Concussion and WCB: TBI Series Part 1 of 3

Real Voices, Real Experiences

“Car accident 5 years ago. Still not feeling myself. It was suggested to go back to work. Still can’t cope. My anxiety levels are high. I get upset very easily and I cry in front of others.” — Injured worker “Took me 3 years to recover from a concussion. Hardest part of my life with a lot of uncertainty and almost no knowledge about it in the medical community. Was left to fend for myself.” — Injured worker “I’m currently in bed suffering from a blow to my head from a freak accident at work that caused a concussion, whiplash, and two herniated disks. I was hospitalized for one week and discharged. But driving home I realized I was not OK. Now it’s constant migraines, brain lasers, eye blurry, paranoia, fight or flight, dizzy, and get stuck in rumination, can’t sleep, and anxiety. I filed a WCB claim that was initially accepted, but later denied because I didn’t black out from the head injury.” — Injured worker “Everyone in rehab knows concussion IS brain injury. Not always mild. TBI patients can be the most challenging to rehab. I have treated gunshot victims, car accident victims, and beatings both adult and pediatric. The ones who deny their deficits due to their brain damage resist therapy and adaptation to deficits, and go on to essentially destroy their lives. Their families can’t take it, their jobs are lost, and they persist in making poor choices. Most times their families and coworkers don’t realize these people are brain damaged, not jerks.” — Clinician

On the surface, an intelligible veneer; underneath, an unintelligible reality

Concussion resides in a category of simple words used to denote highly abstract concepts that often get tossed around casually, even flippantly, as they enter into common usage. And as these dumbed-down terms for esoterica go mainstream, we’re tricked into believing we actually grasp the deeper meaning. Take “time” for instance. In daily life, reference is made to “time” in a very practical sense. It’s a measurement that helps us organize our day, keep track of events, and plan for the future. We casually refer to it as passing quickly or slowly, and it’s segmented into seconds, minutes, hours, days, and years. However, when we delve into the realms of physics and philosophy, the understanding of time shifts dramatically, becoming more intricate and less intuitive. Einstein’s theory of relativity, for example, challenges the notion of time as absolute and unchanging. It posits that time’s passage can vary based on an observer’s velocity and the intensity of the gravitational fields they are in, leading to phenomena such as time dilation, where time can pass at different rates for different observers. Therefore, while the word “time” is ubiquitously used in everyday discourse, its profound implications in scientific and philosophical contexts reveal that our common understanding of it barely scratches the surface of a much deeper and more mysterious concept. The term “concussion” serves as another intriguing example of how a seemingly straightforward word, commonly used in everyday language, actually encompasses an arcane and abstract medical concept. Similar to “time,” “concussion” is a word that many people feel they understand intuitively, but its scientific and medical implications are far more nuanced and intricate. In everyday conversation, a concussion is often casually referred to as simply a knock on the head or a minor brain injury, typically expected to resolve without serious consequences. This colloquial use significantly downplays the complexity of the condition. People generally understand it as something one might get from a fall or during a sports game, with symptoms like a headache or dizziness that are expected to go away on their own.

The nature of concussion

A concussion is a type of traumatic brain injury that occurs when the brain experiences a violent shaking or movement within the skull. This description aligns well with the literal translation of the word “concusses” from Latin, meaning “to shake violently.” To visualize this, imagine the brain as an egg yolk within a shell. The brain, like the yolk, is encased within a hard cavity – the skull. When the head is subjected to strong forces, such as during rapid acceleration or deceleration, or when it experiences a translational (sideways) movement, this can cause the brain to shift or move inside the skull. This movement is not normal for the brain and can lead to injury. This sudden movement can create chemical changes in the brain and sometimes stretch and damage brain cells. According to Dr. Micky Collins, Ph.D., an expert in the field of brain injuries, when the brain moves inside the skull, it results in the stretching of the neuron’s membrane. This stretching leads to the leakage of potassium, a chemical that is typically contained within the neuron, into the extracellular space. This event triggers an increased demand for glucose or energy, a response to the potassium release. Concurrently, there’s an influx of calcium. The calcium, crossing the stretched membrane, enters the cell and causes vasoconstriction, leading to a decrease in cerebral blood flow. At this critical juncture, while the brain demands more energy due to hyperglycolysis, the influx of calcium leads to vasoconstriction, thereby decreasing cerebral blood flow and reducing the energy supply. Dr. Collins explains that a concussion is fundamentally a mismatch between the demand for and the supply of energy to the cell. Notably, this mismatch does not lead to cell death, axonal degeneration, or structural changes to the neuron. However, it does impair the cells’ ability to operate efficiently. Dr. Collins’ research has revealed that this energy problem can lead to the decompensation of different systems within the brain. This understanding has led to the identification of six different types of concussion-related issues.

Diagnosis

You don’t necessarily have to be struck on the head to sustain a concussion. Situations like whiplash can be enough to generate a concussion, given the brain’s jelly-like consistency. The impact force can cause the brain to not only hit the skull but also twist or rebound against the opposite side. According to John Leddy, a renowned concussion expert at the University at Buffalo, this results in a kind of cellular chaos. Brain cells undergo stretching and twisting, blood vessels may leak, and neurotransmitters — the brain’s communication chemicals — are released haphazardly into the spaces between brain cells. This leads to a dampening of the brain’s electrical activity. Research on the concussion cascade indicates that this event is followed by a period of reduced activity in brain cells and decreased blood flow within the brain. Dr. Micky Collins, Ph.D., further elaborates on the current understanding and challenges in diagnosing and treating concussions. He notes that significant progress has been made in comprehending the pathophysiology of concussions, though not completely, with insights gained from animal model research. Clinically, there’s now a better understanding of how to evaluate concussions and apply more targeted treatments. However, Dr. Collins emphasizes a major challenge in concussion diagnosis: the lack of a reliable biomarker. Currently, there’s no blood test, serum marker, or imaging technique that can definitively diagnose a concussion. Concussions are not visible on MRIs, PET scans, magnetoencephalography or electroencephalography. Even cerebrospinal fluid (CSF) analysis, despite being researched, doesn’t offer conclusive evidence of a concussion. The difficulty lies in the nature of concussions being at the cellular level, presenting as an energy crisis without structural changes in the brain. This absence of visible brain alterations makes it challenging to find a biomarker.

Energy crisis

To revisit the fundamental concept of how concussions occur, let’s consider the movement of the brain relative to its protective enclosure within the skull. When the brain moves sharply, the neuron’s membrane stretches. This stretching likely leads to a passive release of potassium from the neuron. As a result of this potassium effusion, there’s an increased need for glycolysis – the process of producing energy (ATP) – to actively pump the potassium back into the neuron, against its natural gradient. This increased demand for glucose is essential for generating more ATP, which is needed to force the potassium back into the neuron, a place it naturally doesn’t want to go. When calcium enters the cell, it leads to vasoconstriction and a decrease in cerebral blood flow. This situation creates what’s known as a metabolic mismatch or energy crisis for the cell. At this stage, it’s important to note that the cells don’t necessarily die from this process. Instead, they operate at a diminished level of efficiency. What’s observed as a result of this energy problem is that various systems in the brain, particularly those requiring a lot of energy, don’t work as efficiently. These systems can decompensate due to the energy deficit.

Fights dirty

Dr. Micky Collins highlights an important aspect of concussions: their tendency to exacerbate pre-existing vulnerabilities or weaknesses in individuals. According to him, concussions “fight dirty,” meaning they disproportionately affect whatever aspects are already weak in a person. This observation underscores the notion that pre-existing risk factors can influence not only the likelihood of suffering a concussion with less force but also the specific type of concussion one might experience. For example, Dr. Collins points out that individuals with a history of car sickness are more prone to getting concussions and are likely to experience vestibular problems following the injury. This susceptibility applies to other pre-existing conditions as well. People with a history of migraines may experience concussions more easily, and the concussion is more likely to trigger migraine-related symptoms. Similarly, those with a history of lazy eye or strabismus (misalignment of the eyes) are more inclined to suffer ocular-related issues post-concussion, even with less force. Furthermore, individuals with a history of anxiety are more likely to experience related symptoms following a concussion. This pattern suggests a concept akin to “neuronal reserve,” which Dr. Collins compares to the idea of cognitive reserve in neurology. Cognitive reserve refers to the mind’s resilience to neuropathological damage. In the context of concussions, a person’s pre-existing neurological and psychological conditions could determine their brain’s vulnerability to injury and influence the specific pathways of dysfunction following a concussion. This understanding is crucial for tailoring concussion treatment, as it indicates the need to consider an individual’s entire medical history and not just the immediate symptoms of the concussion. Dr. Collins continues to elaborate on the vulnerabilities associated with concussions, noting the significant role that gender and other risk factors play in the likelihood and nature of concussion outcomes. He points out that females are more susceptible to concussions compared to males. This increased vulnerability can be attributed to several factors, including differences in neck strength and hormonal influences. Dr. Collins also mentions that females are six times more likely to experience migraines and car sickness than males, which further heightens their risk for concussion-related complications. This gender disparity is evident in the demographics of patients treated in his clinic, where 60% of the concussion patients are female, and 40% are male. The reason for this skewed ratio, as explained by Dr. Collins, is the higher vulnerability of the female population to concussions. Additionally, he observes that females tend to have longer and more complex recovery outcomes compared to males, a difference he attributes to the factors mentioned earlier. Dr. Collins’ insights underscore the importance of considering gender-specific factors and individual medical histories when evaluating and treating concussions. This approach acknowledges the unique risks and challenges different groups may face, leading to more effective and personalized concussion management strategies.

Part two of three

Stay tuned for the next installment in our three-part series, where we will delve further into the nuances of concussions. In part two, we’ll explore the range of symptoms associated with concussions, examine predictors of severity, and discuss the critical role of early and effective treatment. We’ll also shed light on the six distinct types of concussions, assess the effectiveness of various treatment approaches, and consider factors that influence the recovery process. Additionally, the importance of consulting with a specialist and understanding the prognosis for recovery will be highlighted. In the final part of our series, part three, we will navigate the complex terrain of concussion injuries in the context of WCB benefits. This segment will address the unique challenges individuals face when seeking compensation for concussion-related injuries sustained in the workplace, offering insights and guidance on navigating these often challenging scenarios. Meanwhile, if you or anyone you know has suffered a brain injury at work, you can reach out to us for a consultation.
Call (780)-340-5727 to speak with our 541 Eagleson Wynd, Edmonton T6M 0Y4 team for free.
Picture of Ben Barfett

Ben Barfett

Ben Barfett, Principal and Consultant, has spent his life in the construction sector, specifically heavy civil, enviro, commercial, and energy. Having held senior roles in business development, technical advisory, and regional management, he earned his stripes in the field and in head office. Conscious of the interplay between commercial, legal, and execution aspects of construction, his business insights are informed by expertise in WCB policy and enhanced with disability-specific training.

Picture of Ben Barfett

Ben Barfett

Ben Barfett, Principal and Consultant, has spent his life in the construction sector, specifically heavy civil, enviro, commercial, and energy. Having held senior roles in business development, technical advisory, and regional management, he earned his stripes in the field and in head office. Conscious of the interplay between commercial, legal, and execution aspects of construction, his business insights are informed by expertise in WCB policy and enhanced with disability-specific training.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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