
  • Incorporates knowledge about the physical nature of mild traumatic brain injury, which comes from the Medical camp. We need this to educate folks about the nature of brain injury, to explain the inner workings of it and how physical changes in the brain affect its functioning. We need to stop being so squeamish and start calling concussion what it is — a mild traumatic brain injury.
  • Incorporates knowledge about the potential physical, mental, and emotional impacts of mild traumatic brain injury, which comes from the Neuropsychological/rehabilitation camp. We need this to educate everyone affected about the potential issues that may come up, help them craft intelligent coping mechanisms, AND to show that healing and recovery are possible… and where recovery is not 100% complete, there are indeed coping mechanisms that can be used to offset the effects of the injury, or other options available in life to the impacted individual.
  • Has a firm foundation in physical and cognitive-behavioral conditioning and fitness — in Action. We need to not just sit around and think about “this concussion stuff”. We need to put what we learn into action. This is especially important for concussed athletes, because the agitation that can come from TBI can be a huge issue, and the energy needs to be directed in some productive and constructive direction.

This CRP needs to be clearly defined and articulated from the start, even before athletes are concussed. The uncertainty of sitting out for an indeterminate amount of time, with no structured activity and now outlet for this crazy agitation that comes up — and stays — is no way to spend your days, especially as a student athlete with a concussion. If there’s no planned response to concussion in place, and athletes are left hanging with no structure or direction, the experience is HELL, and it’s all the more reason to hide your symptoms or pretend you’re all better before you are.

And that can — quite literally — get you killed.

But when you’re 16 years old, and the only way you’ve found to be the popular, successful person you always wanted to be, has just been yanked out from under you, it’s easy to choose to risk your life instead of honest disclosure. When your whole identity and sense of self hinges on being able to play — and play well — having that taken away from you might as well be death.

Yes, we need a Plan — a cohesive, coherent, well-thought-out program of action to address Concussion in youth sports across the full spectrum of experience, after the injury as well as before it happens. We need to chart a course that offers some level of structure and predictability to kids and parents alike after the concussion, and gives them some assurance in the midst of a situation which is chronically devoid of predictability.

Even if it’s the assurance of knowing what has happened and that there are specifiic, orderly steps they can take to take to address it — without any specific guarantee that it will all work 100% as they hope/expect — at least that would be something.

We need a Plan for addressing Concussion — how to prevent them, how to appropriately respond to them, and what to do during the time period required to recover. Without such a Plan, athletes — at all levels — are going to continue to avoid this issue and not address it directly or modify their behavior. Because sometimes uncertainty is the scariest thing of all. And nobody likes to be scared.

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TBI SoS – Restoring a Sense of Self after Traumatic Brain Injury – The Things We Do for Our Selves

This is the fifth part in a multi-part exploration of sense of self and how it’s affected by traumatic brain injury. Read the other sections here.

Note: I am currently writing a full-length work on Restoring a Sense Of Self after TBI, and I am posting the sections here as I write them (click here to go there now).

The Things We Do for Our Selves

Okay, down to brass tacks. I’ve talked a bit about the abstract, theoretical reasons why Self Matters to TBI survivors. I’ve talked about how it’s critical to have, so that we can continue the work of our recovery, and just living our day-to-day lives. I’ve talked about how we need it, to be part of a community and share our lives with the people we love and need.

Now I want to to talk about the importance of restoring strong sense of self in terms of the negative impact it can have on us, when we don’t have a strong sense — and the not-so-great things we’ll do to strengthen it. And I want to talk about it in terms of physiology, as well as psychology. The physical aspects of a disrupted sense of self are, I believe, key contributors to mood disorders, behavior problems, poor choice-making, and the kinds of risk-taking activities that can not only get us in trouble socially, but can get us brain-injured all over again. I would even go so far as to say that a damaged sense of self is one of the prime motivators that compels injured folks to engage in activities which almost guaranteed to injure them all over again. And if people tasked (officially or informally) with responding to head injuries/concussions — such as coaches, athletic trainers, teachers, doctors, family members, co-workers and employers — don’t address these core issues, the chances of the brain-injured individual putting themself in harm’s way can be pretty high.

See, here’s the thing…  Let’s take a student athlete for example — a junior in high school on the football team. (I’ll call him Junior.) Suppose Junior has been having a difficult time — in school and in life. Like most kids, he’s a bit confused about life. His body is going through changes, and socially he feels inept. He’s had a couple of girlfriends, but he can’t seem to keep them for long. His friends all seem to have girlfriends, and he’s worried about his sexuality. The last thing he wants, is to be “queer” but girls don’t seem very interested in him, and it always feels like such an obstacle course, anytime he has to interact with them.

He’s a good football player, a really capable offensive guard on first string, but it’s the quarterback, tight end, and the wide receiver who get all the attention and glory. His dad isn’t around much, and when he is around, he’s pretty rough on Junior, who gets good grades — but his dad hardly notices. His football coach is the closest thing to a real “Dad” he has, and he really seems to care about Junior and how he’s doing in school and on the gridiron. The trainer and everybody else on the team are like extended family, and the only time he really feels like “himself” is when he’s playing football, practicing, spending time with the team. When football is out of season, there’s not much left for him to do. He’s got a job as a night manager at a local department store, and he’s active in local charity work, but there’s nothing like the feeling of being part of the team. He and his football buddies hang out in the off-season, working out at the gym and following the NFL season all winter long.

Then one day Junior gets hurt in a critical game. A teammate’s knee catches him on the temple, and he goes down briefly. Everything goes a little dim and quiet, then “the lights come back on” and he sees his buddies standing over him, asking him if he’s okay. They seem genuinely concerned — but more about continuing the game. Not wanting to be a wuss and let his team down, Junior jumps up, says he’s okay, tightens his chinstrap, and jogs back to the huddle. He sorta kinda hears what the next play is, but when he’s getting set to go, he’s not really sure what he’s supposed to do, exactly.

So, he just does his thing, blocking and tackling. When the ball changes hands and he heads off the field, the coach and trainer look at him strangely, like there’s something wrong with him. But he gets a drink of Gatorade and sits down, like there’s nothing wrong. When it’s time to get back in the game, he jumps up and hustles out on the field ahead of everyone.

But he’s still not playing 100%. It’s becoming more and more apparent. His reaction time is slowed, he’s clumsy and misses blocks and tackles, and he has a few more hard falls that leave him dizzy and disoriented when he gets up. Junior struggles to understand what’s being said in the huddle, and if he didn’t have other players around him to cue off of, he’d have no idea what to do with himself out there. He’s bound and determined to stay in the game, however. It’s who he is. It’s what he does. He might not be the biggest star on the team, but he’s an integral part of the offense, and he can’t let his team down.

Next time the ball changes hands and he heads to the sidelines, he can see his coach and trainers looking at him with real concern. The trainer comes over and asks him a few questions. When he replies, the trainer tells him he’s got to sit out the rest of the game. They didn’t see him get hit, but he sure as hell acting like he got his bell rung, and he’s not 100%. He’s done a good job, the trainer tells him, but he’s got to sit out the rest of the game.

Junior is devastated. The men he looks up to, who are just about the only reliable father figures in his life, are doubting his ability to play. He’s letting them down. His teammates ask him how he’s doing, when they hear he’s benched, and he shrugs it off and tells them that somebody else needs a chance to get in the game. Watching from the sidelines, as his team advances down the field to win, he cheers along with the rest of the team and celebrates their victory. But he’s not feeling completely “there” and the celebration feels weirdly remote to him.

In the locker room afterwards, he finds that the lights overhead and the loud echoes of cheering, roughhousing teammates are more than he can take. He puts a towel over his head and tries to shut his ears, but he can’t get away from the lights and the noise. The trainer comes over and tells him he needs to see a doctor, because he might have had a concussion. Then the trainer calls his mom to warn her. His dad isn’t home — he’s traveling for business. And instead of being one of the jubilant players who helped his team to victory, he’s now a mama’s boy who’s pushed to the margins and can’t be part of the celebration.

The only good thing about this, is that his dad isn’t around to give him shit about being getting hurt and being a wuss who couldn’t suck it up.

The doctor visit results in the worst news possible : CONCUSSION. “Probably a mild one,” his doctor says, but Junior wonders what’s so mild about this killer headache, confusion, fatigue, and inability to deal with light and noise. The doctor prescribes complete rest for a week — no television, no reading, no activity of ANY kind, including physical activity. Definitely no football. Not till his symptoms clear.

Junior sits it out. He stays home from school, chafing under the change to his daily routine and the loss of his friends around him. Some of his teammates come over to the house to visit, but he’s so tired, he can’t spend much time with them. His symptoms don’t seem to be going away, no matter how much he rests. He’s going out of his mind, climbing out of his skin, and he can’t seem to get his bearings. He feels slow and stupid. Dense. Retarded.

He’s not himself, and the tenuous hold he had on his evolving identity, is slowly slipping away. His friend are all busy doing what they do, and his team has moved on to post-season play, with a chance at the championship. He tries to adjust to things, tries to stay positive and up-beat, but without football and without being part of his team as an active member, he feels like he’s been set adrift on a raft in a vast sea, as all the other boats sail right past him and leave him in the dust.

Junior starts hanging around with the wrong crowd. They’re the pot-heads and partiers who hang out after school at a playground not far from his house. He’s not going to football practice, and his buddies don’t know what to do with him, but he needs some sort of social interaction. Those “losers” he used to laugh at are now the only people who actually make time for him. When he’s hanging around with them, nobody cares if he’s stupid or slow. All that matters is that he drinks and smokes pot and hangs out with them.

That’s easy enough to do. And his new friends realize that this clean-cut football player dude would probably do a pretty good job of getting hold of some beer for them on the weekends. He looks respectable, and with a fake id, he could probably pass for 21, if the light in the bar is dark enough and his id is good enough. They hook him up with a fake id, and drive him out to a bar a few towns over. They drop him off and tell him they’ll circle the block and pick up him up with the sixpack of beer he’s supposed to buy.

Junior takes a deep breath and steps into the bar. It’s smoky and dark and he’s never done this before. He’s also scared shitless, as he approaches the bar, and when he produces his id, his hands are shaking a little from all the adrenaline in his system. As he fakes his way through purchasing “a six” suddenly all the fogginess disappears. As the adrenaline rushes through his veins, he feels a clarity and a focus that he hasn’t felt in months. Suddenly, all of his senses are ON. He’s not dense, and he’s not retarded. He finds himself actually able to carry on a conversation with the man behind the counter, who is clearly skeptical about his age, but begrudgingly sells him a six-pack.

Feigning nonchalance, Junior tucks the six under his arm and saunters out to the street, where his friends are just now coming by to pick him up. Beneath his casual veneer, he’s feeling more alive than he can remember feeling in a very long time.

Jubilation! He did it! They drink the six-pack while driving around on back roads, and for the first time in a long time, Junior feels like he actually achieved something useful. He’s part of a team again, and the adrenaline rush, the focus, the intensity of it all… well, it feels a little like old times. Except this time, it’s real-life, not just on a football field.

This time, too, the payoff is a buzz from the beer, on top of the adrenaline — and by the time his buddies drop him off at home, he’s feeling more normal than he has in a long, long time. In real time, it’s only been a few months of feeling “off”; in teen years, it’s been half a lifetime.

But now he’s back.

You can probably imagine the continuing scenario. Junior’s initial success at buying beer for his buddies continues. He hones his technique, learns the best places to buy booze, and he pushes the envelope, working his way up to buying cases. When the local bar owners catch on and stop selling to him, he finds older guys who will buy for him, and they exchange money and goods at the back loading dock at his work. The thrill of buying from someone else hardly does it for him, however, so he takes up reselling to others, playing middle-man in an informal network of underage drinkers. He expands ihs business into drugs, including some pot and some speed, but he steers clear of the really hard stuff.

With the extra money he makes, he buys himself a nice, fast car, and he starts to rack up speeding tickets. The only thing that keeps him from losing the car is his graduation and moving out of his parents’ house to go to a college (that he barely got into) several states away. His grades never did recover fully after he was benched, and he never did get back into football. His symptoms just lasted too long, and by the time they subsided, he was too entrenched in the party life to give a shit about football or any of those jocks he used to hang out with. He got a new life — one that was almost as full of comaraderie and excitement as his football life — but that got him money and, in some ways, more thrills.

In college, the drinking and drug scene is much more pronounced, but enforcement is a lot more regular, so the thrill of peddling controlled substances disappears. If nothing else, Junior is practical. Plus, he meets up with some guys who are into extreme sports — bungie jumping, rock climbing, backwoods mountain biking, windsurfing, waterskiing, and even skydiving. He gets active again, gets back in shape, and has a new bunch of friends who like to party as much as they like to push the envelope with extreme sports. Once again, he’s part of a team, part of a cohesive bunch of compadres who — much more than was ever true in high school — rely on each other intensely, sometimes for life and death.

Junior does okay in school. Not stellar, but not flunking out. He’s sure he’ll graduate and be able to get on with his life.

The only problem is, he keeps getting hurt. Not big injuries, mind you, but little things. Little stupid things. Like wiping out during waterskiing and messing up his neck and back. Like getting dumped off his board while windsurfing. Like taking some spills while mountain biking and falling a few times while rock climbing. His buddies tease him about it, and he fights like crazy to get back after the injuries. But each time, it feels like a little more of him goes missing. He has a hard time concentrating. He has trouble with lights and noise. He loses his temper a lot. He can’t seem to hold his liquor like he used to. He gets in fights, too. His buddies stay pretty steady with him, they watch his back, and he does manage to keep up. But still, something just doesn’t feel right.

So, he pushes even harder, putting himself in more and more dangerous circumstances to get that rush, that focus, that intensity that keeps him PRESENT as nothing else can. When he’s dull and dense, he feels so stupid, so useless, and he hates feeling that way. That’s not him. It’s not who he is. But when he’s standing at the open door of the airplane with his parachute strapped on, looking down at the earth below… well, it’s magic. And as he’s hurtling through the air, finally — at last — he feels like himself again.

From here, the story could go in just about any direction. Junior could be killed in an accident. Or he could be arrested for assault or manslaughter, repeat the offenses while drunk or high, and spend much of his life in prison. He could experience a religious conversion and turn his life around with the help of his church. He could meet a good woman who gets him back on track. He could find work as a stuntman and do well for himself. Or he could end up unemployable and on the streets with a drug/drinking problem and dementia from all the hits he’s taken.

Anything is possible. Any outcome — good or bad — is as likely as any other. But even knowing he could “fix” the problems to some extent won’t change the fact that losing his connection to his emerging identity when he was in high school scrwed him up. It took him on a detour that separated him from the things that mattered most to him — the things that helped him define who and what he was. And the only way out of that detour, was a massive adrenaline rush that blocked out all the confusion, sharpened his senses and made him feel like he was back.

See, here’s the thing — traumatic brain injury, concussion, head injury, whatever you want to call it, can cause the processing in your brain to slow significantly. And you may not even realize it, a lot of the time. When I had my neuropsych eval and the results for my processing came back signfiicantly slower than I thought they “should be” it was pretty devastating to me. BUT it suddenly made a lot of things make sense. Especially when I looked at how I got myself back to feeling “up to speed”.

Like Junior, I was hurt in a high school football episode (though mine was a lot more informal). I was also hurt in a soccer game. For all I know, I could have been hurt playing baseball, too — I just don’t remember any specific instances. And I spent a whole lot of time over the years looking for ways to pump up my adrenaline and feel like I was up to speed again. Slowing down when you want to go faster can be devastating for a teenager, and the last thing you can do is ask for help because you don’t want to look bad or seem “retarded.” I also spent a lot of time with the party crowd, driving back roads on many a night, looking for booze and smoking weed. Did I like the people I was partying with? Not always. But they accepted me for who I was, and they also stuck together when we were out on beer runs. We had that comaraderie I missed when I was out of sports. I managed to keep myself in games, even after I got hurt (people didn’t know much about concussion back then), but when the seasons were over, and the teams had all dispersed, who was I and what did I have to live for? I wasn’t entirely sure.

Now, over the years after high school, I did manage to get on with my life. I went to college (had four years, but didn’t manage to graduate), and I went on to find jobs and build a life I could be proud of. But that nagging sense of having lost part of myself never truly went away. And after each successive injury — the car accidents and the falls — I felt like I lost a little more of myself. I would build back… but then I’d get hurt again.

And to compensate, to make up for things and develop some sense of myself as a unique individual, I worked my ass off in just about every area of my life. I also got in the habit of pushing the envelope — taking risks, courting danger, doing things that no sane person would do (like buying a one-way ticket to Europe without any clue how I would get back). I went head-to-head with the law. I got myself in trouble (restraining order and all).  I ran around with edgy people who could have gotten me killed.

Those risk-taking, danger-seeking activities made me feel so ALIVE. So together. So with it. When I was high on adrenaline, hopped up on stress hormones, all the pains and distractions of my life disappeared. They just faded away, blocked out by the biochemistry in my brain and body. Going head-to-head with a crazy dude who lived in my apartment building might have been stupid, dangerous, and self-destructive, but when I was doing it, I felt so… “normal”. I actually felt like myself. And as bone-headed as it was to start shouting at a police officer, when I was yelling, I felt more like myself than I had in weeks.

Those kinds of activities, lame-brained as they were, offered me something that no amount of good sense could — a biochemical pump that got my brain moving at a rate of speed that made me feel like a regular person. When I wasn’t pushing the envelope, I felt so dumb, so dense, so useless. I often still do.

But as helpful as these adrenaline-producing activities hav been, they have also stressed and fatigued me and set me up, biochemically, for a TBI-induced case of PTSD that’s far less “serious” than, say, a case induced by war or other violent trauma, but still had an impact. Years and years of working-working-working to get myself pumped and moving at a speed that makes me comfortable, jammed my sympathetic nervous system in permanent high gear, like a runaway Prius, to the point where up until a few years ago, the idea of relaxing was so foreign to me, I had decided that there was no good reason for me to bother with doing that.

And I’ve had to train myself to relax. Seriously.

In terms of my overall life, I have to say that TBI and PTSD have walked hand-in-hand, and my constantly revved state contributed directly to my fall in 2004, which nearly derailed my life and cost me everything. Jammed in permanent high gear (in part because of lacking a clear sense of who I was and what place I have in the world), I was overly tired and not paying attention when I was standing at the top of those stairs. Down I went. BANG-BANG-BANG went my head. And my life turned to shit.

Had I not been injured in high school, would I have made it through in one piece? Who can say? I’d already had several concussions prior to high school, and I had already developed a lot of difficulties with behavior and choice-making. Hell, I was getting in TBI-related trouble when I was 12. So, I can’t lay it all at the feet of the sports concussions. But I suspect that if I hadn’t had those injuries and hadn’t lost touch (in the off-season) with the identity that sports gave me, I might have had a fighting chance to get myself on the good foot and form a better foundation for the rest of my life.

Obviously, there’s no way to tell how things might have gone. But we sure as hell can see how things CAN go, after a traumatic brain injury. It’s never too late to turn things around, but losing your sense of self can certainly do a job on a young — or older — brain and send you down a path that it would be better if you avoided.

This ends the fifth part in a multi-part exploration of sense of self and how it’s affected by traumatic brain injury. Read the other sections here. More to come…