March 16, 2022 -- At age 32, Carole Starr, a Maine-based teacher and amateur musician, was in a car accident and had a concussion.
"Everything in my life changed," she says. She became extremely sensitive to sounds and had to give up playing in an orchestra and singing. She also developed problems with her thinking skills. “When I tried to teach, I looked at the lesson plan I had written, but it didn’t make sense anymore."
Starr consulted several health care professionals who dismissed her symptoms, as she had a "mild" concussion. "The first neurologist said to me -- pardon the language -- ‘Get off your ass and get a job.’ He didn’t understand that I was desperately trying to go back to work and failing miserably."
She is not alone. A new study published in Neurology dispels the notion that "mild" concussions have no lasting impact on mental skills like thinking, remembering, and learning.
The results suggest that problems with thinking and memory a year after a concussion “may be more common than previously thought, although it’s reassuring this happens only in a minority of these patients," says lead researcher Raquel Gardner, MD, of the University of California, San Francisco.
Long-Term, Chronic Effects
The study followed people with a mild concussion, also called a traumatic brain injury (TBI), for a year after their injury, measuring their thinking and memory with multiple tests. The study compared 656 people who’d had concussions, ages 17 or older (average age 40 years old), to 156 people who hadn’t gotten brain injuries.
Those in the study were given up to three neurological evaluations after their injury, 2 weeks, 6 months, and 1 year later. Each evaluation provided five scores from tests of memory, language skills, processing speed, and other brain functions, also called cognition.
The researchers wanted to define recovery after a mild concussion in a way that was relevant for each person, Gardner says, taking into account expectations for test scores based on a person’s age and education and trends in the test scores as time passed.
"What if someone started off cognitively way above average, but their cognition got progressively worse [after the TBI], even if they had not reached the threshold of being ‘below average’?” she says. “If someone experienced a significant decline, we called it a poor cognitive outcome."
The researchers found that close to 14% of people who’d had mild concussions had poor cognitive outcomes a year later, compared to about 5% of people without a brain injury.
Of the people with a concussion who had poor cognitive outcomes, 10% had cognitive impairment only, about 2% had cognitive decline only, and about 2% had both. About 3% of the non-injured people had cognitive impairment only, none had cognitive decline only, and only 1% had both.
"There is a large minority of people who have a measurable cognitive problem 1 year later," says Gardner. The researchers don’t know yet if the problems will continue beyond a year, but they will keep tracking the people who were studied to collect data on cognition and mood and learn more about the long-term effects of mild concussions.
The researchers found several things were associated with a greater risk of having poor cognitive outcomes, including lower education, not having health insurance, being depressed before the injury, and high blood sugar.
People with good cognitive outcomes were more likely to have a higher satisfaction with life a year after their concussion, while people with worse 1-year cognitive outcomes had more distress and more mood problems.
There are many reasons for cognitive impairment after a mild concussion, Gardner says. The injury could have directly damaged parts of the brain, or problems with sleep or mood from the concussion could then cause problems with cognition.
Starr became depressed because the concussion had upended her life. "I felt my life was over, like there was no possibility of a meaningful life again if I couldn’t work or be who I was."
Dispelling a Myth
People have the idea that those who’ve had a mild concussion always get better, says Gregory O’Shanick, MD, medical director emeritus of the Brain Injury Association of America. But the new study shows "this isn’t always the case."
O’Shanick, who is also medical director of the Center for Neurorehabilitation Services in Richmond, VA, believes the issue is much bigger than what the study covered, since it did not evaluate all types of cognitive performance. Also, it didn’t include children.
He points to a relatively new subspecialty, called brain injury medicine, in which doctors are familiar with the parts of psychiatry, neurology, and physical rehabilitation relevant to brain injuries. This enables more targeted evaluation and treatment of people who have had a concussion.
"If you have any concern about your cognitive function, see your doctor and, if necessary, advocate to have more of an evaluation with a neurologist or a neuropsychologist," Gardner advises.
Starr says when she finally found health care professionals who were able to help her, she "literally broke down and sobbed with relief in their office."
It took her many years to grieve the loss of her old life and sense of self and accept her brain injury and the new person she had become.
Starr now teaches people about brain injury at scientific conferences. She founded and supports the survivor volunteer group Brain Injury Voices, and she is the author of To Root and to Rise: Accepting Brain Injury.
"I’ve reinvented myself by focusing on what I can do, one small step at a time."
Corrections: An earlier version of this story incorrectly identified Carole Starr as a professional musician. She is an amateur. Also, Gregory O’Shanick, MD, is medical director emeritus of the Brain Injury Association of America, not emeritus director.