Concussion and Cognitive Exertion

I was recently evaluating a young athlete following a concussion in a sporting event. He was three days out from his injury which involved less than a minute of loss of consciousness. He only had slight symptoms at the time of this evaluation including a very mild headache and slight fatigue. Specifically he said he did not have any light sensitivity. He had a normal physical exam with particular attention to his neurologic exam. His balance testing was not the best but not abnormal. I performed an ImPACT neurocognitive assesment and he was normal across the board based on percentiles. However, what was very interesting is that by the end of the ImPACT test he said he had a terrible headache and his eyes were very light sensitive. He had to turn the lights down in the exam room part way through just to finish the test. This is the second time in recent months where I have had a patient develop a severe headache and photophobia (light sensitivity) when performing the ImPACT test. This phenomenon seems to be a rather interesting marker of the impairment of concussion brought on by cognitive exertion of neuropsychological testing in the recovery phase. This was quite telling as he wanted to know if he could go back to school the following week. I noted that we would have to be careful to craft a list of restrictions and accommodations to meet his temporary diminished "cognitive stamina." Over the last several months I have started asking how the post-injury athlete how they feels after taking the ImPACT test. I have had several who have said they felt a little worse in addition to these two who had a marked increase in symptoms, including photophobia, with testing. This is just one more thing to think about asking in the evaluation of a patient with a concussion. Here is a youtube of a typical concussion patient