Cracking Concussions: Part 2

If you’re just picking up this post, you may have missed the story from Part 1 about my recent patient (Patient 1) who presented with a concussion. I discussed how without my recognition of his symptoms, he may have been misdiagnosed and/or mismanaged.

Mirror this case with another case of a high school athlete (Patient 2) I was treating at the exact same time of Patient 1. Patient 2 sustained a head injury when falling backward onto her head during a home plate collision during a softball game. Her father, a pediatric physician assistant, was on the scene and immediately recognized signs of a concussion. She was monitored and taken to a local emergency department. She followed up within a day or so with a pediatric primary care sports medicine physician, who recommended cognitive rest, a modified school schedule and program, and prompt referral to physical therapy.

Within 3 days she was in my office with similar signs and symptoms of the other athlete mentioned before. We performed several specialized manual therapy techniques to her spine, neck, and head to address the physical ailments from whiplash associated with a head injury. She performed gaze retraining and stabilization exercises to assist with convergence and visual tracking. These are skills necessary for reading, viewing the environment, and sports participation. We also utilized Redcord Neurac, a suspension-based neuromuscular re-education system to help restore her balance and stability. She followed a personalized stepwise progression back to school and softball.

And yes, like every good overachieving and motivated athlete out there, she overdid it. I warned her on her first visit that her symptoms would clear long before she was ready to return to sports. True to form, she felt better and decided to exercise—something like simple jogging and softball throwing. She reported a severe headache the next day and she was unable to fully participate in school.

This is common in concussion recovery, and it is paramount that athletes be monitored as they gradually return to their sports.  It’s also important they be encouraged not to overdo it. The good news is that she learned her lesson and followed the rules. Soon enough, she was back in the classroom and the field.

In her case, she was in the right place at the right time when she was injured. Her dad knew what to do. She got to the right physician, who just-so-happened to be a pediatric sports specialist and affiliated with her school. Her physician had previously set up a concussion monitoring and management program with the school and athletic program for all students, not just athletes.  Importantly, he referred her to physical therapy within a week of her injury. It was the ideal situation.

Ironically, one week before encountering these two patients, I had just had an interesting conversation with my PT colleague who posted this informative blog post about her 8-year-old son’s concussion. She was less aware of the role that sports medicine and neurologically-trained physical therapists play in concussion assessment and rehabilitation.

As with any other injury that keeps a person from participating in their activities of daily living and sports, specialized physical therapists are trained to rehabilitate and safely monitor patients as they return to activities following concussion. According to a 2012 position statement released by the American Physical Therapy Association House of Delegates, physical therapists trained specifically in sports medicine, vestibular rehabilitation, and/or neurologic rehabilitation can play a key role in evaluating and treating the movement impairments, functional limitations, and participation restrictions associated with concussion and mild traumatic brain injury.

Concussion is not only a hot topic on my recent caseload, but it is also running rampant everywhere else. Recently another PT colleague told me of a conversation she overheard at her daughter’s competitive cheerleading gym. Evidently on one girl’s high school cheerleading squad, 4 girls were recently out of commission due to concussions.

Just as participation of females in sports has increased, concussions in female athletes are also a growing issue. Many people may think of male-dominated contact sports such as football, baseball and lacrosse as the most common denominators for head injury and concussion. You may be surprised to know that some statistics show that cheerleading and women’s soccer are resulting in more concussions than other male contact sports. A 2012 position statement by the American Medical Society for Sports Medicine found that in sports with similar rules, female athletes sustain more injuries than their male counterparts.

Females experiencing concussion also report higher number and severity of concussion symptoms as well as longer duration of recovery from concussion. Read here about concussions in competitive cheerleading and here about a 9-year-old softball player who made a full recovery. Visit pinkconcussions.com, the first-ever dedicated online site to education and information on concussions specific to female athletes.

Concussions are not just happening in youth sports, but they’re also becoming famous, too. Much controversy surrounds Major League Baseball’s new rules to ban home plate collisions for several reasons, some of which were due to repercussions of injuries sustained by players. The current news is filled with the story the landmark settlement between the National Football League and 4500 former players claiming the NFL’s responsibility in the long-term health deficits of the players who sustained concussions while playing. There’s also the story of the college football player whose coaches ignored his symptom complaints and pushed him to continue to play. Sadly, that player eventually died.

On the youth level, it may not be on the front page of ESPN, but it’s just as much of a big deal. As of January 11, 2014, all 50 states have enacted legislation mandating some form of concussion “reform” in school and recreational sports leagues. In Georgia State Law, the Return to Play Act was passed in April 2013 and enacted on January 1, 2014. This mandates that all teams and leagues must provide concussion education to parents and coaches, recommend baseline concussion testing, hold athletes from play until cleared by a healthcare professional. In 2008, the state of Washington passed the Zackary Lystedt Law, named for a second impact syndrome survivor who was permanently disabled after returning to sports too prematurely following concussion.

Unfortunately, the sad thing is that these injuries have required state and federal action to bring everyone onto the same page on this important issue. Let’s be honest, even with the laws, “Everyone” and “on the same page” are probably generous phrases. But, it’s a start. We have a long way to go, but judging by how much my twitter feed has blown up with this topic in the last few months, I’d say that we are really getting the word out there.

It’s not just a problem for kids. It’s a problem for everyone.

So—even for you grown-ups out there, the next time you get your “bell rung” (by the way, please don’t use that term) or you just feel a little “fuzzy” after you bang your head on the open cabinet in the kitchen for the 80th time (don’t you just hate it when you do that?)…please put down your computer, your phone, cancel that workout or meeting tomorrow, and consider the long term effects such an injury may have on you.

If you’re an athlete-please tell someone you feel bad. It’s common, but not normal, to feel the way you do after your injury. You’ll get back to your sport faster if you do. No game, school exam, or competition is worth the risk of pushing it too far.

Cracking Concussions: Part 1 new & improved!

Whoops, looks like I missed out on #throwbackthursday. Maybe it’s because I have #chemobrain. Or maybe it’s because I have had several concussions in the past and there’s a likelihood that my memory has been affected-even for some minor tasks like publishing a blog post. Or in this case, re-posting a blog post. In honor of the 2-year anniversary of this blog, I’ve decided to wake up from my 6-month long radio silence and re-publish one of my first posts with a little updated commentary. Nobody likes to reinvent the wheel after all.

Many of us have hit our heads, whether during sports or otherwise, and don’t even realize we have had a concussion. We’re pretty resilient-and smart. And a lot of times we don’t know what we don’t know–even when we are medical professionals who actually treat concussions–and we end up with symptoms we think are characteristic of something else or are “completely normal”:

Oh, I’m just tired. Maybe it’s because I’ve been so busy lately.

I can’t focus. I’ll take a break later. I have to push through and finish this.

My clients seem so unreasonable lately. They just don’t get it.

I have a killer headache. Let me take some medicine.

I keep having trouble with sleep. Maybe I should cut back on caffeine.

I feel like I have too much on my plate and can’t remember all the things on my list. Maybe I need to re-prioritize.

My husband/kids is/are driving me CRAZY lately. I just can’t take them these days.

Driving seems a lot harder. Same with going to the grocery store. There’s just too much going on all at once.

I’m dizzy. Maybe it’s because I’m getting older. I hear a lot of my friends have vertigo.

The thing is–none of these things are normal whether you’ve had a concussion or not. Regarding whether they’re normal if you haven’t had a concussion-that’s another blog post for another day. But if you have recently (say, in the last 1-2 months) had a car accident, whiplash, a fall, sports injury, or even something where you haven’t actually hit your head but your body has incurred trauma–CONGRATULATIONS! You may qualify for the concussion club.

No wait, that’s not something to be proud of. But it is something to be aware of and to tell someone.

Why?

A recent study at the University of Illinois at Urbana-Champaign published in November 2015 showed that two years after incurring a concussion, children ages 8-10 showed lasting deficits in brain function and cognitive performance compared to other children who did not incur a concussion. This means that they are falling behind in school, sports, and likely social function.

No bueno! I don’t want that for MY KID!

Yeah, I don’t want that for your kid, either.

So wait Julie, you’re talking about a study on kids. So why did you begin this post talking about adults? Stay focused, woman!

Maybe it’s my history of concussion talking that has made me move from talking about adults to kids in a matter of sentences. Or maybe, just maybe,  I care just as much about kids as I do about adults.

We’ve heard countless studies about the long term effects of concussion in adults. Don’t believe me? See the blog post below that I wrote 2 years ago, Cracking Concussions Part 1 and its sister post, Cracking Concussions Part 2.

Now it’s finally starting to be studied in kids. Just like everything else in the sports medicine world-we tend to study adults before we study kids.

But the punchline here is that concussions can have long term effects on ANYONE who has one. You don’t have to be an athlete to have a concussion. You can be an everyday average Joe, age 2-122 and have it still affect you.

Quick examples:

  • A friend of mine hit her head almost 2 years ago and didn’t realize she had a concussion. She was in her early 30’s. I recognized her symptoms before she did. Initially within a few days of hitting her head, she didn’t have symptoms. By the time I saw her-several days later, I encouraged her to go home from work. She obliged and was out of work for nearly a week as her symptoms gradually worsened. She saw a sports concussion specialist and had to really ease her way into working and exercising-quickly learning the hard way that it was very easy to “overdo” it without even realizing-until later-that she was doing that. But now–2 years later–she still notes deficits for which she must seek very specialized medical care. The Take Home: You may not be aware you’ve had a concussion. But even when you follow all the rules once you realize you have had one, you may see deficits later. A concussion is the real deal. You can’t see it and it doesn’t show up on a scan or blood test (yet!), but it is an injury and illness with dramatic lasting effects. You can lessen the effects on yourself by following specialized protocols.
  • Another friend of mine was in 2 traumatic motor vehicle accidents within 2 months of each other-also in her early 30’s. She saw deficits in her athletic performance, ability to do her corporate leadership job, and a smattering of emotional and social deficits. She was surprised when I told her she had symptoms of concussion. She ended up seeing a battery of specialists including neuropsychology, vestibular PT, sports medicine PT, neurology, acupuncture and integrative medicine–along with many others. She had some pre-existing issues which made her concussion injuries and illness more difficult to overcome, but 1 year later she still notes deficits in concentration, memory, energy, and other health-related factors. But she has made drastic, leaps-and-bounds progress from where she was 1 year ago. Take home: you can REALLY do all the right things, and it will REALLY help you, but it just takes time to let your body heal and recover.

So, if you or your child have a fall, have whiplash, have an accident where you hit your head or some other body part–chances are, you may have had a concussion. And remember–your chin, your nose, your eye, and your jaw are all part of your head too. Injuries to these areas-no matter how minor you think they are–are officially a head injury.

Concussion symptoms are so sneaky and can rear their ugly heads weeks, months, or even years after your injury. While I never advocate over-treating or over-assessing yourself or your child, it’s always better to be safe than sorry. Seek help from a medical professional who specializes in concussion assessment and treatment. Taking the right steps to care for yourself and your family will lessen the sneaky effects of concussion on you in the long run!

Cracking Concussions: Part 1

Photo credit: http://i2.cdn.turner.com/si/dam/assets/130130184905-pj-hairston-single-image-cut.jpg
Photo credit: http://i2.cdn.turner.com/si/dam/assets/130130184905-pj-hairston-single-image-cut.jpg

“So, I fell and hit my head while playing basketball 3 days ago and blacked out, but the doctor told me it’s not a concussion.”

A month ago, a high school athlete–let’s call him Patient 1–I was already seeing for another injury came in and told me that. Having experience in concussion assessment and rehabilitation, my internal alarm started to sound. This conversation ensued:

“What type of doctor did you see?” -Me

“The emergency room doctor.” -Patient 1

“How did they decide you did not have a concussion” -Me

“They took a CT scan and it didn’t show anything.” –Patient 1

Well that’s good. But um…last I heard, CT scans don’t show a concussion.

“Did they do anything else for you?” -Me

“No, just told me to go home.” -Patient 1

“And what did you do over the last few days?” -Me

“Played on the computer, did schoolwork, and played video games.” –Patient 1

Hmmm…Exactly what you shouldn’t do…

“So, how’s your headache today?”  -Me.

“Pretty bad. Wait, how do you know I have a headache?” –Patient 1

High five to the mentor who taught me to ask that!

“Did you go to school today?” I asked.

“Oh yes!” said Patient 1

Wonderful. Because going to school is a fabulous way to recover from a traumatic brain injury.

“Tell me about how you felt all day. Everything normal?” I asked.

“Well, I had trouble focusing on the board and reading my handouts, so my teacher said I could just listen. I felt nauseous around lunch and didn’t eat much. I really wanted to take a nap after that and could barely keep my eyes open. Later in the afternoon my friends were making fun of me because I was off-balance and walking into lockers.” he said.

My eyebrows raised. It doesn’t get much more “textbook” than that, folks.

I asked Patient 1, who plays multiple contact sports both for school and recreational leagues, if the school administered a computerized or non-computerized baseline concussion assessment. He said no.

Great.

I asked him several questions about his symptoms.  He answered “yes” to almost every concussion symptom on this list:

  • Confusion
  • Clumsy movement or dizziness
  • Nausea or vomiting
  • Memory loss
  • Tiredness
  • Upset stomach
  • Vision problems
  • Sensitivity to noise and light
  • Numbness or tingling anywhere on the body
  • Loss of balance or trouble walking
  • Mentally foggy, cannot think clearly or remember things
  • Slurred speech or other changes in speech
  • Irritable or more fussy than usual
  • Acts differently than normal (does not play, acts fussy or seems confused)
  • More emotional, perhaps very sad or nervous
  • Different sleeping patterns

Then I asked him to perform some simple cognitive tasks like saying a list of 3 numbers backward, remembering a list of random words, and reciting the months of the year backward.   He left out October, August, and May, and put January before March.

Yowza.

Then I did some balance tests. Physical therapists are trained to evaluate and treat balance problems caused by vestibular disorders. The vestibular system is the behind-the-scenes system that detects head movement and helps maintain a sense of balance.  This system is often impaired with a head injury. He lost balance immediately when asked to “stand like a statue” with his feet together and his hands on his hips. When asked to perform this with eyes closed, he reported feeling very dizzy. Just a week before this, he had been doing fine on these tests.

These tests were part of a quick concussion assessment I used to determine if the patient had any cognitive or motor deficits. Though best performed at the time of injury, this test is just one of several research-validated options for kids over age 10. A 2011 study published in the British Journal of Sports Medicine, showed that if the young athlete has not had a pre-injury or baseline assessment, it’s hard to know how “abnormal” his or her results may be. Even if the validity of my test was limited, I knew I needed something to back up what I was suspecting.

After this test, I checked his ability to track an object with his eyes. He could not track a pencil approaching his nose. This is a skill called convergence which is necessary for reading. No wonder schoolwork made him worse! He reported a worsening headache during this test. Meanwhile he asked me to turn off the lights because his head hurt worse.

I’d seen enough. I contacted my colleague, a local pediatric sports medicine specialist. He asked me what the patient’s signs and symptoms were, to which I replied “about as textbook as they come.” He agreed that Patient 1 more than likely had a concussion and would need medical management.

I spoke with the patient’s parents and recommended a prompt referral to the child’s pediatrician. They told me that the patient had a concussion 3 years ago as well. I thought of a scary condition called second impact syndrome. Sometimes occurring in players experiencing a second concussion within the same season or year of the first concussion before the first one heals, Patient 1 did not exhibit signs of this condition. Fortunately, Patient 1 also reported his symptoms before he could potentially re-injure himself.

A lot of players are at risk for this or other serious conditions when they don’t tell someone they feel bad after an injury. Players feel the pressure when they’re injured and often don’t tell anyone. To them, being “benched” from injury may cost them play time, scholarship opportunities, pride, or their first-string spot on a team. A 2013 study from Cincinnati Children’s Hospital found that half of high school football players would continue to play if they had a headache stemming from an injury sustained on the field.

Not speaking up about any injury can really cost you, as evidenced by this story of a player who not only experienced life-threatening issues, but nearly missed out on a year of her young life trying to recover from them.

Patient 1’s parents wondered why they were told he had not had a concussion when at the hospital. There were plenty of reasons for this discrepancy. Sometimes symptoms of a concussion may be delayed, showing up a day or so later. I also discussed with them that a concussion is a functional, chemical process, not a physical one. It was good they sought emergency care for a head injury, as other serious or life-threatening injuries could have occurred. It’s important for a trained physician to determine how to rule those injuries out and make the proper diagnosis and referral. But, because concussion is a chemical and physiological process, it means that the concussion itself would generally not show up on a CT scan. They understood that’s why they were told “the CT scan did not show a concussion.”

brain-300x299

I recommended that the patient begin cognitive rest. This included no “screens,” including cell phones, TVs, video games, and computers—IE, everything he had done the day before. A recent study indicated that lack of cognitive rest following concussion in individuals age 8-23 can impede recovery time. Cognitive rest also includes avoiding school, something that most parents and kids typically do not like to hear. I forwarded them this information about rest from school and activity recommended by an international consortium on concussion management. I again reiterated that they follow-up with their pediatrician for further guidance.

I received a call the next day stating the patient was diagnosed by the pediatrician with a concussion. I eventually saw the patient 3 weeks later upon being cleared by the physician to return to activity. Later he would tell me he missed several days of school and had to make up his exams.

For this athlete, everything was managed perfectly except for a few things. His cognitive rest was delayed. He got worse after spending a day playing video games and going to school. He did not participate in formal concussion rehabilitation PT. In fact, even though I was already treating him for something else, he was instructed to cancel his PT appointments and avoid all activity, then cleared to return to activity without formal testing or monitoring.

Read on to Part 2 to find out what else should have happened, and why we need to improve awareness and management of this problem everywhere.