Fighting Through the Fog of Concussion
FROM THE MAY 2015 ISSUE
Fighting Through the Fog of Concussion
The trauma of a concussion left me struggling to reclaim my mind — and my life.
By Clark Elliot|Thursday, April 02, 2015
RELATED TAGS: BRAIN STRUCTURE & FUNCTION
It took a relatively minor car crash for Clark Elliot’s life to change forever. The resulting concussion turned everyday activities into exhausting trials and left him struggling to regain normalcy.
On Sept. 27, 1999, my world as I had known it for 43 years ended.
I was sitting at a stoplight at the intersection of Oakton and Gross Point Road in Morton Grove, Ill., on my way to give a lecture at one of DePaul University’s suburban campuses, waiting behind two other cars. A steady drizzle was falling.
Without warning, a Jeep skidded on the wet pavement and slammed into the back of my Mazda sedan. My head bounced off the headrest behind me and then was flung forward. I saw stars and blacked out for a second. I was groggy, but I pulled my car out of the busy intersection, drove around the corner and parked on the side of Gross Point Road. I felt shaken up, but only in the way anyone who had been in a relatively minor car crash might.
A Morton Grove police officer arrived to take the accident report, and I got out of my car to meet him.
“Get back in your car and sit there until the ambulance comes!” he said after he got a look at me. “I’m calling them now.” This was puzzling to me. I couldn’t understand why he was so concerned.
The ambulance came, and a pair of young paramedics, a small man and a large one, had me sit inside it as they examined me.
“Do you know your name?” asked the bigger one.
I thought about it. It seemed like an easy enough question. But nothing immediately came to mind. I was reaching into the usual place in my mind, and retrieving nothing at all. How odd, I thought. After a minute I managed, “Sure. Clark Elliott.”
“Well, Mr. Elliott, I think you’d better come with us to get checked out at the hospital.”
“Whoa!” I said. “I can’t do that. I have to get to class.”
“Listen, Mr. Elliott,” said the smaller paramedic. “Pardon my expression, but you’re pretty f—ed up here. We really need to take you to the hospital.&rdquo
“Thank you for your concern,” I said, smiling at him, “but I’m fine. I really can’t go with you because I have to teach tonight.”
I didn’t hurt very much. I’d given a thousand lectures over 12 years without ever missing one. It would take a lot to make me miss class. My students were expecting me to show up shortly and teach for three hours. I felt strange, but I could not recall what it was like to not feel strange.
I couldn’t make sense of what they wanted me to do. I couldn’t see it in the normal way. So I refused to go to the hospital.
“OK,” said the larger paramedic. “We can’t stop you. You’ve got to sign these release forms, and then we’ll let you go. But you are doing the wrong thing.” I climbed out of the ambulance and went back to my car.
The back of my Mazda was all smashed in, but the car was still running fine. So I drove to work, mindlessly following the path I had taken many times before. Later that evening, I thought it odd that I could not remember a single thing about the rest of my drive to work. The details of my evening-class lecture were spotty, but I remember I worked on autopilot and lectured sitting down. There were difficult moments when I stopped midlecture and had to rest my head down on my desk. But DePaul’s graduate students are a bright, multiethnic, salt-of-the-earth sort of crowd, and we joked about my loopiness being caused by the automobile accident. None of us took it seriously.
When I finally arrived home, it was hard for me to get up out of the car. It was hard for me to walk from the car to the house. I had a strange and persistent difficulty unlocking my front door. The next morning, I was still physically exhausted. I tried to get up and start my day, but I couldn’t move. I was giving the command to my body: “Get up!” but it was not listening. Finally, after a long three minutes, once I was able to manage the smallest initiation of motion, I was able to stand up and move normally.
Over the next hour, I noticed several more instances of my being unable to initiate action. I brushed any concern aside, telling myself that my muscles had just been “shaken up” more than I realized the day before in the accident, and that since the muscles were sore and tired, it was hard to get them to respond. It would take me four more days — and a puzzling episode where it took me six hours to realize that I had my shoes on the wrong feet — before I finally got myself to an emergency room for the diagnosis: a concussion.
Concussion and Balance
Unless you have experienced a concussion and lost efficacy in your balance system, you probably have no idea how devastating the effects of this can be in one’s life. Because of inner-ear damage — yet another result of the crash — I had to deal with balance issues every day.
Roughly speaking, the balance system uses three overlapping components: the vestibular, or “inner ear,” system, the visual system and proprioception, the feeling of our bodies in the space around us — a position-movement sensation. While the vestibular system is primary, the other two are also important, and the interaction among the three systems is far more complex than we generally consider.
Whenever I walked around the university — where I had to think throughout the day — I would simply run an index finger along a wall as if I were goofing around. People tended not to notice this much, especially if I kept my hand low on the wall, and it was much better than looking drunk by weaving around in hallways and classrooms.
Photo by Kevin Miyazaki/Redux
Our vestibular and proprioceptive systems give direct information to our bodies to help them stay upright. But there is also a critical feedback loop between these two systems — processed in our brain stem — and our eyes.
The vestibulo-ocular reflex, for example, uses input from the brain’s assessments of position and velocity to stabilize our gaze while we’re moving. Our eyes adjust to stay fixed on an object the instant we move our head because the reflex makes microcontrolled adjustments in the extraocular muscles, causing the eyes to counter head and body movements. You can see this effect by looking directly at your own eyes in a mirror and moving your body around. In addition, these subsecond microadjustments are integrated with our ability to simultaneously adjust for the pursuit of objects moving in our environment as well, so we can turn our heads and bodies while still following the path of a bird flying across our yard. So our balance system controls our eyes.
But the relationship between our eyes and our balance system works in the other direction as well, and our eyes control our balance. When our vestibular system is underfunctioning — as often happens with head injury — our eyes can take over much of the load. We can illustrate this with a simple exercise: 1) Stand on one leg with your eyes open and your other knee up high; usually this is not too much of a problem. Notice the muscle adjustments in the foot that is on the floor. 2) Close your eyes, but continue to stand on the one leg. Depending on how effective your vestibular and proprioceptive systems are, you will experience varying degrees of increased difficulty when you lose the visual input (with a corresponding increase in the microadjustments in your foot). The more your balance depends on your vision, the more you’ll start to wobble when you close your eyes.
Like many concussives, I had many episodes involving motion sickness that gave me trouble. For example, several weeks after the crash, I tried to take the elevated train downtown. Within a few stops, I felt so sick that I vomited in the train car and had to roll myself out through the doors onto a platform.
“I’m sorry!” I said to the variously disgusted and concerned passengers. “I don’t know what happened. I’m sorry.” It took me three hours to recover sufficiently before I could walk home.
On an evening almost a year later, I was exhausted from teaching class, and it was hard for me to walk — it took me an hour to get down the stairs of the classroom building. I didn’t want to face walking up the stairs again in the building where my office was, so I talked myself into thinking it would be OK to take the elevator up to the sixth floor. This was a mistake. Once the elevator doors opened on six, I tumbled out onto the floor and crawled to the wall, where I could prop myself up. I rested there for 15 minutes, pretending to be sitting on the floor reading a book whenever students came by. Then I crawled to my office on my hands and knees and rested on the floor for an hour to recover my equilibrium.
Balance, Vision and Thought
Because I had suffered vestibular system damage, my already-overtaxed and poorly functioning visual system had to take on the extra load of providing for many of my balance needs. But at the same time, any sort of high-level thinking also required those same visual/spatial systems to create the internal images of thought.
Thus, we have the following: Under the cognitive load of thinking — which almost always entailed visualization, pattern matching and generating the spatial imagery to form analogies — my damaged brain would rapidly grow fatigued. The visual/spatial circuitry would get overloaded and could no longer manage its double duty making up for the vestibular system, and I would lose my balance. The same thing would happen when I had to use my visual/spatial circuitry to interpret meaning in complex sensory input — such as speech, or the complicated visual patterns on store shelves. One of the worst combinations would be when I had to use the visual systems in my brain simultaneously for both complex thinking, or sensory interpretation and intense balance calculations.
As my brain fatigue grew during even short periods of cognitive load, my balance would grow progressively worse, and nausea would almost immediately set in. Depending on what I was thinking about, or the physical task I was working on, I would start to lose my balance within five minutes.
I developed a surreptitious remedial balance technique: Whenever I walked around the university — where I had to think throughout the day — I would simply run an index finger along a wall as if I were goofing around. People tended not to notice this much, especially if I kept my hand low on the wall, and it was much better than looking drunk by weaving around in hallways and classrooms.
A neurological oddity that presented itself in my case, and one that you might notice in a concussive who is having balance problems, was that my index fingers would flex upward, with my thumbs out-thrust, while the rest of my fingers were relaxed downward, forming a flexed “L” between the thumb and index finger of each hand. If you put your arms out at slightly less than a 45-degree angle and raise your index fingers in this way, you will likely perceive this as a kind of balance-vigilant position.
Where the Body Ends
Our balance systems are integrated with other important but little-considered systems as well. For example, a collection of nerves in the superior parietal lobe, roughly under the crown of the head, is thought to help us distinguish where the body ends and where the external world takes over. Without the capability to make this distinction, it would be difficult for us to navigate through a world filled alternately with obstructions and openings through them. When brain activity in this area is naturally reduced — for example, when we drop off to sleep or fall into a deep meditative state — our sense of where the body ends is appropriately minimized.
My balance system is shot, and I have to rely on my eyes only, to know which way is up. The flood of data from my senses is overwhelming: the roar from the chain saw engine; the smell of oil burning on the muffler; the feel of branches pressing against me everywhere; sawdust,salty sweat and stinging two-stroke exhaust in my eyes and that I taste in my mouth.
Photo by Kevin Miyazaki/Redux
This body-demarcation sense is taken for granted by people who haven’t experienced a brain injury, but it can be quite troubling when it disappears unexpectedly. It is an interesting question to consider the relationships among the brain’s visual cortex, our balance systems and this body-versus-surroundings demarcation sense. My experience suggests that there is a link. Under brain stress — primarily visual and especially when making excessive demands on my visual system for balance — the boundary line between my body and the rest of the world became blurry.
This was most easily noticed in my almost ubiquitous (though relatively mild) difficulty passing through doorways, going down tunnels (such as stairways and Jetways) and getting into cars when my brain was tired. I would have to put my arms out to “feel” the spatialness of the opening — using my eyes to carefully examine the distinctions between my hands and the surrounding objects — and thus guide myself through manually.
A more striking example of this loss of body-environment demarcation happened five years after the crash, as a result of a set of intense visual-balance demands.
One of the 50-foot trees in my backyard had Dutch elm disease, which can spread throughout a neighborhood, so it had to be cut down. High-ladder tree work of this kind is intense and not for the faint of heart. To set this in context, consider that a pair of supermacho day laborers who earlier had done heavy work on the foundation of my house showed up and said they would cut down the tree for a budget price. They laughed and taunted each other before climbing up the ladder to get to work, but each of them returned down after only a minute — with their knees uncontrollably shaking. They soon gave up and left. I couldn’t afford to have it removed by other professionals, so in the end I had to manage it on my own.
I knew I would have to contend not only with the normal, rather striking visceral reactions of being so high up, but also with the added complications from my brain damage. The following diary passage is from a day when I had climbed 30 feet into the tree to cut off the highest branches, which themselves reached another 20 feet over my head. This episode simultaneously taxed my visual/spatial system for three separate tasks: the intense spatial planning of where the heavy tree branches were to be cut, and would fall; the meaningful interpretation of the incoming barrage of sensory input; and the essential need to keep my balance based primarily on the constantly moving visual input.
I am disoriented because I can’t look down, and so have to get my visual bearings from watching parts of the tree, which are themselves swaying in the wind. It’s all one chaotic swirl of sunlit green. My balance system is shot, and I have to rely on my eyes only, to know which way is up. The flood of data from my senses is overwhelming: the roar from the chain saw engine; the smell of oil burning on the muffler; the feel of branches pressing against me everywhere; sawdust, salty sweat and stinging two-stroke exhaust in my eyes and that I taste in my mouth. I am having difficulty managing the geometry of placing myself — my body, and the chain saw I’m holding — within the context of the moving tree. It’s as though I’ve lost my sense of — the demarcation point of — the boundary between my inner self and the outer world around me. Except for what my eyes can tell me as I stare intently through the fog of my safety glasses at both my boot and the saw ripping through the branch on which that boot is standing, I have no way of distinguishing between the two. I have to manually, continually, walk myself through the connections in the branching of the tree, and the differential branching of my body. I can’t tell the difference between them. Terrifying — given the circumstances, but also fascinating . . .
It goes without saying that after I climbed down, I was unable to walk, or even stand up. Having to manage the chain saw without the natural protection of knowing where my body ended was intense, and the base fear this truly odd experience generated was extreme. It took me a week to get the tree down, and another two weeks after that before my brain recovered.
From The Ghost in My Brain: How a Concussion Stole My Life and How the New Science of Brain Plasticity Helped Me Get It Back by Clark Elliott. Reprinted by arrangement with Viking, a member of Penguin Group (USA) LLC. Copyright © 2015 by Clark Elliott.