Mark: Hi, it’s Mark from TLR. I’m here with Dana Ranahan. She’s the owner of the chief physiotherapist at Body Works Sports Physiotherapy in North Vancouver, multi time winner, the whole outfit, multi time winner of best physiotherapists in Vancouver, and recently voted again in the top three in North Vancouver. How are you doing Dana?
Dana: I’m pretty good, thanks. Thanks Mark for that wonderful, welcome.
Mark: So concussion, what is the deal with concussion?
Dana: Yeah. I mean, concussion has been a big word that’s come up as a topic in sports in the last few years. I think since we’ve started to learn a lot more about concussion and how it affects the brain. I think we’ve taken a little more seriously in how we manage it.
It used to be like, oh, your bell is rung and back to get out there. But now I think we’ve learned a whole lot more in terms of recognizing concussion and learning how to manage it better. Because there’s all kinds of types of concussion that you can get through sport or car accident.
Mark: So what would be, you see a fair amount of this, you guys are specialists in this, trained up in how to diagnose and treat concussion, unless it’s severe. What would the symptoms be that parents, or anyone would be looking for?
Dana: Yeah, I think that’s sometimes a tricky one because we all have this impression that a concussion is, you know, necessarily someone has a significant head impact of some kind and headaches, I think are what people would think of as being the big issue.
And certainly headaches are one of the symptoms.
But the first thing I would look at is what type of trauma has occurred. And, you know, I work a lot with young soccer players. So a lot of time it’s a ball to the head, or it could be a head-to-head impact, or sometimes they have a hard fall to the ground and they get a whiplashing kind of action where their head could hit the turf or it could just be whipping in space. So you don’t even need to necessarily have a head impact to have a concussion, but that would be the most typical one where you have some kind of head impact. And we can see them in other types of traumas like falls. You know, if you fell from a ladder, fell down the stairs or something, you may whack your head.
Or you may have that whiplash type action, which acts like a concussive force to the brain or a car accident. So there’s kind of different platforms where they come from and often we’ll see similar symptoms, but there can be some differences depending upon the actual mechanism of what happened.
So if we look at the soccer player, who’s head to head, they may then come off the field, kind of feel dazed and confused and you go out to see them and they’re kind of looking like this. They need to probably come off because they’re a little disoriented. They feel kind of foggy, dizzy maybe.
So those are common symptoms, headache. Headache sometimes doesn’t come on right away, but usually there’ll be some kind of like my eyes feel funny or they look a little bit spaced out. They can’t see one finger, it’s blurry vision, some dizziness. And then other symptoms we see may come on a little bit later that you may not see in the moment, but if we see those symptoms right away in sport, for example, then the player needs to be removed from play.
And they’re not safe to be returned to the play on that same day. So, because there’s a risk of more serious injury, if they were to have a second concussion. So if a player in a sports situation, adult or child, youth, adolescent has a head impact of some kind with any symptom could be headache, dizziness. Any of the ones I’ve mentioned they need to come out of play and be evaluated by someone. Especially if the symptoms are lasting.
So other symptoms we might see would be, you know, sensitivity to noise or light. And again, those might not be things that come on right away. They may take a little bit of time to come on. So the next day, you might see the child like squinting, having trouble seeing at school because of the bright lights. So they’re having trouble thinking.
So there’s a whole range of symptoms that we might not always associate with concussive impact because I think we usually think of pain and some of the other things are a bit harder to measure. But they all are symptoms under the umbrella of a concussive impact.
Mark: So, it’s not like the movies, James Bond is getting knocked out multiple times and just bumps and back up, shaking it off. That’s not how it works is it?
Dana: No, it’s not. And I think when you get this concussive force, it’s almost like you sprain your knee or your ankle or something, and you know how it swells up in a big fashion and then you can’t continue to play because it hurts. The same type of thing happens in the brain. You don’t get the swelling in the same way as you would in a peripheral joint, but you do get a big biochemical reaction where it starts to trigger things off.
And if they continue to play and they have a second trauma, it can be quite severe. It can be fatal. And so people sometimes don’t realize the severity of what could happen should they have a second impact. And they call that second impact syndrome for that purpose. So anytime someone has it, that’s where they need to be removed from play and they shouldn’t be returned to play unless they’ve been cleared.
If they have ongoing symptoms, unless they’ve been cleared by either a physician or a physiotherapist perhaps, who has training in concussion management and can understand, you know, what the guidelines are.
Mark: So we’ve heard some pretty bad stories about different athletes and, you know, career ending kind of things, or all kinds of ongoing issues as they get older in life, et cetera. So this is critical really, but what would be the typical course of like, how would you diagnose this and then start treating it?
Dana: I think for milder concussions, what they suggest and what the current recommendation is is that they want you to have some rest for 24 to 48 hours. So if you’ve had a concussion and symptoms are not worsening, you had the whack to the head. You got a bit of a headache. Maybe you feel a little foggy, but nothing more severe. Then you want to sort of take it easy and rest for a couple of days. Historically they would put you in a dark room and tell you to turn the lights out and, you know, rest for a period of time. And I think what they found is people would do that for an ongoing period.
And if you do that for too long, then the brain becomes really sensitive and it’s often hard to recover from it. So you can get a prolonged concussion recovery, which we call post-concussion syndrome. So typically if things settle within the first sort of couple of days. The person can probably start going back to activity without too much medical or treatment intervention, maybe just a bit of advice and education about how to manage it.
But if the symptoms are ongoing past a couple of days, they need to start slowly, gradually introducing cognitive like school workload, meaning thinking loads and physical loads to see how they can respond. And if any of those things elicit worse symptoms, then that is definitely something that they need to have evaluated because then we can start directing care. So we can understand, well, what is causing the symptoms?
Maybe they have something going on in their inner ear. Maybe they have a neck issue related to it. Maybe it’s just some advice on pacing and gradually building back up again. And so there’s a lot of things that we can do to help them recover from the concussion quickly and sort of get them back to activity and get them back to schoolwork.
Sometimes like kids will need time off of school or people need some time off of work to allow the brain to recover, kind of like you injure your knee. But it doesn’t mean lock yourself in a dark room. It just means to allow you time to sort of slowly build back up a little bit again. And there are some cases where we see prolonged concussion symptoms and those are much harder to manage because there’s usually a longer course of recovery.
So if we see young athletes or adults even, have had repeated concussions, often as time goes on, if they have more and more concussions over time, then the symptoms can become more severe and harder to recover from. Especially if they haven’t had good management in the past. So I think you can get kind of a cumulative effect. So managing the earlier concussions and understanding how to protect yourself, I think is really critical for your future brain health also.
Mark: So what about getting knocked unconscious? How’s that on the scale of good to bad concussion?
Dana: Loss of consciousness is something that we look at because it is an indicator of more severe injury. So if someone had a loss of consciousness, I would think it is a more, potentially more severe concussion. And the question is how long they had consciousness. And if they have any amnesia around the incident, because then we’ll decide how severe things are based on that. But most times people would have a loss of consciousness probably are going to need some intervention because they probably had enough of an impact that will require some medical assessment. So that is usually a worst symptom.
Mark: And how does it work with going into the, I mean, hospitals are full of all kinds of things. We’re still in the middle of COVID all kinds of craziness around that. Some ICU are full, some hospitals aren’t accepting patients and stuff. What’s the protocol. How does a physiotherapist who’s trained in this fit into that system?
Dana: Well, I think certainly, we are trained in assessment and treatment of concussions, but we do work very closely with the physicians and I think it’s very important for us to have some connection with the physician involved to help manage the care.
However, that being said, I think a lot of people tend to think of going to their doctor first. And, you know, we all know everyone’s busy and now with COVID, people have been doing all appointments on phone or on zoom with their family physicians, and often waiting quite a long period to see their physicians because everyone’s busy and with changes in schedules and so on.
So I think waiting for your family physician could be a problem for some people, if there’s a delay in waiting. If someone is having worsening symptoms and you know, let’s say they having worsening headaches, or they start to vomit, you know, nausea becomes worse, they’re vomiting than it is a case where I would tell them to go to the emergency because there’s a potential that they could have a brain bleed or something like that.
That’s a worst symptom that may need a surgical decompression. Now the risk of those is usually quite small, but if the symptoms are higher, getting worse and not abating, I think it needs immediate medical attention. Now, if we have symptoms ongoing, like let’s say that have a bit of headache still, or just not feeling well, you know, they could come in and be assessed by us and start their treatment right away.
They don’t need to see a physician necessarily in the beginning, if it’s not severe increasing symptoms. But if there’s anything that came up, we would definitely want to be in contact with the physician because there may need to be some medical examinations, like, you know, an MRI or x-rays or whatever is involved or medication, or we might need help with in terms of overall management. So you usually, as a physiotherapist, if we’re assessing someone, we would be in contact with their physician, with the consent of the patient, of course, to help manage the care.
However, it’s kind of a tough line between emergency, you know, you go to emergency for every little thing, especially with COVID and with the huge waitlist. I would say no, however, concussion is a tough one. And if the symptoms are worsening, they probably do need to go to emergency. You know, if they’re getting an increase in their symptoms, that’s not abating. Then it needs to be investigated to rule out anything more serious despite the lineup. Unfortunately that’s the challenge with our system.
But if it’s not more serious and they just have some symptoms that are persisting, they’d be fine to come in and be assessed by a physiotherapist. And when I’m on the sideline at a game, I will usually try to give some advice and work with teens. So, you know, then the parent is helping their care.
I’ll give some advice to the parent because it looks like they’re getting worse. So I think, okay, monitor them in the next couple of hours, if things are getting worse, go to the hospital and you know, you can give them some advice in the beginning.
But that’s kind of the information I was hoping to put out to the public today. Just so people have a better framework of what to do if this kind of thing happens.
Mark: So bottom line, it’s not like the movies. You can’t get smoked multiple times in the head and lose consciousness and just shake it off and continue on. There are serious ramifications. Exactly. You need professional diagnosis and treatment in order to, exactly, make sure you don’t lose your marbles.
Dana: And then the treatment then can be directed to your specific needs. Right. So I think that’s also the challenge, like sometimes there’s general principles, but if you have specific things, you might need some specific guidance.
Mark: Body Works Sports Physiotherapy, you can reach them at body-works.ca. You can book your appointment there, or you can call them (604) 983-6616. Award-winning physiotherapy clinic in North Vancouver. Call Dana. She will get you feeling right again. Thanks, Dana.
Dana: Great. Thanks so much, Mark.