Monday, 23 June 2014

Noggin News

Next weekend is the Canada Day Long Weekend. Days of relaxing, hanging out at home or cottage, playing or possibly fixing up things around the house and yard. There's likely to be some alcohol consumed by some. Others will head off for extreme sport and rugged adventure. This is a weekend when Emergency department waiting rooms may fill beyond capacity. A time when we typically see  lots of accidents and injuries. Some of those will be traumatic brain injuries (TBI) commonly known as  "concussions".

The truth is anyone at any age at any time can acquire a traumatic brain injury. What we see in our clinic is probably fairly representative. People of all ages have sports injuries including contact (hockey, football, rugby, boxing), non-contact (skateboarding, rollerblading, cycling, skiing, and soccer - the goal scoring "header"), and so called extreme (motorcycle racing, horse racing/riding, hang-gliding). There are the renovation/home maintenance crowd who fall from the unsecured ladder (eaves troughs, christmas lights, wasp nest), fall from the chair balanced on the kitchen table (changing lightbulbs, reaching the top shelf, killing spiders), or receive a blow to the head (think falling sheet of drywall). There are the everyday injuries like the person who falls (ice, water, vodka) or is in a car accident.  And there are the workplace injuries where equipment or objects fall on the head.

Now you might think that I'm breaching your confidentiality and talking about you on my blog but the truth is I have seen all of these injuries many many times. There are lots of you out there. Some of you I saw in my primary health care clinic. Others when I worked in the Trauma Intensive Care Unit. Seriously. In 2009, 94,000 people aged 12 years and older experienced concussions in Canada (Stoller). That's just the cases that were reported. And lots of people do not seek medical care for concussion often because of the mythology that surrounds head injuries.

Myth #1: You can only get a concussion with a major blow to the head. Concussion occurs when your brain is jolted and knocks against the inner walls of your skull. Imagine that the soft brain floats inside the skull surrounded by cerebrospinal fluid. Any acceleration or deceleration of the head can cause the brain to smack into the bony skull around it. This can happen with a blow to the head or sudden acceleration/deceleration such as a car crash or being violently shaken (Mayo). In other words anything that rattles the brain can cause damage. You don't actually have to smack your noggin on anything to get a concussion or brain injury.

Myth#2: Concussions go away quickly. If you don't have a lot of symptoms at the time of injury you will be fine. Damage to the brain can be mild or significant. There can be bleeding in the brain which can be fatal or there can be no bleeding but altered brain function. Both of these can develop immediately after injury or show up hours and days later. This is why it is incredibly important for anyone with an injury or signs and symptoms of a concussion to seek immediate medical care.

There are definitely some people who have greater risk of significant damage. As we age our blood vessels and body structures become more fragile. In simple terms anyone over the age of about 50  "breaks more easily". Anyone on medications or with conditions that compromise their ability to clot blood will bleed more easily. Children often lack decision-making skills and will engage in high risk behaviours (In truth the same can be said about many adults. Ahem). (Mayo). Anyone with a history of migraines, depression, mood disorders, anxiety, developmental disorders, learning disabilities and ADHD are more at risk for prolonged recovery (CDC).

The symptoms of brain injury can be subtle or very noticeable. It's important to recognize the signs of brain injury not just for yourself but also for your family and friends. Intervene and ensure they get appropriate medical care and prevent them from doing anything that could worsen their injury such as continuing to play sports or driving a vehicle. Click here to view a Pocket Guide to Concussion Recognition Tool. 

Myth#3: if you don't lose consciousness at the time of injury then you don't need to go to the hospital or see a health care provider. In the immediate post-injury period people can experience headaches, blurred vision, balance and coordination problems, difficulty concentrating, and problems with memory. Some people will lose consciousness but the truth is that this is actually quite rare and most people with concussion never lose consciousness at all (Mayo). Others will feel dizzy, experience some amnesia, feel confused or "foggy",  or have fatigue. Some people have nausea, vomiting, slurred speech, ringing in the ears or have "head pressure" (Mayo).

Other symptoms are delayed and will not appear until hours or days after the injury. This includes irritability or personality changes, sleep disturbance, sensitivity to light or noise, problems tasting or smelling, and psychological problems such as depression. Young children may be more irritable, have altered sleeping and eating patterns, cry excessively, or be listless (Mayo).

Unfortunately there can be long-term effects from brain injury. Within the first 5 years after injury there is a higher risk of developing epilepsy or seizure disorders particularly in children (Mayo). Some people have post concussion syndrome for months after injury including ongoing headaches, dizziness, vertigo or difficulty with thinking and memory. 

Possibly the more frightening risk is that of cumulative brain injury. Repeated concussions can eventually lead to permanent and possibly progressive impairment that reduces the ability to function. And this is where rehab comes in. 

There is such a thing as rehabilitation for the brain after brain injury. In the rehab period the patient limits activity and brain stimulation in order to decrease concussion symptoms and enhance recovery. What's important to understand here is that the brain needs rest from both physical and mental activity. We definitely want to avoid further injury (i.e. no quick return to sport or activity) but we also want to reduce stimulation to the brain and that can mean gradual return to school, work, and activities that make the brain work. Yep that includes watching TV, gaming, computers, using mobile phones, and driving (CDC-School Professionals). That's why there are both "Return to Learn" and "Return to Play" guidelines in paediatric medicine. 

Return to Learn acknowledges that accommodations need to be made for the concussed student so they may not be able to write tests or take notes in class for a while. They may also need more time to compete assignments and have work load spread over a longer period of time so they can do work in 15 minute intervals and take rest breaks (Persson). Depending on the symptoms some children will need to decrease their exposure to the school setting which tends to be overflowing with visual and audible stimuli (Persson).  Click here to learn more about Return to Learn. Click here to view a Guide for School Professionals. 

Return to Play makes similar recommendations for return to sports after head injury. This is specifically for children but is easily applicable to adults. There are five steps that the patient progresses through. They cannot advance to the next level until they are able to perform step activities without any concussion symptoms. In the immediate recovery period they engage in only complete physical and cognitive rest and then advance through light exercise, moderate exercise, non-contact exercise, practice and then play.  Click here to learn more about Return to Play. You see this type of rehabilitation used by sport professionals who are graded back into activity. 

Regardless of age there is often tremendous pressure from the patient to return to sport and everyday activity too quickly. It's critically important for the people around the patient - family, health care providers, coaches, teachers, and friends - to help the patient rehabilitate at an appropriate pace. At the time it seems like getting right back into the hockey tournament or race is crucial. But the risks are great and the patient likely lacks the judgement in their concussive state to make a good decision.

And you know what they say about an ounce of prevention…. 

  • wear appropriate helmets & protective gear for activities
  • wear seat belts in all vehicles - if it moves & has a seat belt, wear it!
  • think before you play - make good choices about risks
  • safety at work - use protective gear, have work buddies close by
  • safety at home - gates on stairs, no loose carpets, good lighting
  • ask for help with repairs & renovations - use the right equipment, have a buddy to help
  • choose the right footwear - Yak Trax on ice
  • avoid substances that alter your judgement - alcohol & sports aren't a good combo

Thanks for reading Getting Healthy With NP Sam. Comments welcome - click the pencil icon below.

Concussion (Mayo Clinic)
Concussion Assessment Tool (
Concussion & Return to Learn (Persson)
Returning to School After a Concussion: Fact Sheet for School Professionals (CDC)
Return to Play (Centre for Disease Control - CDC)
Do physicians, emergency department physicians, and paediatricians give consistent sport-related concussion management advice? (Stoller et al, Canadian Family Physician)


Anonymous said...

Just wondering ....if someone has had a concussion, or two, before is it okay to do activities like high impact aerobics? Just wondering if all that bopping around isn't such a great idea? Last concussion almost 10 years ago...

Thanks in advance.

Samantha Dalby said...

Best idea is to book an appointment with your MD or NP and ask them. Generally speaking if you have no symptoms of concussion and no recent injury and you don't have any problems when doing aerobics you will probably be fine. But it's always best to have a conversation who knows all the details of your health profile and history. Thanks for your question.