Unraveling concussion assessment and treatment with Dr Daniel Brown

In this episode Daniel covers how we can measure concussion and the different system and tests we need to be aware of for concussion. We also go into how long the condition can last, it’s impacts and how to pragmatically treat it in a graded approach.

Dr. Daniel Brown is a research physiotherapist with an interest in sport-related injuries, including concussion. His central focus area is concussion symptomatology and the vestibular system and cervical spine complex among combat sport athletes. He has experience working in with musculoskeletal and sporting populations where he has worked in professional settings, including the Gold Coast Titans, QLD touch football association, and international combat sport athletes.

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Transcript

SPEAKER_03 0:00

What happens is that it's a functional injury versus a structural. So we won't actually see on our standard imaging models this brain injury itself. People with a concussion will present with things potentially like a loss of consciousness, but we need to take into consideration that only around 10% of a concussion presentation will actually have a loss of consciousness. As we become more aware of the long-lasting impacts of concussion, we thought it'd be a great time to have Dr. Daniel Brown on, who is a PhD and lecturer at Griffith University. Daniel has a special interest in head injuries and concussion rehabilitation. Really interesting episode where Daniel went over how concussion can impact multiple systems, and we really need to have multiple objective assessments to rule in and out those different symptoms. The other interesting thing was how long concussion can last and how in private MSK clinic care, we can really miss it or miss the mark with treatment. He went over a very pragmatic and graded approach to treatment of concussion. Please enjoy this episode. I found it really interesting myself. My name is Michael Risk and this is Physio Explained. Welcome, Dan. Thank you for joining us. Thanks, Mark. Thanks for having me on here. I really appreciate you inviting me on board. We're talking concussion treatment. And concussion rehab. And you've got an interesting background in combat sports. So we'll tie that in a little bit. But what is concussion? If we start there, because you're telling me about what can potentially happen when someone presents to a hospital. So how would you define concussion? Yeah, so it's actually quite interesting. I'll start with the thing we see a lot in clinic or with discussions with individuals and athletes, coaches or family members is the fact that someone or this athlete will present to the hospital and and I'll go have an MRI or a CT scan. And unfortunately, sometimes I'll get the tick of approval and leave and read into that as I don't have a concussion rather than I don't have something more sinister like a fracture or a bleed on the brain. So concussion itself is a form of a mild traumatic brain injury and it's induced by mechanical forces that are transmitted up to the brain. So we get this motion in the brain that occurred. And what happens is that it's a functional injury versus a structural. So we won't actually see on our standard imaging models this brain injury itself. So people with a concussion will present with things potentially like a loss of consciousness, but we need to take into consideration that only around 10% of a concussion presentation will actually have a loss of consciousness. Again, if I were to allude around to say combat sport athletes, Generally, they'll say, I didn't get knocked out, so I don't have a concussion. Coming back to understand that only 10% of them may actually have a loss of consciousness. Other things that people might present with is antalgic aid or ataxia, so that loss of balance, maybe some other neurological signs. And then you'll see this cascade of potential symptoms. So things like dizziness and headache, fatigue are all really common symptoms that we'll see after someone has a concussive injury. You're saying it's broad and there can be many types of functional deficits that would show up. And it sounds like there's no scan that is sensitive enough to tell us. So if we then went to the clinic scenario where we're seeing a patient, what kind of assessments or assessment tools would you look out for? And maybe even a step before that, what questions would you ask that might help you identify which tools to use? That's a great question. So firstly, we need to establish whether we think this individual has a concussion or a suspected concussion. So one key bit of information is the mechanism of injury. Was there force that was then transmitted to the brain that would result in this injury? So if we're thinking in, say, our football codes, was there a big shot in our fighting codes? Did someone take a big punch to the head or did they get slammed to the ground? So all those things will give us that mechanism and we can get that out of our patient interview process. Some cases they'll have video review, which can really be of benefit to the healthcare provider to actually see the incident that has occurred. Then the other things we would want to understand is what are some other confounding factors that may influence this? this presentation. So if someone has, say, a history of mental health disorders or learning difficulties or ADHD, maybe alcohol or substance abuse, we need to take that into consideration when we're looking at, is this a concussive injury? From there, if, say, we're thinking that this person is a candidate or has a concussion, typically, depending on when we see them, the first thing we're going to do is run them through something like the Buffalo treadmill test. So we're looking at their ability or tolerance to exercise. Something I will caveat as well, when we're looking at athletes, there was a big push in previous iterations was rest is best. The first thing we're going to do is rest. In one of the recommendations in the combat sport world, they've got a nice rehab program, except it still states that after a week of rest, which was the cornerstone, However, what we're seeing now and with the latest update to our consensus statements is that we want to return someone to some form of submaximal exercise around that 24 to 48 hours after the concussive event. So sorry, I just want to bring that up. Something that's a really important point to make is that we don't want athletes sitting in dark rooms, not doing anything. And then when we're talking about activity recovery as well, we're not just talking about physical recovery, but also that cognitive recovery. Although people might say, don't use your phone, don't use your screen time. After around 48 hours, we want to start building back normal patterns. So in clinic, we can start to talk to them about, particularly through that patient interview, getting an understanding of what are they doing? What are they not doing? Is there anything that they're fearful of? So once we've done that Buffalo treadmill test, again, everyone's different. There's a myriad of pathologies or say different systems that might be at play here. So we might need to do our vestibular and ocular motor screening tests as well. Something like the VOMS. I'm not sure if everyone's heard of that, but you can readily available online. It's a really great tool to use as a nice quick screening for vestibular and ocular motor function or impairment or contribution to symptom presentation with athletes after a concussion. Then we've got our from a physio standpoint, our cervical spine assessment batteries that we can do. And so we were talking off air that it's hard to say what a treatment pathway would be because there could be multiple levels of contribution. Would it be worth explaining maybe a common treatment pathway or a little bit on what you might do as a physio for each one of those unique presentations? If I can give you a little bit of maybe a case study situation that I've had in the last couple of months. So I had this young individual come in. They were about four weeks after a suspected concussion. I was fortunate enough to actually see the, in this case, fight and see what happened. Presented with dizziness, headaches, concentration issues through our discussion. There was a number of points that were brought up and it was when I exercise, I get dizzy. So then with this couple of trains of thought here, when he's exercising, is he dizzy because he doesn't have the tolerance to the exercise? Or is his vestibular system not able to process that input? So if he's running and he's got that bouncing up and down, does he not have that VOR ability, vestibular ocular reflex ability to actually take in the information and process it? So from there... ran through a Buffalo treadmill test, which is really good because at least what we can get from that is what is their heart rate or what intensity can they get up to before there's an exacerbation of their symptoms. So with the latest consensus statement, what they're allowing for now is that we can have a mild increase in symptoms through exercise. So no more than that two out of 10 increase that then resolves quite quickly, you know, within 30 minutes after the activity starts. So doing this Buffalo treadmill test, we look at their intolerance to exercise or how much exercise that they can do if we try and put a positive spin on it, how much exercise they can do. Then we can work out a percentage of their heart rate max. That is their baseline to start doing the exercise at. That can be quite provocative for this individual. In this case, it was. So we didn't do any additional testing after that point. From there, the next thing was, okay, I really want to have a look at how that vestibular ocular function was going. through, again, using something like the BOMs, which the BOM is great because you also use that, say, with teleconference. I've used this with athletes during teleconference where they're reporting. All it is is that provocation of symptoms. They report back to you how you're feeling. So you get a good understanding of a nice, easy battery of their vestibular ocular function. From there, we set up a bit of a reheat. It did have some vestibular signs. So using, firstly, just some accommodation and then some habituation activity. We built that back and what we found was with a graduated and paced return to his activity, we built up his function or his tolerance to exercise and also found that we were able to help that vestibular input as well and start to come up with those new pathways and use that neuroplasticity to improve his sensitivity to head motion in relation to space.

SPEAKER_00 10:19

Thank you.

SPEAKER_03 10:49

You started with it's a biomechanical injury, but really the evolution and layers of the biopsychosocial model are like coming through. Like you're considering all of these aspects, their history, their screen time, their sleep, and then a really good objective assessment. Is this driven by vestibular, by neck? It's really fascinating to see how you work through that. It sounds really clinically fascinating and challenging at the same time. I was saying to you off air, I hadn't had much exposure to concussion myself as a physio. And I was still thinking that old school advice of rest, dark room, goggles on, no screen time. That's the advice I'd heard just through the grapevine of club sports, I guess. So, it's really, really solid information. Is there any return to sport guidelines, timeframes, and are they linked to severity of symptoms? Or is it a blanket statement like, two, three weeks or a blanket rule of a test that they should pass? So although in many professional sports, they'll have a timeline, you can't return before this. So I'm not that well involved with the football codes as much these days, but it was 11 days in league or something like that. And then the three weeks before rugby, they're sort of just general time. But like anything, we need to look at the individual and it's always a patient-centered approach. What does this person present with? But typically, our best case scenario, there is a step-by-step or stepwise guide into return to sport. There's another thing, which is a different conversation, which is return to learn or even the office assessments. We're looking specifically at return to sport. We will start at that low level, sub-maximal aerobic exercise. And then when a participant or an athlete can perform these activities, so it might be something like firstly, just going for a walk, that low level activity. And that doesn't exacerbate the symptoms. Remember, we can have that mild increase of that zero to two sort of increase in that symptom provocation as long as that recovers. After 24 hours, they can then move on to that next step. So the next step might be, okay, now we're going to increase that aerobic exercise to light or moderate. So you're increasing the percentage of the heart rate max. Then from there, they might get into sports specific exercise drills. So we're going through these steps. So this is a six-step process. Once they can get through step three, then they can return to a non-contact sort of drill. So you're more, you know, you're exercising at more of a high tolerance. You're challenging passing drills. If you're thinking combat sports, they might be doing things like shadow boxing or bag work, or you're really challenging not just their heart rate or their exercise tolerance, but you're challenging that vestibular input. You're challenging those cervical afferents. So you're challenging... These three systems in particular that we as physios are interested in, in particular, to see if they can get through that. And again, they have this no increase in their symptoms here at this point, then we can move on. From there, we can build up into that full contact practice. And the last point would be return to play. So realistically, best case scenario, no barriers in the way the person feels psychologically ready to return. You're still looking at over that three week to four week mark. To be confident that they're going to return with the ability to feel confident participating in that sport. That's a really beautiful framework. It's almost aligning with a musculoskeletal injury, right? The rehab and the concepts you've covered. I wonder, is that the reality? Do people have three to six weeks off with concussions when those mild symptoms are persisting because they can't see it or feel it like a calf tear or a hamstring tear? Unfortunately, no. Not, I think, particularly if you're looking at the grassroots, I think a lot of it just goes undetected. They feel, oh, I've got a headache yesterday, now I feel okay. But there's this metabolic change that occurs in the brain that takes up to 30 days to 45 days for that metabolic change to recover. And that's that, we can't see that structurally.

SPEAKER_01 14:55

Yeah. So, it's

SPEAKER_03 14:56

metabolic change. So, they go, I feel okay, I'm going to go and perform, you know, my sport again. I'm going to take another knock.

SPEAKER_01 15:02

And

SPEAKER_03 15:02

that next knock, you know, that then sends them down another path. Unfortunately, what we found with the combat guys is... about 60% of them are back to some form of sparring or fighting within two days of their suspected or their reported concussion injury. Dan, that's been a super insightful episode. Thank you for your time. You've taken us through everything, the assessment, the treatment, the considerations and the return to sport. And we said we would put your contact details in the show notes because you're happy for some people to reach out and you could guide them with more information. So thank you for your time. No, thank you very much. Appreciate being on here.