ABCs of a concussion (part 2)

[Music] You are listening to Concussion 101, a patient's guide to getting ahead again. [Music] Episode 2, ABC's of a concussion, Part 2. In today's show, your host, Dr. Tahir Chug, sports MD and medical director at the York Region Concussion Clinic, will continue where he left off and talk about the diagnosis, recovery time and management of concussions. Enjoy. [Music] Welcome to our second podcast. It's me again, Caitlin Hano, the occupational therapist from our clinic. Again, I will be interviewing Dr. Chug, continuing where we left off last week. Let's start simply. How is a concussion diagnosed? So, before we even consider a concussion diagnosis, the first step is always to rely out a more serious injury. In the last episode, we reviewed the red flags, and so those have to be looked for. Once you're satisfied that you're not missing a more serious injury, you can start working on identifying a concussion, all the areas affected, how they're affected, and what you can do about them. Ultimately, concussion is a clinical diagnosis. That means you need a good history, physical exams, and investigations may or not be called for. So, concussions are very complex. Can you do all that in one assessment? No, the history and physical exams are very involved, like you said, and usually done over several visits with professionals from different disciplines working together. That being said, not everything about the extent of the patient's concussion will be known on that first visit. That doesn't mean that treatment doesn't begin until we know everything. Usually, treatment and assessments go hand in hand and tandem. Also, something to keep in mind is everyone has unique pre-existing neurophysiological strengths and weaknesses. Before the concussion, so whether the patient was aware of it or not, these differences become an issue that needs to be identified to help facilitate rehabilitation. That sounds good, but how do you know if a condition was there before an injury, if the patient wasn't aware of it? You never really know, but you have your suspicions. At any rate from a rehab perspective, it doesn't really matter, because if you find something and the patient's game to fix it, then we go ahead and fix it. Recently, we started doing this thing called the neurological risk assessment for athletes in high risk sports, with the goal of identifying these patients. Basically, it sounds like you're asking that question before a potential concussion. Yup, with the hope of preventing a prolonged concussion in the event they get one, or with the aim of improving performance in sports or school. What do you usually find? We mostly find binocular vision problems and neuro-mustro-control issues. For example, we recently performed this on a hockey team and found that 20% of the team had abnormalities that would complicate post-concussion care and would affect their performance in school and sport right now. For example, one athlete had dysfunction of his visual system. I know we're going to be going into the visual system in more detail in a future episode with the optometrist, but just for those who are interested, his visuals were with accommodation. Again, that's the ability of the eyes lens to thicken and thin the virgin system. So that's the ability of the eyes to turn inwards and outwards as objects are moved closer and farther away respectively. And his ability to control tracking objects was affected. And his ability to process what he was seen was being affected. And interestingly, after we gave the results to the family, his mother told us that on recent standardized testing, he scored 90% in all sections except for reading comprehension, where he scored 30%. That's quite a big difference. And our findings explain this. It's interesting to note that the classes he chose to attend require less reading comprehension and everyone just chalked it up to his personality. Now, to get back to my point, if we didn't identify this issue now and he came in with visual problems post-concussion, we may have still suspected he had pre-existing issues. But because of what we would see on exam at that time and because of what his mother told us, but it wouldn't really change our management. How do we detect areas of neurological performance that may have been set a skew? So daily life is like a real-life stress test. This means that things that you do day-to-day will stress your neurophysiology. And if you're not able to swing it, it's going to cause you symptoms. Practicing biofeedback in our program, we become intimately aware of the things that stress our neurophysiology in real time. So for example, say a patient comes in and she tells you that she has sensitivity to fluorescent lights. And she gets headaches with reading. You have to think that the visual system is impacted, right? Right. So we have a patient now who jokes that he thinks his concussion put him into menopause because he feels tired all the time, especially with exertion, he feels cold and hot often. His sleep is off and his blood pressure is different. These are all symptoms of dysfunction of the autonomic nervous system. Say, for example, the patient tells you that busy areas bother her and she seems to be bumping into things. And certain motions make her dizzy. You have to think of vestibular effects. These are just examples, but generally these different systems are all interrelated. Nobody truly has a stereotypical effect in just one system. How did the systems interact? Can you give me an example of how they relate? For example, autonomic dysfunction is going to make you feel a bit dizzy, but it will also affect the ability of your eyes to accommodate on things. So if we just jump ahead and go straight to vision therapy for people with vision problems and autonomic dysfunction, we may not be getting the most bang for our buck. Also, you also want to treat things that can help boost performance in affected systems. Maybe things are not even related to the injury, for example, if someone had low B12 before the injury. But what's functioning just fine then? Maybe by replacing it now, it's going to make a big difference. Because we do know that replacing B12 can help someone with their energy, sleep, cognition, and even help them with the nervous systems function in general. Right. So why not go ahead? What I'm getting at is that in concussion, many systems are affected and all these systems depend on other systems. And so the assessment is quite broad if you want to uncover all facets of the injury. What kind of assessments do you typically do? Well, you have to take thorough histories, specialized physical exams often require specialized equipment also. For example, you need to assess neuromuscular control issues, vestibular issues, autonomic dysfunction. You need to look for findings that identify hormonal issues or deficiencies of some sort. You need to do binocular vision exams. And this is more than your family optometrist likely does. It goes past 2020 vision and looks more at visual performance. All these things require specialized equipment and skill set. Sometimes you need to do some investigations. And for example, it depends on the clinical picture. Say the patient has fatigue and you suspect hormonal issues. You may want to do some blood work. Say the patient has sleep issues. You may want to do a sleep study. And I think a really overlooked area in the assessment process is just observing one's response to rehabilitation. Can you tell me a little bit more about that? For example, we've been treating this patient who had constant dizziness typical of visual vestibular mismatch in addition to other problems she had. And she started improving with various therapies which caused her clinical picture to take an interesting turn. It became obvious that what she had was vestibular migraines. A clue was that her dizziness would let up entirely. And she would do amazingly on some challenging tasks. And a few days later after a certain trigger, the dizziness would come back. Without any associated headache, which can often be the case with vestibular migraines. So we strategically went ahead and treated it her headaches or her migraines with medical management. And in addition to the lifestyle management, she was already receiving. Okay. So one question we get from a lot of our patients. How long does it take for a concussion to heal? So that depends on a few things. Number one, your pre-existing neurological function. You're likely not aware of the strategies you use. Neurophysiologically for postural control, balance, regulating your emotions, regulating your sleep, cognitive skills, learning, even binocular vision. However, all these things are assessed post-concussion and will affect your recovery. Okay. Your past medical history obviously is really important. Like say, for instance, you had migraines before. For example, we had one patient who had blood pressure before. And to get rid of his nightmares, we had to change one of his blood pressure medications to another one. So that information is important. We had one lady who had very significant iron deficiency that was difficult to treat. And she really started to take a big turn for the better. Once we got her hooked up with a hematologist who was able to arrange for some iron infusions for her. Obviously, people with psychiatric history are at risk of a prolonged recovery. And even more mundane things like having a low pain threshold or some people have motion sickness, that will affect how long it takes for your concussion to heal, possibly. I remember last week. You mentioned that mindfulness often comes up. Yes, your personality makes a big difference. For example, are you someone who takes as it comes or do you despair whenever there's a setback? Are you good at relaxing and giving yourself a break or do you demand perfection of yourself? The perfectionists are people we notice that take a bit longer. Are you open minded to learn new things or are you more set in your ways? Are you someone who has to win or do you just enjoy the game? Generally an attitude of mindfulness is helpful. In concussion rehab, we're training many neurological processes that you learn as a child. Think of the state of mind you had as a child. Did you ever try to balance walking on a curb? I try not to remember long, long story. Well, when kids try to walk on a curb to maintain their balance, when they stumble off, they don't chastise themselves or not being perfect. They just get back up on there again and do it again. You know what I mean? Another thing we see in the program is people who are impatient. They just had enough of this injury and they just want to get back to things. But we have to keep in mind that even when you're feeling better, many times you have to keep the accommodations going for a while longer to maintain your rehab gains and prevent setbacks. What about the injury itself? Does that factor into recovery? Yeah, there are many studies looking at many different symptoms and correlating it with how long it will take for the concussion to resolve. For example, dizziness has been correlated with a higher risk of prolonged recovery. But generally, the more symptoms you have, pulse concussion or the more severe those symptoms are, the more likely you are headed for a prolonged recovery. And kids as well take longer to reheal, right? Yes. Kids take longer to heal, definitely. What about your life situation? Absolutely, that makes a big difference. So say for example, you have financial issues or you've got commitments that are uncompromising or say you're going through something right now that's pretty distracting and unpleasant. You may not be able to get the necessary care or take advantage of the care to its fullest. Practically, some insurance companies have policies that also hinder patients' progress. Another example would be an ununderstanding work environment that can delay your recovery. Fortunately, though, I noticed that general public is becoming more educated about concussions. Let's hope that more education, like this podcast series, can help further this progress. Yeah, let's hope. Especially for patients who don't have easy access to programs like ours. If you can't find a center close to you, this is another hurdle, obviously. You know, you have to be able to identify all the neurological medical and functional problems in a timely fashion. And ideally, it'll all be done within a network of people that they can all work together to serve the bigger picture. So once you find that center, and it's hopefully located nearby, how are concussions managed? I'm just looking for a brief description because I know that we're going to be going into those management strategies in much greater detail in future episodes. So they're managing a multidisciplinary setting. It's just like a football team. You've got your quarterback, your wide receiver, your safety, and so on. And if the care is well coordinated, you may win the Super Bowl. It's just like that for concussion care. Everyone has their role. They're working together to serve the greater picture, and the result should be greater than some of its parts. So what's that first step? I find the first step is educating the patient because a lot of them come in, they're fearful, and you want to demystify what's happened to them. You want to give them hope and enthusiasm. And I think a big part is just once they understand, they can become more intuitive because there's many things they're about to embark on. Right. Can you give me some specifics? Well, I'm just going to preface this by saying that all these systems are interrelated. And so there's a lot of overlapping concussion treatment. So a lot of the treatments will treat many different conditions. Okay. Can you give me some examples? Like, for example, necks. So a lot of people have neck issues post concussion. So we can treat them with manual techniques to help increase the range of motion and decrease their pain. But ultimately, you want to train their neuromusster control. Muster ability to control their neck properly using the most efficient movement patterns. And then you're going to want to integrate that into their whole body movement patterns. So like, for instance, you want to make sure that they're using the neck properly while they're doing squats and lunges and many of the activities of their sport. Sometimes they find it hard to do that. So that's when biofeedback is really useful. It gives them that auditory tone, let them know that they're not firing the muscle the right way or something like that. For many patients, there's a correlation between stress and the neck. And so psychological techniques are really important. A lot of patients, when we give them the rehab, then they go back to work to a bad ergonomic environment. They inadvertently train the wrong postures again because the ergonomics are not suited for a proper posture. So ergonomics becomes important. And many of our muscles colledal patients, especially like our car accident patients, we have many muscles colledal injuries, they're all treated the same way. Okay. All right. So how do you manage symptoms that aren't muscular, skeletal in nature? Well, sleep is a big one. And you're going to be given an episode on that next time. Yep. That's a large topic, but mostly it revolves around cognitive behavioral therapy for insomnia. Autonomic nervous system dysfunction. I know we mentioned that before. So there are many ways you can treat that. Some examples would be to strategically design a cardiovascular exercise program or to use energy management techniques just by teaching them how to budget their lifestyle and so on. Psychological support is important. Mindfulness training, cognitive behavioral therapy. Biofeedback training helps a lot, especially HRB training. Cognitive behavioral therapy for insomnia. All of these are good options. Moved in psychiatric conditions are another big one. And for that, a lot of overlap again. So education is important. CBT, mindfulness. Treating other general medical conditions. That you might have picked up on in the past medical history. Or sometimes they develop issues that you weren't aware of. Biofeedback is helpful. Medication, sleep management. Part of mood problems is energy. And low energy causes mood problems. But to treat the fatigue and low energy aspect, again, energy management helps. Psychological support. Relaxation training. CBT for insomnia. Treating the mood issues. Treating the active general medical conditions that might be prevalent at that time. Cardiovascular exercise training. Identifying any kind of deficiencies in their blood work. Or identifying hormonal issues. All of these things are useful. It sounds like there's a lot of overlap between management techniques. Absolutely. Yeah. Vistibular issues, for example, are another one. So vestibular therapy helps for vestibular issues. But we also employ a lot of mindfulness in that. A lot of biofeedback, neuromuscular retraining. All issues are managed similarly with vision therapy and vestibular therapy. Energy management, biofeedback, ergonomics, prescription glasses, of course. Headache is a big topic. And in many ways, it's treated similarly to people who don't have concussions. The only thing is with people with concussions, they have many other affected systems. So it tends to be a bit more challenging. However, for most of those patients, they seem to get better just with the lifestyle management and treating their other conditions. For some patients, we need to treat them medically also. And I guess another common area where we treat patients would be speech and language and cognitive issues. And these can be helped by treating all the things that just mentioned. And then we have specialized treatment for that too. Okay. So what about considering the functional consequences? Everything you just mentioned, they were all sort of investment strategies that will eventually yield fruit. But what about right now? How can we help the patient carry on within their current budget, so to speak? Well, okay, let's break it up. So let's start off with sports, looking at athletics. So we have protocols in place that slowly and safely introduces patients back to their exercise. We know that exercise strategically used is medicine for concussion patients. So for every patient, we identify the best way to slowly get them back into their exercise. And as those investments show fruit, we'll progress them faster and more. Another area beyond athletics would be extracurricular activities. So oftentimes they can't do what they want to be doing with their free time. So you help them to find other things. I remember one kid, he started learning Spanish. And in fact, they found that learning a language in another study I read can help ward off or delay dementia. So it makes you wonder, maybe it's a useful thing also in this context, but there's no study that I know of. It's looked at that yet. It would be cool to do. Yeah, maybe we'll do it. Maybe. For work in school, accommodations are provided and slowly relaxed, again, as those rehab strategies show fruit. And I think there's one overlooked, one commonly overlooked area. And that's the strain that this injury puts on people's relationships, personal relationships. I find it helpful to bring the family in for the first meeting once in a while afterwards just to educate them and to deflect some of the pressure off the patient. And then teaching the patient, the patient relaxation strategies is very useful. Sometimes there's better ways to deal with their stress than to do things in a way they'll make things worse for them at home. And I think another practical thing is financially, if we can support the patient and advocate for the patient so that they can receive their short-term disability benefits and take the time to fill those form to properly express what the patient's going through. It'll take a lot of pressure off them and help them focus on the rehabilitation. Okay, give me the bottom line. The bottom line is this. There are many systems affected post-concussion and there are many available treatments. And they need to be strategically coordinated by the treating team. But most importantly, we can't forget to treat the patient. We need to always keep in mind the challenges the patient faces when she leaves her room. - Mm-hmm, right. Okay, so here's our last question, and one that we get from a lot of patients as well. Our concussion's preventable. - Often they're not, and often they are. For starters, and I'm thinking back to a kid we had earlier in the year, try not hanging from planters when you're drunk. - That's a good idea. - Try not to leave the cabinet doors open when your spouse is bending down to get something from the drawers. And I'm speaking from personal experience, I've done that. Basically common sense goes a long way. We had a patient recently who, I wasn't really aware of this bubble phenomenon, like bubble soccer and bubble gladiator, but she got a concussion doing that. And I started looking at some footage on YouTube, and have you ever seen what happens to these people's heads when they're going, when they actually collide with each other? - No. - We should have a look, because again, think back to that bowl of a jello analogy that we discussed earlier on. And so she had a concussion from that. Work safety is a big one. We see a lot of people coming from work accidents, and I think the ergonomics set up counts for a lot. All of us can think back to a nasty hit we saw in a sport that we wish we never saw. So I think that highlights an important point, that sporting culture and a safe style of play will go a long way. I think, and this is why the podcast is here, I think the best way to kind of foster this sort of awareness is through education. A bell concussion, and a bell to magnificence of our brain, and the role it plays in everything we do, sport, art, school, work, sleep, everything. - All right, that brings us to the end of our second podcast. So join us in the next episode when we talk about sleep. (upbeat music) - Thank you for listening to the Concussion 101 podcast. If you enjoyed it, please subscribe to our podcast on iTunes and leave us a review. For more information about concussion related topics, visit us at www.yorkconcussion.ca. Stay tuned for our next episode. (upbeat music) (upbeat music)