Post-Concussion Syndrome: A Physician-Mother’s Perspective
I think a third barrier to broader acceptance of what I believe is an effective treatment, is lack of imagination or perhaps intellectual/professional laziness. We don’t understand how it could work, and anyway we believe in the treatments we are using which we contend have been demonstrated to work pretty well. As I commented in part to Brooke de Lench in an October 2013 article on the very helpful website, MomsTEAM.com (7), “Medicine is both a pragmatic (evolving practice by “what works”) and an intellectual (building knowledge by hypothesis driven investigation) pursuit. It is inherently conservative – appropriately so – in order to ensure that new treatments are safe and effective. There are many examples of theoretically sound treatments which, after greater use, were found to be not only ineffective, but dangerous.”
On the other hand, of course, the history of medicine is full of examples of medications/treatments that worked, so we used them long before we understood their mechanism of action. I think as we understand more about brain function in health and disease we will learn exactly how the treatments applied in the Carrick program positively influence the injured areas they are devised to treat.
As I observed to de Lench in the MomsTEAM article, “But sometimes conservatism can hinder the development and more widespread use of important treatments. This is especially a problem in today’s highly specialized world of medicine, where communication between specialties about promising treatment modalities may be limited. It is always easier to do what we have always been doing pretty successfully than to keep checking “outside the box” for something that might work better.”
As a perfect example, “In my field of surgery, it took decades for the technology of laparoscopic surgery to move from gynecology, where it was first introduced, to general surgery and then to surgery in general, and beyond to robotics and complex access procedures such as those described by Dr. Rovin. You could say that this was the biggest development since anesthesia, but it had to overcome professionally entrenched opposition to become the standard of care it is today.”
Changing the future
I suspect that some of this conservatism will need to be overcome to bring these promising techniques of diagnosis and treatment into the mainstream of concussion management. No doubt this will happen, as it always does in medicine, by a combination of empirical progress (subjective and objective data supporting the use of these techniques in post concussion and other traumatic brain injury patients) and intellectual advances (research into the neurological mechanisms that underlie both injury and recovery). The data from Carrick et al, showing sustained improvement in PTSD scores at 3 months post- treatment, supports the contention that real and durable neurological changes have been brought about by the treatment process. I believe that additional studies will corroborate these findings and bring this approach into the mainstream.
In the meantime we should consider these words from Jerome Frank in his excellent chapter on The Placebo Response and the Role of Expectations in Medical and Psychological Treatment:
Humans are time binding creatures, so assumptions about the future have a powerful effect on their present state.” Hope may have been an evolutionary requirement for human survival as suggested by the neurobiological studies such as those mentioned earlier. But even the ancients intuitively recognized the role of hope in human affairs in legends such as that of Pandora’s Box: When all the evils have been released, there is still hope and it is a powerful force for change.
Finally, as noted by Kaptchuk and Miller (3), in the New England Journal article, “Medicine’s goal is to heal, which can include cure, control of disease, and symptom relief or provision of comfort”. As we assess the efficacy of new treatments for traumatic brain injury, we would do well to include all the elements of the goal.
Anyone who has suffered from post-concussion syndrome or TBI, or is close to someone who has, knows that there is a desperate and increasing need for new effective therapy. We must encourage, study, support and facilitate implementation of promising therapies regardless of the discipline from which they originate.
- Tyler ME, Kaczmarek KA, Rust KL, Subbotin AM, Skinner KL, Danilov YP. Non-invasive neuromodulation to improve gait in chronic multiple sclerosis: a randomized double blind controlled pilot trial. J Neuroengineering & Rehab. 2014;11:79-89.
- Carrick FR, McLellan K, Brock JB, Randall C, Oggero E. Evaluation of the effectiveness of a novel brain and vestibular rehabilitation treatment modality in PTSD patients who have suffered combat-related traumatic brain injuries. Frontiers in Public Health 2015;3;Article 15: 1-8.
- Kaptchuk TJ, Miller FG. Placebo Effects in Medicine. New Eng J. Med. 2015;373(1): 8-9.
- Sharot T, The Optimism Bias. Current Biology 2011;21;23:R941-945.
- Sharot T, Korn CW, Dolan RJ. How unrealistic optimism is maintained in the face of reality. Nat Neurosci. 2011;14:1475-1479.
- Garrett N, Sharot T , Faulkner P, Korn CW, Roiser JP, Dolan RJ. Losing the rose tinted glasses: neural substrates of unbiased belief updating in depression. Frontiers Human Neurosci. 2014;8, Article 639: 2-9.
- Brooke de Lench. “Post-Concussion Syndrome: New Therapies Offer Hope.” (http://www.momsteam.com/health-safety/post-concussion-syndrome-new-therapies-offer-hope-says-mom-hockey-star-Caitlin-Cahow) (October 16, 2013)
- Frank JD, Frank JB. Persuasion and Healing: A Comparative Study of Psychotherapy (Johns Hopkins University Press, Baltimore and London 1993).
Originally presented at the International Symposium On Clinical Neuroscience, Traumatic Brain Injury & Neuro Degeneration. Orlando, FL, December 10-12, 2015