Physical Symptoms

Systems

Balance includes the ability to stay upright, maintain positions, and react to forces that could cause you to fall. It allows us to be able to move through our environment safely. Three systems help keep your balance:

• Sensory system: Sends your brain information about where body parts are in space and what type of surface you feel
• Vestibular system: Sends information to the brain and muscles to help you maintain balance, and to the brain and eye muscles to help you see clearly when your head is moving
• Vision: Sends your brain information about spatial relations and surroundings

Causes

• Benign paroxysmal positional vertigo (BPPV): BPPV occurs when crystals located in the inner ear get knocked loose and move out of place. The dislocated crystals cause the person to feel as though they are spinning. This commonly occurs when getting in and out of bed or with moving your head. This sensation can last several seconds to a few minutes. The condition is not life-threatening. It’s one of the most common vestibular disorders. It’s usually successfully treated with different positioning techniques performed by a physical therapist or doctor.
• Cervicogenic dizziness: Dizziness and/or lightheadedness can occur with neck pain, stiffness, or headache. This may happen with neck and head movements or holding the head in one position for a long time.
• Motion sensitivity: People sometimes experience dizziness that related to different movements. They may move very stiffly or slowly and avoid certain positions. Sometimes symptoms can occur with motion in the environment. After mTBI or concussion, a person might experience motion sensitivity related dizziness, nausea, headaches, or imbalance with movements, walking, turning, and riding in a car, as well as in busy environments and with bright lights.
• Vestibular ocular reflex (VOR): The VOR is responsible for the ability to see clearly when moving. Changes to this reflex after mTBI or concussion can cause dizziness when walking or moving, being in busy environments, trying to read, and when driving or riding in a vehicle.
• Additional causes
  • Medications
  • Metabolic changes
  • Some cervical spine injuries
  • Anxiety
  • Panic disorder
  • Migraines
  • Blood pressure changes
  • Other neurologic conditions

Symptoms

The vestibular system is often affected with mild traumatic brain injury (mTBI) and concussion. Symptoms include:

• Dizziness with rolling over in bed, lying down, sitting up, standing up, or walking
• Loss of balance frequently or loss of balance with specific activities or movements
• General dizziness
• Frequent falls
• Being unsteady with movement
• Difficulty focusing vision during movement
• Nystagmus, the rapid involuntary movement of the eyes
• Vertigo, a sensation of feeling off balance that can make it feel like you are spinning, or the world is spinning

Changes in the vestibular system can result in falls or decreased balance. This can cause:

• Injury to joints, muscles, and bones
• Limited ability to engage in leisure activities
• Limited ability to return to work
• Increased need for help from others

Treatment

• Vision or vestibular ocular reflex (VOR) exercises
• Repositioning techniques for BPPV
• Habituation exercises to reduce sensitivity to movement
• Walking and/or balance exercises
• Education

Ways to cope

Pain is a normal experience and acts as our body’s alarm system. Many areas in the brain are involved in perceiving pain, making each person’s experience unique.

Chronic or persistent pain is defined as pain experienced for 3 to 6 months or more. It can interfere with daily activities, reduce your attention, affect sleep, and reduce quality of life. Chronic pain creates changes in the brain, meaning pain is more complex than just the actual injury or tissue damage.

Chronic pain and mental health impact each other. Chronic pain often exists with post-traumatic stress, depression, or other psychological conditions. Living with post-traumatic stress or depression may worsen chronic pain. Living with chronic pain is a stressor itself, and pain may limit the ability to engage in previously enjoyed activities. In this way, pain can affect mood and quality of life.

Many people with chronic pain may use prescription medication to reduce symptoms. Studies have shown that people with both chronic pain and other psychological conditions were more likely to be prescribed opioid pain medications. These individuals may be more likely to use medications in a risky way, such as not taking it as prescribed. Make sure you tell your treatment provider all the
prescription and over-the-counter medications you are taking. Let your provider know if you’re taking more pain medication than prescribed, you’re combining pain medications, or if your pain is not improved despite using pain medications.

Finding a balance between avoiding activity and overdoing is important to your recovery. It’s fine to feel a little sore after activity, but not to the point where your pain prevents you from going about your day. Your care team can help you find ways to pace your activities. Some helpful tools for pain management may include:

• Cognitive behavioral therapy
• Correct posture
• Exercise, based on provider recommendations
• Healthy diet
• Healthy lifestyle
• Heat and/or cold treatments
• Massage techniques
• Pacing yourself
• Relaxation or meditation strategies
• Staying active
• Supportive sleeping positions

Ways to cope

Several types of headaches are commonly associated with mild traumatic brain injury (mTBI) and concussion. Many people take over-the-counter pain relievers, such as aspirin, acetaminophen, and combination medications to manage their headaches.

Tension headaches

• Pain description: Dull, pressure, and tightness that can feel like a tight band around the head
• Causes: Muscle tension, stress, and other
• Other symptoms: Fatigue, irritability, poor sleep, and trouble concentrating
• Treatments: Medications, relaxation techniques, biofeedback, massage, stress management, and physical therapy

Migraine headaches

• Pain description: Moderate to severe throbbing that may be worse on one side of the head
• Causes: Genetics, weather changes, hot weather, lack of sleep, hormones, stress, certain foods, hunger, dehydration, strong odors, strenuous exercise, and bright light
• Other symptoms: Nausea, vomiting, light, noise and smell sensitivity, pain with physical activity, and dizziness
• Temporary changes in vision and/or other sensations, also known as auras: May include seeing flashes of light, zig-zagging patterns, or blind spots; numbness, tingling, or weakness; and speech problems
• Treatment and prevention: Prescribed or over-the-counter medications, resting, limiting light and noise during migraine, and using an ice pack
  • Daily prevention: Medications as prescribed and avoiding migraine triggers
  • Other treatment strategies: Relaxation exercises, following a sleep schedule, keeping a headache diary, acupuncture, biofeedback, massage, and exercising as tolerated

Cluster headaches

• Pain description: Sharp, boring, severe, and rapid
• Causes: Uncertain, may run in families, may be caused by certain medications used to treat heart disease; and may be triggered by changes in sleep
• Other symptoms: Nasal congestion, tearing in eye, feelings of agitation or restlessness, and redness of eye
• Treatment and daily prevention: Prescription medications or medications that contain caffeine
• Daily prevention: Prescribed medications that reduce the frequency of headaches

Cervicogenic headaches

• Pain description: Dull, moderate to severe pain that may start in the neck and radiate to the head and face
• Causes: Irritated muscles, discs, tendons, and joints in the upper neck that refer pain to the head
• Other symptoms: Decreased range of motion

Rebound headaches

• Causes: Overuse of pain relief medications commonly causes rebound headaches, making headache symptoms worse. A rebound headache occurs when the effects from the overused over-the-counter pain medications wear off. The pain and frequency of rebound headaches can increase over time.
• Treatment: Speak with your doctor about what medication is right for you. Your doctor can recommend medication options and strategies for headaches during your recovery.

Treatment

Seek urgent medical care if the headache:

• Feels like the worst headache of your life.
• Feels different than your usual headaches.
• Feels like an abrupt, sudden headache.
• Starts suddenly or is aggravated by exertion, coughing, bending over, or sexual activity.
• Presents with persistent nausea and vomiting.
• Presents with fever or stiff neck.
• Presents with seizures.
• Is a result of a new head trauma or a fall.
• Presents with changes in vision, speech, or behavior.
• Presents with weakness or change in sensation.
• Does not respond to treatment and is getting worse.
• Feels like you need to take more than the recommended dose of over-the-counter medications for pain.
• Is disabling and interfering with work and quality of life.

Ways to cope

Hearing refers to the awareness of sound and placing meaning to that sound. It begins when noise vibrations travel through the ear and then to the brain. Sound is measured by its volume and pitch.

Millions of people in the U.S. have some degree of hearing loss. The condition is usually described as slight, mild, moderate, severe, or profound, depending on how well a person can hear the volume or pitches most strongly associated with speech. It can be temporary or permanent. There are three types of hearing loss:

• Conductive: Problems in the middle or outer ear. In some cases, this type of loss can be temporary. Common causes include colds, allergies, ear infections, and earwax blocking the ear canal.
• Sensorineural: Problems with the auditory nerve or with the sensory hair cells in the inner ear. This is the most common type of permanent hearing loss. Common causes include illness, harmful drugs, a jolt or blow to the head, ongoing exposure to loud noise, and age-related changes.
• Mixed: A combination of conductive and sensorineural hearing loss that occurs at the same time.

Multiple factors within the ears can impact the ability to hear sounds and to hear others speaking. These include poor room acoustics, lack of speaking clarity, background noise, or distortion.

Try these strategies for coping with hearing loss:

• Look directly at people’s faces when they speak.
• Reduce background noise as much as possible.
• Ask people to repeat or clarify information you do not understand.
• If hearing aids are recommended, wear them, and keep up with any required maintenance.
• Use the closed captioning features on your TV, computer, or other devices.

Ask others to take these steps to help you hear them:

• Establish eye contact with the listener.
• Repeat information if the person does not hear or understand what you have said.
• Speak loudly, clearly, and directly. Avoid shouting.
• Avoid talking from another room.
• Have important conversations in a quiet environment.

Seek help for hearing loss if you:

• Have a sudden loss of hearing.
• Can no longer identify familiar voices.
• Start to avoid social situations because of difficulty hearing
• Keep turning up the volume on the TV or when listening to music.
• Have ringing in your ears (tinnitus) that is bothersome and/or does not get better.

An otolaryngologist, also called an ear, nose, and throat (ENT) doctor, or an audiologist can assess your hearing.

Hearing aids

Here are some tips for maintaining hearing aids:

• Remove hearing aids and gently wipe with a soft cloth. You can use audio wipes, which will also disinfect the devices.
• Consider placing hearing aids on a folded towel or pad on the table where you are working to prevent damage from accidental drops.
• Inspect the part of the tubing that goes in your ear.
• Use the brush or wire pick to clear any visible wax from the tubing.
• Open the battery door and put your aids in the case, leaving the battery door open. This will dry out any residual moisture and help to prolong the life of your battery. Remember to close the battery door when you take your aids out of their case to use them.

Here are some things to avoid to maintaining hearing aids:

• Do not use solvents or alcohol on the hearing aids, as there is a possibility that they can break down the hearing aid material or damage the circuitry.
• Do not place the hearing aids in direct heat, such as leaving them in the sun or in the car, and using a hair dryer while wearing them.
• Do not allow your hearing aids to get wet. This includes showering or bathing and going to the swimming pool or sauna.
• Do not drop your hearing aids. Your hearing aids may survive a fall on a carpet or other soft place, but hard surfaces can damage your hearing aids.
• Do not leave your hearing aids, hearing aid batteries or hearing aid care products within the reach of children or pets.

Ways to cope

Increased sensitivity to different sights, sounds, movements, and environments is common after mTBI or concussion. Changes in how the brain processes incoming information from our senses can cause your brain to interpret normal things that are seen or heard as something that is unpleasant, irritating, or uncomfortable.

This increased sensitivity, or sensory sensitivity, can lead to other common physical symptoms that include:

• Balance problems
• Dizziness
• Eye strain
• Feeling overwhelmed, irritated, or anxious
• Headache
• Lightheadedness
• Nausea
• Trouble concentrating

Changes to how your brain processes incoming information after mTBI or concussion can affect sensory systems in different ways.

• Vision: You use your eyes for almost everything you do on a day-to-day basis. The muscles that control your eye movement can be affected after mTBI or concussion. This can cause eye strain, blurriness, trouble focusing, and other vision changes.
• Vestibular system: This system inside the inner ear plays a role in balance and with keeping your eyes focused on objects as you move.
  After mTBI or concussion, you may not be able to focus your vision as effectively while moving. You may also become more sensitive to different movements, including moving your head. Changes can also cause dizziness, vertigo, lightheadedness, motion sensitivity, nausea, and balance problems.
• Hearing: Listening is involved in many everyday activities. Sensitivity to certain types of noises such as background chatter, or noises of different volumes or pitches may occur. Changes in attention can also impact listening and understanding.

Sensory sensitivity usually improves within the first several weeks after injury for most people.

Here are some tips to manage this condition:

• Gradually increase time spent in environments that cause symptoms instead of avoiding situations altogether.
• Perform important tasks that require more focus, like studying or paying bills, in a quiet environment with fewer distractions.
• Add scheduled rest breaks into routines and activities.
• With exercise, symptoms should not increase by more than a little bit and should not last long afterwards. Start with low-impact exercises, like walking or a stationary bike, then progress to other exercises as you feel better and with guidance from your medical providers.
• Avoid wearing hats, sunglasses, and ear protection unless they are really needed. It’s fine to wear sunglasses or a hat when outdoors in the sun, but avoid using them indoors. It’s also fine to use ear protection if needed in louder places or around loud machinery, but avoid using them in other situations. It is better to use pacing and
  symptom management strategies instead.
• Relaxation tools, like breathing techniques or using calming smells and tastes can also help to manage sensitivity symptoms.
• Talk to your healthcare provider if sensory sensitivity symptoms are not improving or lasting longer than expected.

Ways to cope

Myofascia trigger points are areas of the myofascia tissue, between the skin and muscles of the body, that become painful with touch, stretch, or pressure. They cause the muscles to work in an imbalanced way.

Trigger points in the neck can be common after a mild traumatic brain injury (mTBI) or concussion because the muscles become stiffer as they try to protect the head and spine after the injury.

Headaches that come from the neck are called cervicogenic headaches. Typical symptoms include reduced mobility in the neck, tenderness, postural changes, pain on one side, shoulder instability, and changes in breathing patterns. Postural changes include forward head posture and scapular elevation and forward rotation and are typically due to weakness in certain muscles over-activation of other muscles.

Certain muscles in the neck are more prone to trigger points after this kind of injury, and these muscles can refer pain to other parts of the body, such as the head.

• Semispinalis capitis: A muscle in the back of the neck. It is common to see trigger points in this muscle, especially after a whiplash-related injury.
• Sternocleidomastoid (SCM): A muscle in the front of the neck that can become tight after a mTBI or concussion. Based upon the location of the trigger point in the muscle, it often refers pain either around the eye, across the forehead, or on the back of the head.
• Suboccipital triangle: A group of four muscles on both sides at the base of the skull on the back of the head. When a trigger point forms in these muscles, it is common to have pain on both sides of the head on the temporal bones.
• Upper trapezius: When trigger points form in this muscle, the pain will form from the neck, move up behind the ear, move over the top of the ear, and then down in front of the ear.

Treatment

There are many different interventions available to treat trigger points.

Stretching exercises can improve the length of the muscles and decrease the tightness of them. Strengthening exercises can improve weak muscles, reducing the muscle imbalance that is seen with trigger points.

Research shows that sustained deep pressure helps release trigger points. This can be done in a variety of ways. First, soft tissue mobilization can be done by a physical therapist to loosen the restrictions in the muscle tissue. There are also ways to perform self-soft tissue mobilization with tools at home such as a tennis ball.

Another option for treatment is dry needling, performed by a physical therapist certified in the procedure and utilized when manual therapy is not enough. It’s common to see a specific pattern of neck muscle imbalance.

Other interventions involve providing deep pressure to the trigger point to help with its release.

Ways to cope

Vision can be defined as how we see and process things in our environment. Vision is made up of three areas:

• Visual integrity, or how well your eye sees, involves clarity of vision (acuity) and eye health.
• Visual efficiency, or how well your eyes move, involves eye movement and eyes moving together, known as teaming.
• Visual information processing, or how well your brain interprets what your eyes see, involves hand-eye coordination (visual motor skills), understanding where objects are in space (visual spatial skills), and finding, using, and remembering things you see (visual analysis).

The information our eyes see travels through both sides of our brain to be interpreted. Vision problems occur when there is an interruption of communication between the eyes and the brain. When vision problems occur, many difficulties in everyday activities can arise, ranging from difficulty reading, blurry vision, headaches, and becoming overstimulated with visual information.

Here are some of the vision problems that are common after mild traumatic brain injury (mTBI) and concussion:

• Blurred vision
• Changes in eye position
• Difficulty judging distances
• Difficulty quickly changing visual focus between objects
• Difficulty seeing objects in your side vision
• Double vision
• Eye pain, strain, or fatigue
• Eyes are unable to follow a moving object
• Headaches when using eyes
• Light sensitivity
• Squinting or closing one eye to see better
• Unable to move both eyes inward to focus on an object
• Nausea, dizziness, or headaches in visually busy environments

Here are some of the effects these vision problems can have on daily activities:

• Bumping into things
• Clumsiness
• Difficulty with eye-hand coordination
• Difficulty with cooking tasks
• Difficulty with driving
• Discomfort with maintaining eye contact
• Eye strain and/or headaches when reading and during screen time activities
• Losing place or skipping words when reading
• Squinting when looking at something
• Trouble locating items in a store

Treatment

Talk with your doctor if you are experiencing visual changes since your injury. They may recommend you to specialist care.