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Concussion in Sports · Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast.

0:00
Welcome to the Deep Dive. We're the podcast where
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we take stacks of dense information, really sift
0:05
through all the noise, and pull out the crucial
0:08
bits of knowledge, the surprising insights, so
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you don't have to wade through it all yourself.
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That's the plan. Today, we're diving into something
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that affects millions, truly millions of lives
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every year. But it's still often, well, quite
0:20
misunderstood. Concussions. We tend to think
0:24
of them, don't we, as just a bump on the head.
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But the reality is, it's far more complex than
0:29
that. Absolutely. I mean, did you know, for instance,
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that just in the US, somewhere between 1 .6 and
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3 .8 million sports -related concussions get
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reported each year? It's a staggering figure.
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And that's just sports. If you look at Ontario,
0:42
in Canada between 2008 and 2016, over 1 % of
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the entire population got a formal concussion
0:49
diagnosis each year. And the key point there
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is formal diagnosis. Experts are pretty convinced
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those numbers significantly underestimate how
0:57
common they actually are. So it's almost like
0:59
a hidden epidemic of the brain. And it goes way
1:02
beyond just athletes on a pitch. That's a really
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crucial point to start with. Because the common
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idea, you know, the one you see in films or here
1:09
in general chat, is that most people who get
1:11
a concussion, they'll just sort of shake it off.
1:13
Right. Back to normal in a few days. Exactly.
1:15
Back to baseline within days, maybe a couple
1:17
of weeks. But. As we'll unpack in this deep dive,
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that's not the whole story, not by a long shot.
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A significant number of people, probably far
1:26
more than we generally realize, go on to experience
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what we call persisting post -concussion symptoms,
1:33
or PPCS. And these aren't just minor headaches
1:37
that linger. We're talking about a profound disruption
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to someone's life. Symptoms can last for months.
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sometimes even years, it can fundamentally change
1:46
how they function, day -to -day, their well -being.
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It's serious. Okay, so that's our mission for
1:52
this deep dive, then, to get past those surface
1:54
-level ideas and really unpack the nuances. How
1:57
do we, whether we're healthcare professionals,
1:59
coaches, parents, or just trying to be informed,
2:02
how do we spot who might be at higher risk for
2:04
this prolonged recovery? And what does the latest
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research, the really cutting -edge stuff, tell
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us about how to manage this condition? Because
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it is pervasive. Right. So we're going to draw
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on quite a range of sources, comprehensive medical
2:15
overviews, some fascinating new scientific studies
2:18
coming out of Canada, and established sports
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medicine guidelines. We'll sift through it all.
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Exactly. The goal for you listening is to get
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a rapid but really thorough grasp of this, hopefully
2:30
spark some aha moments, and move past the common
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assumptions to a genuinely well -informed view
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on concussions and this whole post -concussion
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syndrome picture. Okay, so precisely. It's not
2:42
typically a structural injury you can see on
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a CT or MRI. It's about how the brain is working.
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And importantly, it's a specific type of mild
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traumatic brain injury. or MTBI. Ah, okay. So
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people use those terms interchangeably, MTBI
2:58
and concussion, but they're not quite the same.
3:01
Not technically, no. A concussion is really the
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subset of MTBI. MTBI is the broader category,
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which might include injuries with more structural
3:09
changes. A concussion, by definition, implies
3:12
this temporary functional disruption. Got it.
3:14
And the symptoms can vary quite a lot, can't
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they? Hugely. From things that are very subtle,
3:19
maybe just feeling a bit off or foggy, to more
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obvious periods of confusion or even brief laws
3:24
of consciousness, there's a whole spectrum. And
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that timeline you mentioned earlier about how
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long symptoms last, that seems absolutely critical
3:30
here. It really is. It helps us categorize things.
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So we often talk about an acute concussion if
3:36
the symptoms resolve fairly quickly. Which is
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typically how long? Generally within about 14
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days, two weeks or so. But when those symptoms
3:43
stubbornly stick around for 90 days or more,
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three months, That's when we start talking about
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prolonged post -concussion symptoms, or PPCS.
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90 days. That's the benchmark. It's a common
3:54
one? Yes. Although, it's worth noting, you sometimes
3:57
see slightly different timelines in the literature,
4:00
particularly for sports concussions, where persistent
4:03
symptoms might be defined as lasting longer than
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four weeks. Right. But that distinction between
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acute and prolonged, that's really important,
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isn't it, for how you manage it? Absolutely vital.
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Because the approach to care, the kind of resources
4:15
someone needs, their likely prognosis, it all
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shifts quite dramatically once symptoms go beyond
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that initial acute phase. And managing this,
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especially the prolonged cases, it's not a one
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-person job, is it? Definitely not. Effective
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concussion care, particularly for PPCS, is inherently
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interprofessional. It really does take a village.
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Who's typically involved? Oh, a whole range.
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Physicians, of course, but also physiotherapists,
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neuropsychologists are key, occupational therapists,
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sometimes speech and language therapists, social
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workers. It's a team effort because the concussion
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can impact so many different parts of a person's
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life, physical, cognitive, emotional, social.
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Okay, that makes sense. So you mentioned some
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surprising research. Yes, this is where it gets
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really interesting. As we unpack some of the
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latest findings, especially from a big observational
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study done right here in Ontario, you might find
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some of the results, well, quite counterintuitive
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actually. How so? Well, we're going to challenge
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some perhaps deeply held assumptions about who's
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most at risk for that prolonged recovery. For
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instance, some factors that we've traditionally
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thought were strong predictors for persistent
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symptoms. Right. They might not hold up quite
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as strongly when you directly compare people
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with acute symptoms versus those with prolonged
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ones. Really? And conversely, other factors,
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maybe things that haven't been discussed as much,
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seem to emerge as surprisingly significant. It
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could really shift our understanding of who's
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vulnerable and why. Okay, I'm intrigued now,
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so we'll get into the nuts and bolts of that
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study. We will. We'll explore the... the underlying
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path of physiology to what's actually happening
5:50
in the brain. The metabolic changes, the structural
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shifts at a cellular level after the injury,
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and how knowing that is guiding new approaches.
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And then the practical side, evaluation diagnosis.
6:01
Exactly. How do we effectively evaluate and diagnose
6:04
concussion? What does a structured evidence -based
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recovery plan look like? including that crucial
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graduated return to play protocol that's so vital
6:13
for athletes, but the principles apply more broadly
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too. Okay, brilliant. It sounds like this conversation
6:18
might genuinely shift how we think about brain
6:21
injury and recovery. Let's dive in. Tell us about
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this Ontario study. Right, so this study is titled,
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Characterizing the Profiles of Patients with
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Acute Concussion vs. Prolonged Post -Concussion
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Symptoms. It was an observational study done
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across multiple sites. Part of a bigger project?
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Yes, part of a larger initiative called Connecting.
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And they collected really rich, patient -reported
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data from seven different concussion clinics
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right across Ontario. And what's powerful about
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that multi -site approach? It gives great diversity.
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They included clinics that focused on sports,
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others on acute care, and some tertiary care
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centers. So it wasn't just looking at, say, elite
6:58
athletes or people only in central Toronto. Ah,
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so a real mix. Geographically diverse, too. Exactly.
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That geographical and functional mix is a real
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strength. It gives us a much broader, more generalizable
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picture of concussion in the real world, not
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just in specific pockets, a much more comprehensive
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view of who's getting concussions across different
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settings. Makes sense. And how did they gather
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the information? They were very thorough. They
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collected a standardized set of data points from
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everyone, usually at their first clinic visit
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or within about two weeks of it. And who was
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included? patients age 16 or older who had a
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clinical diagnosis of concussion that lined up
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with the Berlin Consensus Statement from 2017
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is basically the gold standard internationally
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for a diagnosis. And they had to be able to give
7:44
informed consent, obviously. Were there people
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they specifically excluded? Yes. And that's important
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for understanding the focus. They wanted to look
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specifically at what we'd clinically call a concussion.
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So. Anyone with abnormalities on CT or MRI scans,
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anyone needing neurosurgery, or those with really
8:01
complex multiple injuries were out. Okay. Also
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excluded were people with significant pre -existing
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neurological or developmental issues, or if the
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concussion -like symptoms were triggered by something
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non -traumatic like a seizure or a migraine.
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So they really narrowed it down to isolated,
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traumatically induced concussions. Precisely.
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That rigorous approach meant they could get clearer
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insights into the recovery pathways specifically
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for concussion without result being confounded
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by more severe injuries or other conditions.
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And then they split these participants into groups
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for comparison. Yes, very cleverly for this analysis.
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They created two distinct groups. First, the
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acute concussion group people whose symptoms
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had been around for 14 days or less. Okay, a
8:43
quick resolvers. Exactly. And second, the prolonged
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post -concussion symptoms group, the PPCS group,
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where symptoms had persisted for 90 days or more.
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That three -month mark again? Right. And importantly,
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to really sharpen the difference between those
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two ends of the spectrum, they deliberately excluded
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patients who were in the middle. The subacute
9:01
phase? Yes, those with symptoms between 15 and
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89 days. Taking them out created a very clear
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contrast between rapid resolution and genuinely
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prolonged problems. It allowed for a much more
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focused comparison. Right, that makes methodological
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sense. What sort of data did they actually collect
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on these people? It sounds like a lot. It was
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incredibly comprehensive. They went way beyond
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just basic demographics like sex and age. They
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looked at marital status, education level, geographic
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region where people lived, ethnicity, even annual
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household income. So, a rich socioeconomic picture.
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And injury details. Absolutely. Not just when
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the injury happened, but how the mechanism of
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injury. Now, obviously, how many days have passed
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since the injury when they were assessed. What
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about their medical background? A deep dive there,
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too. Any prior concussions, other medical conditions
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happening at the same time, vascular risk factors,
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history of chronic pain, any developmental disorders.
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And critically, they gather detailed information
10:00
on any history of mental health disorders and
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any pre -existing problems with headaches or
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migraines. Those are often cited as risk factors,
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aren't they? They are indeed. They also looked
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at healthcare use, how often people had been
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to A &E, their GP, or seen rehabilitation specialists.
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It was a truly holistic data set, capturing a
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huge range of potential influences. And they
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used standardized tools for assessing symptoms,
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I assume, to keep things consistent? Yes, absolutely.
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They used established measures, for instance,
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the Sketney 5, the sport concussion assessment
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tool. I've heard of that one. It's widely used.
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It helps assess 22 common concussion symptoms
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across different areas, physical, cognitive,
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emotional fatigue. So things like headache, dizziness,
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feeling foggy, irritability. Exactly, those kinds
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of things. They also used the Sheehan Disability
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Scale. What does that measure? That's a really
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useful tool because it gets at the patient's
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perception of their disability, how much the
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symptoms are actually impacting their life, looking
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at things like days lost from work or school,
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and also days underproductive, where they might
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be physically present, but just not functioning
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at their usual capacity. Ah, OK. So it gives
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quantifiable measures for what can feel like
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a very subjective experience for the patient.
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Precisely. These tools provide objective data
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points. So this brings us to the study's main
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goal and where you said the surprising findings
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came in. Yes, this is where it really challenges
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some common assumptions. The researchers initially
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wanted to see if patients in the acute group
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and the PPCS group differed significantly on
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four specific factors, often flagged as key risk
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predictors for prolonged symptoms. Which were?
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Sex, having a history of mental health disorders,
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having a history of headaches or migraines, and
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having had previous concussions. OK, those are
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the ones you often hear about. Exactly. And the
11:46
prevailing wisdom, the sort of statistic often
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quoted, is that maybe only 10 % to 20 % of acute
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concussions go on to become persistent. Right.
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So based on that, you'd logically predict that
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these known risk factors, mental health issues,
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migraines, maybe being female, previous concussions
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would be much more common in the PPCS group.
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They should stand out as clear warning signs.
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That makes sense. So what did they actually find?
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Did those factors show up more in the prolonged
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group? Well, this is the kicker. Quite remarkably,
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And actually, contrary to what many would expect,
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and indeed, contrary to the study's own initial
12:21
hypothesis, they found no statistically significant
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differences between the acute group and the PPCS
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group for history of mental health disorders,
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pre -existing headache, or migraine history,
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or sex. No difference at all. No statistically
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significant difference. Let me give you the numbers.
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They're quite striking. In the acute group, 37
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.3 % had a history of mental health disorders.
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In the PPCS group, 37 .9%. Virtually identical.
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Wow. And for sex. The acute group was 61 .1 %
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female. The PPCS group was 66 .3 % female. Again,
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when you analyze the statistics across the whole
12:55
large group, that difference wasn't significant.
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That really is eye -opening, because it seems
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to fly in the face of that idea that these factors
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single out the 10 -20 % who will struggle long
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term. It does. It strongly implies that the baseline
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vulnerability may be linked to these factors,
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might be much more similar across everyone who
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sustains a concussion rather than just predisposing
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a small minority to poor outcomes. So what does
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that mean practically for a doctor seeing a patient
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or a coach? It means you can't just look at someone,
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see they don't have a history of anxiety or migraines,
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and assume they're automatically low risk for
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prolonged symptoms. It suggests we need to perhaps
13:36
focus more on the injury itself, the immediate
13:39
symptoms, rather than relying too heavily on
13:42
these pre -existing conditions as definite predictors
13:45
of a long recovery versus a short one. Okay.
13:47
What about previous concussions? That's almost
13:49
always mentioned as a big risk factor. That also
13:51
showed no significant difference between the
13:52
two groups in this study. Really? Why might that
13:54
be? Well, the study offers a thoughtful explanation.
13:58
A history of concussions is a known risk factor,
14:01
yes, but it's a risk factor not just for developing
14:05
persistent symptoms after a new injury, but also
14:07
for sustaining another concussion in the first
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place. Ah, I see. So... People in both groups
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might be equally likely to have had prior concussions
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just by virtue of having had a concussion now.
14:18
Exactly. It might be a characteristic shared
14:20
by many people who seek care for concussion,
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whether their current symptoms resolve quickly
14:25
or not. It highlights how tricky it is to interpret
14:27
risk factors. Are they predicting future problems
14:30
or just describing the population already affected?
14:33
It's about the nuance of how these factors operate
14:35
over time. Okay, so if those factors, mental
14:38
health, migraine, sex, prior concussions, weren't
14:41
the clear dividing lines between the acute and
14:43
prolonged groups, what did stand out? What did
14:47
differentiate them? This must be where the study's
14:49
secondary aim comes in. Precisely. When they
14:52
look at the broader demographic and injury profiles,
14:55
some clear and potentially actionable differences
14:57
did emerge. Like what? Age was a big one. The
15:00
PPCS group was significantly older, on average,
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than the acute concussion group. Much older.
15:06
The average age for the acute group was 32. For
15:09
the PPCS group, it jumped quite substantially
15:11
to 44. 12 years difference on average. Yes. And
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when they looked at age categories, the odds
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of being in an older age group, particularly
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40, 49, 50, 59, and especially 60 plus, were
15:23
significantly higher for people with PPCS compared
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to those aged 29 or younger. How much higher?
15:29
Dramatically higher for the oldest group. The
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odds of someone age 60 or over being in the PPCS
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group were over nine and a half times higher
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than for someone under 30. Nine and a half times,
15:40
that's huge. So middle and older age really seems
15:43
to be a significant factor for prolonged symptoms.
15:46
This study strongly suggests so, yes. It challenges
15:48
older ideas that maybe age wasn't such a major
15:51
factor. Why might older age lead to slower or
15:54
less complete recovery? Is it biological? Well,
15:57
one common theory revolves around something called
15:59
cognitive reserve. Like the brain's backup capacity.
16:02
Sort of, yes. Think of it as your brain's ability
16:05
to cope with damage or stress. Maybe it's efficiency
16:08
or flexibility. As we age, that reserve might
16:12
naturally decrease a bit. So the brain just have
16:15
less capacity to compensate for an injury and
16:18
recover as efficiently as a younger brain might.
16:20
So it's less resilient to the disruption. Potentially,
16:23
yes. While not all previous studies have found
16:26
such a strong link, this large real -world comparison
16:29
in Ontario really points to age, especially being
16:33
40 or older, as significantly impacting how recovery
16:36
unfolds. It also makes you think about how age
16:38
interacts with other things, like education level,
16:41
which might influence your cognitive baseline
16:43
before the injury even happens. Okay, so age
16:45
is a major differentiator. What else stood out?
16:48
The way the injury happened, the mechanism of
16:50
injury, that was another critical finding. How
16:52
so? Transportation -related incidents, so car
16:54
crashes, bike accidents, motorcycle collisions,
16:57
were significantly more common in the PPCS group.
17:00
Very much so. The odds of having had a transportation
17:03
-related injury were four and a half times higher
17:05
in the PPCS group compared to the acute group
17:08
when you compare them against injuries caused
17:10
by falls or falling objects. Four and a half
17:13
times. Again, that's a massive difference. Why
17:16
would being in a crash make prolonged symptoms
17:18
so much more likely? Is it just the force involved?
17:21
That's likely part of it, certainly. The forces
17:24
in those types of collisions can be greater and
17:26
more complex. Think about the rapid acceleration
17:29
and deceleration. That can lead to more widespread
17:32
sort of shearing forces within the brain tissue.
17:34
But is it only physical? Probably not entirely.
17:38
There's also the significant psychological stress
17:40
and emotional trauma that often comes with being
17:43
in a serious accident. Post -traumatic stress.
17:45
Exactly. We know there's a considerable overlap
17:47
between symptoms of PTSD and persistent concussion
17:50
symptoms. And then there's another layer. That's
17:52
right. Litigation. Involvement in insurance claims
17:56
or legal proceedings, which is pretty common
17:58
after road traffic accidents, has also been consistently
18:01
linked with persistent symptoms. Ah, so it's
18:04
a complex mix, the physical injury, the psychological
18:08
impact, maybe even the stress of legal battles.
18:11
Precisely. It creates this really complicated
18:13
interplay that can definitely hinder and prolong
18:16
the recovery process. It's not just a bang on
18:18
the head, it's an event. with potentially wide
18:21
-ranging consequences. That makes a lot of sense.
18:24
Okay, so we have age and mechanism of injury
18:26
as clear differentiators. You mentioned geography
18:30
earlier, did where people lived show any differences?
18:33
Yes, and this pointed towards potential issues
18:35
around access to care. The geographic data showed
18:38
that patients in the PPCS group were significantly
18:41
more likely to live outside of metropolitan Toronto.
18:44
Really? In the surrounding region? Yes. The odds
18:46
of living in central Ontario, southwestern Ontario,
18:49
or other more rural or semi -urban areas were
18:52
significantly higher, around four to four and
18:54
a half times higher, for patients with PPCS compared
18:57
to those living right in Toronto. That's fascinating.
19:00
What might that be telling us? Is care better
19:02
in Toronto, or is something else going on? Well,
19:04
it raises really important questions about equitable
19:06
access to specialized concussion care. It's possible
19:10
that while Toronto, being densely populated,
19:13
might have long waiting lists for specialist
19:15
care. One study mentioned an average wait of
19:18
10 months for tertiary MTBI care there. Ten months.
19:21
Wow. Conversely, it could also mean that patients
19:24
outside the major city center just have fewer
19:26
options nearby, fewer specialist clinics, less
19:30
access to that interprofessional expertise needed
19:32
for complex cases. So if they can't get the right
19:34
help quickly enough, the symptoms might just
19:37
drag on. That's a plausible hypothesis. A lack
19:40
of timely, appropriate intervention closer to
19:43
home could contribute to symptoms becoming prolonged.
19:46
It really highlights a potential systemic issue.
19:49
How does location affect concussion care? We
19:51
need to look deeper into resource allocation
19:53
across different regions. Okay, that's a really
19:55
important system level point. Now, what about
19:57
the symptoms themselves? The study used the SCAT
19:59
T5. Did the PPCS group just have symptoms for
20:02
longer, or were the symptoms themselves different
20:05
or more severe? They were definitely more severe.
20:07
While both groups obviously had symptoms, the
20:11
PPCS group consistently reported significantly
20:14
higher perceived symptom severity across all
20:17
the SCET T5 domains. The fatigue, emotional,
20:21
cognitive, and somatic physical symptoms. So
20:23
more intense symptoms across the board. Yes.
20:26
For example, fatigue symptoms were much more
20:28
prevalent in the PPCS group. And fatigue often
20:31
goes hand in hand with emotional symptoms and
20:34
sleep problems after concussion. And emotional
20:36
symptoms like anxiety or irritability. Those
20:39
also tend to increase months after the injury
20:41
in people with prolonged issues, which aligns
20:44
with what this study found. It suggests a much
20:46
more pervasive and debilitating cluster of symptoms
20:49
in those who don't recover quickly. What about
20:51
the cognitive ones that brain fog people describe,
20:53
the trouble concentrating or remembering? Again,
20:56
consistent with other research. While cognitive
20:58
problems often get better relatively quickly
21:01
in acute cases, maybe within days, they can unfortunately
21:04
persist for years and people with PPCS. That
21:06
must have a huge impact on daily life, work,
21:09
study. Absolutely massive. And similarly, those
21:13
physical or somatic symptoms like chronic headaches,
21:16
persistent dizziness, that awful sensitivity
21:19
to light or noise, they were also significantly
21:23
more common and severe in the PPCS group. Are
21:26
any particular symptoms early on seen as predictors?
21:29
Yes. Reporting a high number of somatic symptoms,
21:32
especially headaches, right in the acute phase
21:34
after the injury is often considered one of the
21:37
better predictors that symptoms might persist
21:39
for longer. It shows how all these different
21:41
symptom types, physical, emotional, cognitive,
21:44
can weave together into this complex challenge
21:46
for patients. Makes it really hard to treat sometimes.
21:49
It really sounds like getting the right evaluation
21:51
and management right from the start could make
21:53
a big difference. Can we talk a bit about the
21:56
overall approach to assessing and managing concussions?
21:58
What are the key steps, whether it's an athlete
22:00
or someone from that car accident? Yes, absolutely.
22:03
The foundation, the absolute cornerstone, is
22:05
a thorough history and physical examination.
22:07
What does that involve? You need every detail
22:10
about the injury, how it happened, the forces
22:12
involved, was there any loss of consciousness,
22:15
however brief, and critically, any previous injuries.
22:18
Then, a detailed past medical history is vital.
22:22
Checking for those potential influencing factors.
22:25
Exactly. Previous headaches, migraines, any history
22:28
of depression, anxiety, chronic pain, dizziness.
22:31
These can all shape the recovery path, even if,
22:34
as the Ontario study showed, they didn't perfectly
22:37
distinguish the acute from the prolonged group
22:39
in that comparison. And the physical exam. A
22:42
full neurological assessment, checking cranial
22:44
nerves, vision, reflexes, muscle strength, proprioception.
22:48
That's your sense of where your body parts are
22:50
and sensation. It's about building that complete
22:52
clinical picture. For athletes, there's often
22:54
that immediate sideline check. What's crucial
22:57
there? That immediate sideline evaluation is
22:59
critical in sport. First priority is the primary
23:01
survey checking, airway, breathing, circulation,
23:04
the absolute basics. And crucially, looking for
23:06
any sign, any sign of a spinal cord injury. Neck
23:09
pain, altered sensation. Yes. If an athlete's
23:13
mental state is off or they complain of neck
23:15
pain, you must assume a cervical spine injury
23:18
until it's proven otherwise. Safety first. Are
23:21
there immediate red flags that mean straight
23:23
to hospital? Definitely. Things like a deteriorating
23:26
level of consciousness, a really severe headache
23:28
that keeps getting worse, any new focal neurological
23:32
deficits like weakness on one side, those warrant
23:36
immediate emergency transport for urgent brain
23:38
imaging. And assuming none of those red flags,
23:41
what happens next on the sideline? Then you move
23:43
to the secondary survey, focusing specifically
23:46
on cognitive function and those classic concussion
23:49
symptoms. The absolute rule here, the non -negotiable,
23:52
is that any athlete showing any signs or symptoms
23:55
suggestive of a concussion must be removed from
23:57
play immediately. No finishing the half. Absolutely
24:00
not. No return to play on the same day, full
24:02
stop. Their health is paramount. Far more important
24:05
than the game. And that's where tools like the
24:07
Scatty 5 come in useful again. Precisely. The
24:09
Scatty 5 is designed for that situation. It's
24:12
standardized, widely used for athletes age 13,
24:15
and up there's a child Scat 5 for younger ones
24:17
too. What does it involve? It has components
24:19
for immediate on -field assessment, looking for
24:21
visible signs, asking quick memory questions
24:24
like the Maddox questions, using the Glasgow
24:26
Coma Scale for consciousness level. And then
24:28
off the field? Yes. Ideally in a quiet, private
24:32
space. There's the standard assessment of concussion,
24:35
the SAC, test checking orientation, memory, concentration.
24:39
There's also the BSS test, the balance error
24:42
scoring system to objectively measure balance,
24:44
which is often affected. Are there other tools
24:47
used? Yes, things like the impact test. which
24:50
is computer -based. It looks at verbal and visual
24:52
memory, processing speed, reaction time. Often
24:55
you compare the athletes' post -injury scores
24:57
to their own baseline scores taken before the
25:00
season started. Ah, having that baseline is helpful.
25:03
Very. And the King -Devick test is another one,
25:05
looking at eye movements and concentration by
25:08
having the athlete read numbers quickly. These
25:10
tools give objective data to help the clinician
25:12
make informed decisions. So lots of assessment
25:14
tools. What about brain scans, CTs, MRIs? You
25:18
said earlier they don't diagnose concussion itself,
25:20
but when are they needed? That's a really common
25:22
point of confusion. Yeah. You're right. Generally,
25:24
advanced imaging like CT or MRI is not needed
25:28
to diagnose a concussion. Remember, it's primarily
25:31
functional. Most scans will be normal. Okay.
25:33
But imaging is absolutely essential in acute
25:37
head trauma if those red flags we mentioned pop
25:39
up. deteriorating status of your headache, focal
25:42
signs? Exactly, or a suspicion of a neck injury.
25:46
In an emergency setting, a CT scan is usually
25:48
the first choice. It's quick and good for ruling
25:51
out skull fractures, bleeding inside the head,
25:54
intracranial hemorrhage, or brain bruises, contusions.
25:57
And MRI, when would that be used? MRI gives much
26:00
more detailed pictures of the brain tissue itself.
26:02
It can pick up more subtle structural damage.
26:05
Specialized sequences like diffusion -weighted
26:07
imaging are particularly sensitive to the shearing
26:09
injuries we talked about. Can it show functional
26:11
changes, too? Functional MRI, or fMRI, can actually
26:15
show changes in blood flow patterns in the brain,
26:18
that cerebrovascular reactivity, especially in
26:20
the acute phase. And if symptoms are really dragging
26:24
on, say for more than a month, an MRI might be
26:26
done later to make sure there isn't some other
26:28
underlying neurological issue mimicking the concussion
26:31
symptoms. Okay, so imaging has a role, but it's
26:34
more about ruling out other serious problems,
26:37
not diagnosing the concussion itself. Precisely.
26:40
Diagnosis is primarily clinical, based on the
26:43
history and examination. Right. Let's talk about
26:45
treatment, then. The old advice used to be just
26:48
rest, dark room, do nothing. Has that changed?
26:50
Oh, massively. Our understanding has really evolved.
26:53
The initial step is still immediate removal from
26:56
whatever activity caused the injury or makes
26:58
symptoms worse. And definitely no same -day return
27:01
to play or demanding activity. But not weeks
27:04
of bed rest. No, absolutely not. For acute concussions,
27:07
the current recommendation is actually a very
27:09
brief period of relative cognitive and physical
27:11
rest, typically just 24 to 48 hours. Just one
27:14
or two days. Yes. This is not strict bed rest
27:17
in a dark room. We now know that prolonged complete
27:21
rest can actually be detrimental. It can lead
27:24
to worse outcomes, more anxiety, depression,
27:27
and even prolonged physical symptoms. So what
27:30
does relative rest mean then? It means minimizing
27:33
activities that actively provoke or worsen symptoms.
27:37
So maybe reducing screen time, avoiding noisy
27:40
environments, not doing strenuous physical exercise
27:43
right at the start, just taking it easy initially.
27:45
And then what? Then, that short period of initial
27:48
symptom limited rest should be followed quite
27:50
quickly by starting a carefully structured and
27:52
supervised graduated return to activity protocol.
27:56
This is fundamental to good recovery. Ah, yes,
27:58
the graduated return to play protocol. That sounds
28:00
key, especially for athletes, but you said the
28:03
principles apply more broadly. They do. It's
28:05
relevant for students returning to school, people
28:07
returning to demanding jobs. It's a structured
28:10
step -by -step approach to systematically reintroduce
28:13
physical and cognitive challenges. How does it
28:15
work? How gradual is it? Typically, each stage
28:18
lasts at least 24 hours. So assuming someone
28:21
stays symptom -free at each step, it usually
28:22
takes about a week to get through the whole protocol
28:24
and be cleared for full return to sport. A week
28:27
minimum. And why is that stepwise approach so
28:30
important? It's vital because it allows the brain
28:32
time to adapt and heal while gradually increasing
28:35
the demands placed upon it. It helps prevent
28:38
symptoms flaring up badly and reduces the risk
28:41
of getting re -injured by doing too much too
28:43
soon. Can you walk us through the stages? Sure.
28:46
It usually goes something like this. Stage one
28:48
is symptom limited activity. basically daily
28:51
activities that don't provoke symptoms. The aim
28:53
is rest from demanding tasks, less screen time,
28:57
quiet environments, maybe life's cool or work
28:59
activities if tolerated. Okay, taking it easy.
29:02
Stage two is light aerobic exercise. Once they're
29:05
symptom -free at rest, they can start things
29:06
like walking, swimming, gentle stationary cycling,
29:09
keeping the heart rate fairly low, say below
29:11
70 % of maximum, no resistance training yet.
29:15
The goal is just to increase heart rate gently
29:17
without symptoms. This actually helps brain blood
29:19
flow and recovery. Right, so activity isn't bad
29:22
if it's the right kind. Exactly. Stage three
29:25
is sport -specific exercise. More dynamic movements
29:28
now, like running drills, skating for hockey
29:31
players, throwing. Still no head impact activities
29:34
though, adding movement and agility back in.
29:37
Getting closer to the sport. Stage four is non
29:39
-contact training drills. More complex training
29:42
here. passing drills, team plays, starting some
29:45
progressive resistance training perhaps, building
29:48
exercise tolerance, coordination, cognitive load
29:51
of practice, but still no contact. Crucially,
29:54
no contact yet. Stage five is full contact practice.
29:58
This is the big step before competition. Returning
30:01
to normal training, including contact drills
30:04
appropriate for the sport, all done in a controlled
30:06
practice setting. It's about restoring confidence
30:08
and checking skills under pressure. Stage 6 is
30:12
full return to play. If and only if the individual
30:15
is completely symptom -free through all those
30:17
stages and gets clearance from a healthcare professional,
30:20
then they can return to normal games or competition.
30:22
And what if symptoms come back during one of
30:24
the stages? That's the key rule. If symptoms
30:27
return at any stage, you drop back to the last
30:29
stage where you were completely symptom -free,
30:32
rest for another 24 hours, and then try progressing
30:35
again. So listen to your body. Don't push through
30:37
symptoms. Absolutely. This patient systematic
30:40
approach is what really minimizes the risk of
30:44
prolonged problems or getting hurt again. That's
30:46
a really clear framework. What about people whose
30:49
symptoms do persist beyond that acute phase?
30:52
Someone in the PPCS group, for instance. Are
30:54
there more specific therapies beyond just gradual
30:57
activity? Yes, definitely. When symptoms persist,
31:00
the approach needs to become much more targeted.
31:02
And that interprofessional team really comes
31:04
into play. What kind of targeted therapies? Well,
31:07
medications might be considered for specific
31:09
symptoms. For persistent headaches, maybe low
31:11
-dose amitriptyline, which works on nerve pain,
31:14
or something like sopranolol, if migraines are
31:16
a feature. And for the dizziness or visual problems
31:18
people often get. Those are incredibly common
31:21
and disabling. There are specific screening tools
31:23
to pinpoint the cause. Is it the inner ear, the
31:26
stabler system, eye movements, ocular motor,
31:30
or maybe neck issues contributing? And based
31:32
on that, based on the findings, you get active
31:34
therapies, things like cervical physiotherapy
31:37
for neck pain and stiffness, specific vision
31:40
therapy exercises prescribed by an optometrist
31:43
or therapist to retrain eye tracking, focusing
31:46
and coordination, or vestibular rehabilitation
31:49
exercises from a physio to help with balance
31:51
and dizziness. These are active treatments, specific
31:54
exercises, not just passive waiting. Is there
31:57
any way to objectively know when someone's brain
32:01
is ready for more vigorous exercise, especially
32:03
if they've been struggling with symptom flare
32:05
-ups? Yes. There's a useful tool called the Buffalo
32:08
Concussion Treadmill Test. How does that work?
32:10
It's a graded exercise test, usually on a treadmill,
32:13
that helps determine the heart rate at which
32:15
symptoms start to appear or worsen. It helps
32:18
figure out a safe threshold for aerobic exercise.
32:20
So you find their symptom threshold. Exactly.
32:22
Then you can prescribe exercise just below that
32:25
threshold. The goal is to gradually increase
32:28
their exercise tolerance over time. Once a patient
32:31
can exercise for about 20 minutes at a target
32:33
heart rate, symptom free, for a few days in a
32:35
row, they're generally considered physiologically
32:38
recovered enough to handle more activity. Does
32:40
that mean they're ready to play sport again?
32:42
Not necessarily full contact sport. Physiological
32:45
recovery doesn't always perfectly align with
32:47
being ready for the cognitive demands and physical
32:50
risks of competition. But... It's a key milestone.
32:54
It allows them to get the benefits of safe aerobic
32:56
exercise, which we know aids overall recovery.
32:59
Okay. So pulling this all together beyond the
33:02
specific exercises or medications, what's the
33:05
big picture of you on managing concussion, especially
33:08
when symptoms linger and really disrupt someone's
33:11
life? The big picture, the absolute necessity,
33:14
is that interprofessional team approach we mentioned
33:16
earlier. It's not just helpful, it's essential
33:18
for truly comprehensive holistic management.
33:21
Remind us who's on that team again. It can be
33:23
a wide range, depending on the patient's needs.
33:26
Neurologists, neuropsychologists, physiotherapists,
33:29
occupational therapists, speech and language
33:32
pathologists, sometimes social workers, psychologists
33:34
or psychiatrists, if mental health is a factor.
33:37
They all need to work together. Why is that collaboration
33:40
so crucial? Because it ensures all the different
33:43
aspects of the person's recovery. The physical
33:46
symptoms, the cognitive difficulties, the emotional
33:49
impact, the social challenges, returning to work
33:52
or school are all addressed at the same time
33:55
in a coordinated way. The STATPRL source we looked
33:58
at really emphasized how much populations like
34:01
veterans and athletes benefit from this kind
34:03
of integrated care. Are there specific programs
34:06
that use this integrated approach? Yes, there
34:08
are. For instance, studies have shown that programs
34:10
like CogSmart, which combines cognitive rehabilitation
34:13
training with support for returning to employment,
34:16
can lead to quick recovery and fewer people developing
34:19
post -concussion syndrome. This seems particularly
34:21
helpful for veterans who might also have PTSD
34:24
alongside the concussion. That integrated care
34:27
is what makes the difference for long -term outcomes.
34:29
So addressing those other conditions like depression
34:32
or anxiety or PTSD is a really important part
34:35
of concussion management, too. It's not just
34:37
treating the head injury in isolation. Exactly
34:40
that. Treating those comorbidities, the conditions
34:43
happening alongside the concussion, significantly
34:46
helps recovery from the concussion symptoms themselves.
34:50
We know, for example, that getting people into
34:52
controlled exercise early on helps prevent prolonged
34:55
symptoms, partly because it reduces depression,
34:58
anxiety, and sleep problems, which are all so
35:00
common after concussion. It's a powerful non
35:04
-drug intervention. And the other absolutely
35:07
crucial factor both for preventing prolonged
35:09
symptoms and for successful treatment is patient
35:12
and family education. What kind of education?
35:15
Setting realistic expectations is huge. Explaining
35:18
that symptoms are often worse than the first
35:19
week or two, but usually do improve. Busting
35:22
myths, like the idea you need to lie in a dark
35:24
room for weeks we know now that can be harmful.
35:27
Empowering them with knowledge. Precisely. giving
35:30
patients and their families accurate information,
35:33
strategies they can use themselves, and confidence
35:35
that recovery is possible. It shifts them from
35:38
being passive sufferers to active participants
35:41
in their own healing journey. That proactive
35:44
mindset is key. Okay, so let's try and synthesize
35:49
all of this. Thinking back to the Ontario study
35:52
and everything else we've discussed, What are
35:54
the main takeaways? What does this evolving landscape
35:56
really mean for us? Well, it certainly brings
35:59
us back to those surprising findings from the
36:01
Ontario study. That direct comparison between
36:04
the acute and PPCS groups really did throw up
36:07
some counterintuitive results, didn't it? The
36:09
ones about the traditional risk factor? Yes.
36:11
The fact that sex, a history of mental health
36:14
issues, and a history of headaches or migraines
36:16
didn't show up as significantly more prevalent
36:19
in the PPCS group compared to the acute group.
36:21
especially when you think about that commonly
36:24
quoted 10 -20 % progression rate. It challenges
36:26
that idea, doesn't it? That only a small specific
36:29
group with those factors is destined for long
36:31
-term problems. It really does. It suggests the
36:34
baseline vulnerability might be much brawner,
36:37
more similar across many people who get a concussion,
36:40
regardless of those specific pre -existing conditions.
36:44
That fundamentally changes how we should think
36:46
about identifying who's at risk. So we can't
36:48
just tick those boxes, female, history of anxiety,
36:52
history of migraines, and say, ah, high risk.
36:54
It seems not. Based on this direct comparison,
36:58
it really forces us to reevaluate how we identify
37:01
people who might struggle. It suggests it's probably
37:04
a much more complex interplay of factors rather
37:06
than just a few simple predictors telling the
37:08
whole story. But some factors did clearly stand
37:10
out in the study as differentiating the groups.
37:13
Yes, absolutely. Age was significant. Patients
37:16
over 40 were at substantially higher odds of
37:18
having prolonged symptoms. And the mechanism
37:21
of injury, those transportation -related incidents
37:24
carrying much higher odds, those are things we
37:26
really need to pay close attention to right from
37:28
the initial assessment. And the geographical
37:30
finding. that finding about higher odds for PPCS
37:33
outside the major metropolitan center, that really
37:36
points towards potential access to care disparities.
37:39
That needs looking at from a healthcare system
37:41
perspective. It's not just about the individual
37:43
patient. It's about the system they're navigating.
37:45
Right. This deep dive has definitely painted
37:47
a more complex, more nuanced picture of concussion
37:50
than just a bump on the head. And it leaves us
37:53
with a really important, maybe even provocative
37:55
question for you, our listener, to think about.
37:59
If that... commonly cited figure, that only 10
38:01
-20 % of people develop persistent post -concussion
38:04
symptoms, is actually, as some research hints,
38:07
a significant underestimate, maybe closer to
38:09
50 % in some real -world settings. What does
38:12
that really mean? What are the implications for
38:14
our healthcare systems, for our communities,
38:16
for how we understand brain injury? It suggests
38:18
a much larger burden than perhaps we've acknowledged.
38:21
Exactly. This deep dive suggests many more people
38:25
might be struggling with prolonged recovery,
38:28
often without having those classic risk factors
38:30
we used to focus on. So what more do we need
38:33
to uncover about this sort of unseen burden?
38:36
And how should this evolving understanding shape
38:39
how we prevent, diagnose, and support the millions
38:42
affected? It really pushes us towards thinking
38:45
more holistically, doesn't it? Beyond single
38:47
factors, towards more integrated care models
38:50
that are accessible to everyone? Absolutely.
38:52
Well, we really hope this deep dive has given
38:54
you a fresh perspective and some valuable insights
38:57
into the complex world of concussions and prolonged
39:00
post -concussion symptoms. Hopefully some useful
39:02
takeaways. If you did find this discussion illuminating,
39:05
we'd be grateful if you could take a moment to
39:07
rate and share this deep dive with your colleagues
39:09
or anyone in your network who might benefit from
39:11
these critical insights. Thanks for joining us.
39:14
Thank you for joining us on the Deep Dive.