The Champion Within
This is a series with fascinating and inspiring people, and what it takes to be the best you can at whatever your endeavours may be.
We will learn from others as to how they have handled themselves in their own pursuits, and so that we can apply to ourselves.
We’ll talk about the necessary support and how important it is, to have the best and appropriate systems around us, so that we can be the best possible. We’ll discuss aspects of ourselves that we can all develop.
This is a show with inspiring people, including musicians, artists, athletes, medical specialists, business entrepreneurs and more…in the pursuit of excellence.
I’m Jason Agosta, a health professional and former athlete, and I'm fascinated in people’s stories, my own involves developing certain attributes over time, but also things that were not done well or were significantly missing.
Join me on The Champion Within in discovering that everybody has a story, and everybody has a message.
@the_championwithin
@jasonagosta
jason@ja-podiatry.com
The Champion Within
Ep.23 Katie Davies: Tackling Concussions in Sports...
As I sat down with Katie Davies, a distinguished physiotherapist, the gravity of neurological challenges in sports truly hit home. Katie, with her wealth of experience in neuro rehabilitation, joins us to unravel the complexities behind those two words—concussion and recovery—that resonate deeply within the athletic world. Through her journey from a sports-loving teen to an expert in the field, Katie shares invaluable insights into the nuances of helping athletes navigate the often turbulent waters of recovery after a head injury.
Navigating the intricate landscape of neurological conditions, Katie and I delve into how the world of sports is evolving when it comes to managing brain injuries. From dissecting the pathophysiology of concussions to discussing the impact of preexisting conditions on recovery, we're pulling back the curtain on what really goes into the personalized treatment plans. The notion of 'one-size-fits-all' is left behind as we emphasize the vital role of healthcare professionals in crafting tailored rehabilitation programs, ensuring athletes can return to the game they love with confidence and safety.
Wrapping up, we tackle the misconceptions clouding sports-related concussions, stressing that an injury does not spell the inevitable end of an athletic career. Touching on the contentious debate over helmet efficacy and the meticulous balance between risk management and the benefits of sports participation, we aim to empower our listeners with a balanced perspective. For those hungry for more, our conversation extends beyond the podcast with resources and a statement on concussion available through concussioninsport.gov.au, providing a gateway to further exploration and understanding of this critical topic in sports health.
www.neurorehab.com.au
@neurorehabgroup
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@jasonagosta
Welcome back to the Champion Within. This is episode 23, where we chat with fascinating people with inspiring stories. I am Jason Agosta and thanks for tuning in. In this episode we discuss head injury and concussion. There's been a growing concern in both Australia and internationally about the potential health issues for athletes in particular, from repeated head trauma and concussion episodes. If managed appropriately, most episodes of concussion resolve over a short period of time. Complications can occur, however, including prolonged duration of symptoms and potential susceptibility to further injury. Over recent years, there's been elevated public awareness of concussion and increased focus on the importance of diagnosing and managing concussion appropriately.
Speaker 1:Concussion has become a contentious issue and sometimes controversial. There are differences in opinions, the media seems to have focused on negative connotations of concussion and there is so much known but also a lot we may not know, and many experts are very careful in what they say, which is a problem in itself. In passing on information and messages to assist others, there is a strong message that concussion is treatable. Importantly, individuals need to be assessed by an expert. It's a complex issue and a serious issue, and I spoke with Katie Davies, director and physiotherapist of the neurological rehabilitation group here in Melbourne. So thanks for joining me. It's so good that you come on. Well, thanks for having me on. Yeah, pleasure.
Speaker 2:I don't think I'm very good at this stuff, but you know I'm good at chatting, so hopefully that comes across.
Speaker 1:You always have to do a talk, honey simple. It's what you do all day at work.
Speaker 2:Yeah, problem is, I started 12 hours ago, so I might start slurring soon.
Speaker 1:Yeah, well, the 12th hour hey.
Speaker 2:And I'm not Stephen Wannagetti, so I probably don't have as much staying power as you.
Speaker 1:I want to ask you why neurology? As a physiotherapist, what sort of took you fancy and fascination with neurology?
Speaker 2:Well, I played heaps of sport growing up and I feel like I was a bit of a troubled teenager and I feel like sport really saved me. Why?
Speaker 1:what way tell me?
Speaker 2:I don't know. I struggled to find my feet, just went to lots of different schools, ended up at a school that had rowing. Met a really quick bunch of people through rowing and rowing just was something I could really sink my teeth into it was also hockey and lots of other sports and tennis, but rowing really was. There was a real sense of teamwork. You know you're working with another group of people to make it go fast and I love that.
Speaker 2:And then I always wanted to do physio. I never remember wanting to do anything else, but being sporty. Growing up I always saw physios and my auntie's a physio. I've always looked up to her and I thought physios for me. Then when I went to uni, thinking I'd be the next Olympic physio, I was training at a high level for rowing and when I quit rowing because I was nearly failing physio, I was like I won't go to the Olympics for rowing but maybe I'll go with the physios. Then I got into my placements and my first placement was at the Royal Talbot and I was taught someone who'd had a subarachnoid hemorrhage to walk again and I just thought this is amazing, how good is this?
Speaker 1:Life changing, contributing to someone's like you know turn around and nature turn around in their life.
Speaker 2:Yeah, and at the same time I was coaching, I quit rowing but kept coaching, and I think what I loved about coaching was you. I always coached the second crew and you had a group of nine kids that were disappointed to miss out on the first.
Speaker 2:Some were excited to get into the seconds because they made it and you had to make a boat go fast and the psychology or the building up people. You became part of their lives there in year 11 and 12 and you really felt like it was meaningful. And for me, I got the same kick out of being involved in someone's life. You met their family, you became part of their extended crew and I was lucky enough to get so I loved it.
Speaker 2:In third year, fourth year, uni, I was like no, I don't want to do sports physio anymore, I want to do neuro and at the time my auntie who's probably the reason I went into physio was like you've been so one-eyed about sports, you should really get a physio assistant job, being in a sports physio practice, just to make sure. And so I did, because she knew someone. So, friend of a friend, I got a job in a you know, in a mass sports private practice and it ended up being it was down in St Kilda and the people that own your rehab group rented rooms off there so they had session times down at this practice. So I'd be working on one of the footy players and I'd be watching what Anne Booth was doing, who used to own the clinic, and after my shift I'd go up and say, oh what, what were you doing with that?
Speaker 1:patient.
Speaker 2:Like that looked really interesting what you were doing with that kid and I ended up doing in my holidays spending some time with her and neuro rehab group, anyway. Then I graduated, rotated around the Royal Melbourne and ended up over in London doing neuro stuff and I just I never, ever wanted to do anything else. I was probably.
Speaker 2:now that I'm doing concussion, I've gone the full cycle back to sports and probably should have spent more time learning about the neck in my earlier years, but I've gone back to retrain, but no, I don't know. For me, neurology is a really creative side of physio. I feel like no two strokes are the same. You could be an amazing technician, but you have to win the patient over. You've got to become part of their life. They have to want to come and see you. They have to be invested in their rehab and yeah, I don't know you. Just you end up becoming a part of their life and really it's really meaningful to me.
Speaker 1:I think what you're saying is there is obviously a real depth to the purpose of what you're doing, like someone can come and see me about their shin pain or running technique or whatever, but you're actually like dealing with like significant, life changing injuries, but you're life changing in what you contribute in rehabilitating. Yeah, so I can understand why that's so fascinating. Tell me, has neurology itself, like the whole wiring from brain to the rest of the body? Has that been like just incredibly fascinating to you?
Speaker 2:Yeah, the pathways and understanding. I still think there's so much we don't know, and I don't think I'm the most intelligent physio. I'm definitely not the most intelligent physio out there and my understanding of the pathways of the brain and the way it works is definitely below a lot of people out there.
Speaker 2:But what I know is that the brain surprises you and we don't know, Like you can look at two people that have similar injuries, one's catastrophic, they're both catastrophic and one will end up walking out of rehab and the other one. And yeah, there's a lot of predictive markers, but there's also a lot of surprises.
Speaker 1:Yeah.
Speaker 2:Yeah, there's a lot we don't know, but I think the more we learn. Parkinson's disease, for instance, has come a really long way in the last 10 years with neuro protection and the different sort of exercises you can do early in their diagnosis. So it's exciting because you're on the frontier of things that can change.
Speaker 1:Yeah, okay.
Speaker 2:So the impact you can have.
Speaker 1:I'm sorry.
Speaker 2:The impact you can have.
Speaker 1:Yeah.
Speaker 2:We still don't know what we can do and if we can do more.
Speaker 1:Yes, yeah. So it's a little bit endless in a way.
Speaker 2:Yeah.
Speaker 1:At the moment. Just it's still discovering so much. Yeah, tell me a lot of the people that you work with. Are they more trauma patients and have had head injuries, or are they people who have just developed, I suppose, pathologies or diseases like Parkinson's or other?
Speaker 2:A bit of everything.
Speaker 1:Yeah.
Speaker 2:So I think the exciting thing about working in private practice and working at Neuro Rehab Group is we see anything that presents yeah. We've got. We see traumatic brain injury, acquired brain injury like stroke, but we also have progressive diseases like MS, parkinson's and everything that comes with that. Yeah, yeah, and then the NDIS has had a whole lot of disability management. So our days are really varied, which is really exciting.
Speaker 1:It's cool We've also got a big strong vestibular arm.
Speaker 2:So we've got 20, I think we've got 29 physios and six EPs these days and within that group there's a subgroup that maybe 10 of us that treat vestibular and within that about five or six that treat concussion. So you know, your day can really vary with who you're seeing. You might see a hoist dependent PBI patient and then you move on to an MS patient who's working on their walking to a Parkinson's and then a couple of vestibular, so it's a really varied case.
Speaker 1:I should mention the vestibular patients, the vertigo patients is that right?
Speaker 2:Yeah, so that sounds like it's a big part of what you're doing. Yeah, huge part of what I've ended up doing. I sort of just fell into it, but yeah.
Speaker 1:Okay, and the MS is obviously multiple sclerosis, yep, are there any of these diseases which are more sort of prevalent now, or do we just hear more about Parkinson's in recent times, for example?
Speaker 2:I don't know. Are we getting, are we? I'm not a Parkinson's expert. I wish, I wish I had one of my peers, george. Roy Kelsa sitting next to me, but I think maybe we're better at diagnosing it early and they're presenting earlier. Maybe it's an aid-being population and so we're getting more Parkinsonism recognized in the older population.
Speaker 1:Yeah, okay, so go back to the sport and you mentioned concussion. So this is one of the reasons I was really keen to talk to you. Are we seeing more cases of concussion or are we just hearing more in the media? Because it's obviously been a really big deal and a focus of NRL, afl over the, you know, recent times.
Speaker 2:So the numbers increasing of concussion cases- the numbers are definitely increasing, but is that because we're recognizing it more? Yeah, are we hyper-vigilant? I think as a community we're definitely moving in the right direction and that we're recognizing concussion better, removing people from play and making sure that they're safe when they return to play. Does that mean we're not picking up a whole cohort of people that are presenting to ED that would have probably just recovered in a five or six day period?
Speaker 1:Sure, yeah, okay.
Speaker 2:And I suppose I'll preface it with saying that I deal with the rehab of concussion. So my knowledge and my expertise isn't in the sideline management and game day management of concussion, it's more in the rehab of people with persistent symptoms.
Speaker 1:So the longer term patients.
Speaker 2:Yeah, yeah, I did with. Traditionally I've been dealing with like for the last 10 years with people that have symptoms beyond two weeks, which we traditionally talked about them as being the persistent prolonged concussion symptoms patients.
Speaker 1:The two is a magic number. Sorry, I didn't mean to interrupt.
Speaker 2:No, no, that's all right. There is no magic number. There's so much. There's a lot of confusion out there. I think the thing with concussion is I said earlier that I love I love neuro, because no two strokes are the same. No two people with their mass are the same. It's the same for concussion. Concussion is a mild head injury, a very transient, small like mild form of mild head injury, but it is, and so therefore everyone presents completely differently. So I will see people now at two or three days to give advice and do early treatment, but five years ago I probably wasn't seeing them till two weeks.
Speaker 2:So yeah, that's not to say there's not stuff we can do early, but they may recover on their own. So I'm answering the question. To answer your question, I think it's a column A and column B. I think we're recognizing it more rightly so, and we're creating it Do.
Speaker 2:I think we're probably. There's a lot of hype and we're building up. There's a lot where a lot of people are presenting when as concerned and worried when they might not have been 10 years ago, probably as well. So I think we're getting more people because we're recognizing it, which is a good thing, but I also think there's a lot mixed up with it, with what you see in the media.
Speaker 1:Sure, tell me, concussion itself is injury to the brain because of movement of the brain against the skull.
Speaker 2:Yeah, so essentially, when you have an impulse that goes to the head, but it doesn't have to be a hit to the head. It could be a hit to the shoulder, but you get a shaking of the brain, inside the skull, and you get stretching of your wires through the brain, your axons and essentially the membrane of the axon. The myelin becomes a bit leaky and we think there's iron transportation issues. Okay, so, and that causes the brain to go into an energy bit of an energy crisis. The mitochondria don't work very well and you have a temporary slow. The axons get slow, the synapses are inefficient.
Speaker 1:Right. So this is all the new part of the neural pathways.
Speaker 2:Yes.
Speaker 1:The energy cells, the mitochondria axons.
Speaker 2:That's what we think, that's our best guess. That's what's happening. We're seeing Disruption. Disruption across the pathways of the brain and it's usually temporary and it's at a really minute cellular level and are imaging at the moment. So our MRIs, our CTs, our standard imaging is not picking up any damage because there's no focal lesion, there's no bleeding, there's no breathing, there's no hematoma. So the difference between a structural mild head injury is that you have changes on brain scan. We don't get general, we don't get changes on routine brain scanning. But with some advanced studies we're seeing some change in functional MRI and biomarkers. We just don't know what it. That's not my area of expertise Because I deal with the person, but we just the research is suggesting that we don't know exactly what those changes mean.
Speaker 1:Right so.
Speaker 2:There's acknowledgement that something is happening in the brain at a cellular level, but we just don't know exactly what it is.
Speaker 1:Well, this is a complexity of neurology though, isn't it? Yeah, yeah, so if I go to a sporting event, someone gets hit really hard or to the head or other, and they have a degree of concussion. What would be the most common signs that some young boy or girl at Foody this weekend has signs of concussion?
Speaker 2:So you might see on the field, you might see a sign would be that they fall to the ground and they have a loss of consciousness, or they get up and they're a bit wobbly or they're a bit confused at the time. But most of the patients I see don't have an episode like that. They might get hit in the head, but that night they might have headaches. So the two most common forms, common symptoms, are headache and fatigue.
Speaker 1:Yeah.
Speaker 2:So kids, kids, adults headaches and fatigue, and then we talk about there being a cluster of symptoms. So there might be emotional symptoms, so they might have mood irritability. So you know, people might cry when they don't usually cry. Afterwards they might be angry, yeah. So you have that mood, that mood area. They might have cognitive problems, so a sense of fogginess, feelings like they can't process that, they're problem-solving ability and they can't think straight. And then the third thing where I get involved is the physical domain. So from a physical point of view, they might be dizzy, they might have visual problems, they might feel nauseated, car sick, headaches, neck pain, yeah.
Speaker 1:Is the visual sort of disruption? Is that common?
Speaker 2:Yes.
Speaker 1:Yeah.
Speaker 2:So often they feel like they're visually slow. They might struggle in busy environments. They really struggle when they're. When you're in a sense of a state of movement, like a passenger in a car or on public transport, your vestibular system or your system that tells you about your internal GPS. And when you're moving around, your vestibular system is quiet, it's steady because you're sitting in the car, but your visual system is saying we're moving, and so they find those sort of environments quite challenging. Being on a treadmill, your vestibular system is saying I'm moving, your visual system is saying no, the world is still so. That conflict between the two systems. They might struggle with that.
Speaker 1:Okay, right, so these are things that people listening could should recognize. If, junior, you know cops are blow Now the head. A fatigue, emotional, like you said. The mood changes, fogginess. Then there's the physical changes. Can I ask you've just you've made me think of a scenario that I was became aware of last year where a young footballer and quite young, like 13 or 14, I'd become aware that he had had like five and cussive episodes within, I think, 12 months. Now, is that going to leave some sort of mark on him or disruption? Is there some long-term effect if we have successive injuries?
Speaker 2:Really hard without seeing him. If that was a patient that presented to me and he within 12 months, I would be assessing him and seeing how he presented. So as a physio I would assess his visual system, his vestibular system, I'd get him exercising. We've got an excellent EP that we would refer to to look at high-level exercise and I'd check out the neck and if all that checked out and they did he did a really high-level return to play given the history, he would be someone that I would send to assessment with a neuropsych that we work really closely with concussion neuropsych and probably a sports doc. And the thing is, if they checked out and everything checked, you know it's fine. Then you know often it's really depend.
Speaker 2:As I said, it's so patient dependent. Yeah, the thing that frustrates me is when I see in the media comments about patients I'm treating or comments about individuals about whether they should return to play or whether they shouldn't. Because you might. Everyone's concussion history is different. You might have one or two concussions but they're really slow recoveries. They need a lot of rehab and the impact on the mental health isn't great. And so for them the decision is let's not return and play because the consequences of another concussion is that it's going to go this way.
Speaker 2:But you might have someone else that has a number of concussions and but they recover. Within a two week window they go back to perfectly normal. And do you deny them the right to play on going? It's a okay trying to answer your question very carefully, because I understand. And it is such a political space. You know you don't want to say the wrong thing, but no, I get it yeah but this is the controversy, though, isn't it?
Speaker 1:Because what you're saying is this young boy could be perfectly fine and he could return to sport, but then the next person has all those other negative effects and that is going to be disastrous for their mental health or physical attributes. But all we hear about in the media is oh, someone's been hit once, twice, three times and the rules are that he's got to stay out, or there's a decision by officials that that person has to stay out for a period of time without actually knowing that he may, he or she may or may not be. Okay, that's what we're seeing in the media, isn't it?
Speaker 2:Like this one so inflammatory. And the other thing we're seeing is lots of different sports, having lots of different stand down protocols, and everyone if I had a dollar for every physio that asked me what should I do with my concussion? And the answer is you treat what you see you know, everyone gets it and you treat what you see, but you also. It's more than managing their physical side. It's managing every part of them and it's different. That's different for everyone.
Speaker 1:Yeah.
Speaker 2:Yeah, so it is. It is difficult because the stand down periods 14 days, 21 days, three weeks, four weeks that will be every. Every number is going to be okay for some people but not okay for others.
Speaker 1:Yeah, yeah, yeah.
Speaker 2:So we're trying, we've got this really strong opinion on how concussion should be managed, but it's not. It's not an ACL injury. Yeah, you know a lot of my footy players are really frustrated because you know they see in the paper, well, mr X is out for, or Mrs X is out for X amount of time, concussion, acl, nine months. You know, they know, yes, there is no pathway.
Speaker 1:Yeah, okay. Well, I think that's a really strong message to pass on, though, that you just really need to see the right person to evaluate the situation. Yeah, that's the message you're passing on here, because there's such great diversity in the outcomes posts. You know, injury.
Speaker 2:For most people, but not everyone needs to see someone like me, and there's not enough.
Speaker 2:There's not enough people, that there's not enough health professionals that understand enough about concussion in the community to. But when you think about it, 80%, 75 to 85% of adults are going to recover within a normal timeframe. Yeah, and 60 to 80% of our kids will recover in a normal timeframe. So so to your friend who? So the question you asked me before about what happens when someone has a concussion on a Saturday, well, I would expect them that night to be tired. They might not sleep very well. They'll have a headache the next day, they might feel a bit groggy, they might feel a bit sick.
Speaker 2:Get them up, take them for a walk, get them hanging out with a friend one on one. Don't take them to a birthday party at bounce, yes, because that will over stimulate them. But get them, if they're age, do age appropriate exercises. So if there's someone that uses a computer at school or at work, get them on a computer. Get them doing little bits of pieces of their life, get them kicking a footy and if things, if they feel, if their headache goes up from a two out of 10 to a five out of 10, then you probably need to think about maybe doing reduced hours at school the next day or work, and you know, the whole idea is that you build them up gradually. I think.
Speaker 2:And that they don't. You don't take them off training because they need to see their friends, they need to do things, but build it up over the course of a week, that with bits of pieces of their life whether it be socialising, academic, school, reading, and and build them up bit by bit so that the end of the week their life looks more like what their life would normally look like. If that makes sense?
Speaker 1:Yeah, absolutely. So you make me think that is there. It may not be appropriate for everybody, but is there sort of a bit of a blanket rule that two weeks is what you should be taking it or how long you should be taking it easy for post post concussive episode?
Speaker 2:Yeah, general rule. So the the AIS guidelines came out last two weeks ago and I was involved in helping them, so I should support them.
Speaker 2:They say 21 days back to sport, like back to contact sport and 14 days back to contact, but that's symptom free or tickling the symptoms a little bit in that period of time. My concern is, if we say two weeks back to normal, people will just take two weeks off school and work after a concussion and that's not necessary for a huge part of the population. They can go back at on day 234. I think what we do know is that when I see, when we assess people and see people clinically that are stirred up post concussion, we will clinically return them to play, nor feel like they've made a clinical recovery and we think there's a bit later, like it's a. There's a a period of time whether it be a few days or a week later, that their physiological system recovers. So from some of the physiological studies, like the functional MRI and the biomarkers and all these other testing, we don't know exactly what it means, but we think that the physiological recovery is a little bit longer than how when symptoms go away and people return to a normal life.
Speaker 2:So yeah if you're, if you're worried at all, it's better to take a bit longer. So two weeks for 80. It's a really hard question to answer because it's not the same for everyone right now.
Speaker 1:No, no, no, I get it.
Speaker 2:Two weeks, 21 days, is for 80% of the adult population and 60 to 80% of kids will be fine. Might be appropriate, yeah for the people that are slow, my concern is that they just sit there and wait for two or three weeks and then go. All right, I'm good to go, and then they get and and what happens if there's successive injuries?
Speaker 1:is there a layer upon a layer upon a layer of problems?
Speaker 2:If you don't recover, if you don't, if you get if you go back too soon. If you go back to saying it's no good, you're likely to to regress. So if you, if you go back, if you're still symptomatic and I suppose this is like the answer to this question is twofold. We're seeing a lot of our footy players, rugby players, who may recover from their concussion. They return to play, but they're a different player.
Speaker 1:Yeah.
Speaker 2:And we wonder whether and maybe they haven't had treatment because they've recovered. They've recovered symptom-wise. But you think about your vestibular system. It keeps the world in focus. It's our internal GPS. It enables us to move quickly, turn quickly, know where the ball is, know where the goals are, know where an opponent is. Our visual system it's sharp. It keeps the world in focus. It allows you to track a ball through the air. Our autonomic system controls our fight-flight. It allows us to exercise at really high levels. These elite players are really fit and their necks are strong. So they have a concussion, they physically recover, but then they change the way they play and then they end up in my clinic because maybe they're playing a different, maybe they're not as sharp. So, to answer the question you asked and I think I'm digressing, which I often do because I'm very passionate about this topic- that's good.
Speaker 1:I love it so good.
Speaker 2:To answer your question, if you have a concussion. There is strong evidence to suggest that if you have a concussion, you're still headachey, dizzy and not feeling quite right and you have another concussion that's bad. That will mean that you're likely to have a projected recovery and you have a consistent concussion and what happens?
Speaker 1:What's bad about that?
Speaker 2:I don't know. This is the world according to Katie Davies. Are you shaking up a brain at a cellular level? That's in a crisis, a metabolic crisis. The pathways aren't working very well and you're giving it another. The pathways haven't realigned appropriately and they don't have to regenerate because they're not broken. And that's, I think, a really important point, because when we're dealing with a patient with MS or a stroke or a TBI, they've got an area where we're dealing with brain plasticity. We're trying to push brain, so our reps have to be high, our dosage has to be high to improve their function. But we're not dealing with regeneration here. The pathways are there, they're just slow because the iron it's sort of like.
Speaker 1:I love that people don't educate, don't understand.
Speaker 2:It's like when you used to call you look like you might be more of my age Like when you used to call overseas and you'd have a cross-wire and you'd get a different language, because this is when you'd pick up the landline.
Speaker 2:So the hardware's intact, it's just the software's not working. They nearly need a control load delete. So that's where my physio rehab is small. Like they only do reps of 10. They only do it once a day, whereas if I've got a stroke patient I'm getting them to do thousands of reps and I'm getting them to do massive dosages because I'm trying to change the plasticity of their brain.
Speaker 1:So yeah With exercise, is returning to exercise either intensely or does it have to be intense? But if we return to exercise, is that another way of measuring where you're at in your line of rehab post-injury? Because from what I understand and what I've read, there's the high intensity exercise after two or three weeks is a great indicator Are you ready to go or not?
Speaker 2:Yeah, so post-concussion, your autonomic I've mentioned the autonomic system controls all your automatic body functions. So post-concussion you can struggle to exercise because your heart rate when you exercise doesn't go up well and can alter the control of blood to your brain. So you get influx of blood to the brain as you exercise. So in a percentage of patients post-concussion, yep, so you can have. And the reason that you have the altered blood flow of the brain is the autonomic disruption. And what we see in the clinic is people struggling to exercise. So they'll find that they will be able to get their heart rate to a certain point and then, beyond a certain point, their symptoms will come on and they'll go up quickly In a proportion of patients it's not in every patient, but it's in people that struggle physiologically or autonomically post-concussion.
Speaker 1:Yeah, okay.
Speaker 2:And so the treatment for that is to exercise them at 85% of that barrier. So say you, we test people on a treadmill and say we get them to the treadmill and we get them to 130 beats per minute and their heart rate, their symptoms come on. We then give them a program of 20 minutes of exercise at 85% of that heart rate and gradually increase that as they can do it without the symptoms coming on.
Speaker 1:Okay.
Speaker 2:So that progressive. And that's, I think, where this whole concept of graded return, graded loading, comes into play, because that's a way of treating that system. But I think my problem with a lot of the sports is that we talk about graded return so everyone goes, oh, go for a walk, then I go for a faster walk, then I go for a job, then I go for a run, and that's one part of the management. You've also got to do the graded return for the visual system and the vestibular system, and that doesn't mean getting expert opinion, it just means spending time on the computer doing a bit of reading, doing some ball skills and turning around.
Speaker 2:Yeah, Emptying the dishwasher, bending over like, but then gradually so you're right Doing. Once you get to the point where you can exercise at an intensity, a good intensity, like at your max heart rate, that's a good sign that you've recovered at a physiological level or an autonomic level. But, you could still be struggling in the other departments.
Speaker 1:Yes, I can understand, but it sounds like it's a crucial thing for sports anyway to make sure that that level is Like you mentioned. 85% is done gradually, yeah, and you have to get through comfortably with being asymptomatic. That's the important thing as long as symptoms don't go up.
Speaker 2:It's not just I can do it.
Speaker 1:I can do this thing. I can ride my bike up here or flat out. My heart rate goes right up, but the important thing is no symptoms.
Speaker 2:Yeah, or the symptoms don't get worse yes.
Speaker 1:Okay, are there sports that stand out as far as the numbers of concussion?
Speaker 2:It's a really good question.
Speaker 1:Because what I want to know, what do you reckon? Well.
Speaker 2:I Highest percentage.
Speaker 1:Well, I think here in Australia it's probably AFL, I'd say, without a doubt, mate, I'm assuming, I don't follow the footy and I don't read anything about it, but I would assume. But my question to you is, and I would think maybe aligned with AFL, is soccer or football? Because it just amazes me and I just was cringing every time I saw this at the World Cup where the girls were just headering the ball from 45-50 metres down the pitch and the velocity of the ball must be. There must be so much force on their head and I couldn't help but think about what's going on with your brain. So I don't. I'm not sure whether the numbers are higher or in one or the other, but I'm sure those two sports have got to be right up there.
Speaker 2:Well, so per 100,000 athletes and this is research going back quite a few years. Is it Victorian research? I think it's Victorian research. Motor racing and jockeys, like jockeys, have a high percentage of athletes per 100,000. And they look at a lot of the different horse racing. They all categorise differently. So you've got so many different. You've got dressage and the ones with the cart. Obviously we don't see a lot of jockeys. We see a percentage probably one or two per cent of our clientele through the door is jockeys, but there is a massive proportion, it's a huge proportion of jockeys per 1,000 athletes that have concussions. But we don't hear about it, we don't talk about it, we don't see it. But we see in the clinic. It's definitely AFL. Afl and rugby are probably, but when you look at them per like, in a percentage of athlete, they are a lot less. And I don't know. You could go into a lot of health economics discussions about why we see.
Speaker 2:As I said, it's such a I feel like a lot of the time I'm careful with You've just got to be so careful about what you say in this space of time. So everyone's. My strong opinion is that concussion is and I you can definitely chop bits of this up, but you know concussion is so treatable.
Speaker 1:Sure yeah.
Speaker 2:An overwhelming number of patients that come through our clinic will cover and go back to sport and go back to play and my kids will play. If my kids want to, they'll play footy. But you know, if they have a slowed recovery or if they have signs of anxiety and depression and it gets worse post-empression, then I'll consider whether they go back to play as an adolescent and into year 12 and year 11.
Speaker 2:But, I won't not allow them to play because I'm worried about it. Yeah, so, and I feel like the message we don't see in the community is how treatable concussion is Well it's a strong message to pass on here.
Speaker 2:Yeah, because I was looking the other day at some data directly. We had 22 concussion referrals in November and I would say that of those 22, we discharged 21 or 22 of them within a two month, like within a month to two months, three months period. But you don't see that in the media. You see, and it's not to say that those symptoms aren't real and there's, you know, there's definitely people out there really struggling post concussion. That, yeah, it's.
Speaker 1:The majority can be treated.
Speaker 2:The majority can be treated and it's more complex than it just being. You have a hit to the head, you've got post concussion. Yes, your life has been ruined like this. Just a whole lot of other compounding factors. Yes, yeah.
Speaker 1:But where we started with this, we were talking about how complex or how interesting and fascinating the world of neurology is, but how complex it is and how much we don't know. There's a lot we do know, but there's a lot we don't. That's what you're saying here, and people can have strong opinions based on your own experiences as a practitioner like yourself, and that's perfectly fine. After years of experience, I think that's perfectly fine and there will be, but we have to accept there's differences. The problems seem to be when we hear things in the media that this is a disaster, that person shouldn't be playing, and what you're passing on and the vibe I'm getting from you is that this may not be as serious as what it comes across in the media In most cases and they're treatable.
Speaker 2:Yeah, I suppose it's. Is it serious? It's serious, it's serious and I'm proud of the way, as a community, we were managing concussion. Like I look back at is that horse horn grand final and people going back on to play after they've had huge you know the bandage around their head. They've had lots of consciousness, like we definitely we. We are managing so much better now and we should not be doing that.
Speaker 1:Yes, but do?
Speaker 2:I have people turning up to my clinic who have kids in year eight, who've had one compulsive injury where they were symptomatic for a few days and they're saying that they'll never let the kid play footy again. Yeah, and the kid's really upset and having secondary problems socializing because they're not allowed to play footy again. I just I think.
Speaker 1:It's a bit harsh.
Speaker 2:Yeah, I just yeah, it's so it's. It's a serious issue, but I don't think it's a. I don't think it's a. I think it needs to be taken seriously and we need to be looking at everyone seriously, but I don't think we need to be alarmed.
Speaker 1:Yes. So take it seriously but realize that this is treatable.
Speaker 2:Yeah, this is treatable. Take your head injury I feel like there's a lot of dooming bloom.
Speaker 1:Yes, it sounds like it's become the like the dirty word of sport, and you know physical sports, team sports at least. Anyway, yeah, this is. I don't know where this is at the moment. I have no idea. All I know is that in the past, many, many years ago, we're talking about helmets in sport and whether helmets are effective or not, Is there a place for helmets in reducing head injuries, or do they make? Do they make things worse? Because of the velocity of the the, the blow is further away from the head with the helmet and therefore the rotational forces are, you know, much larger Great question.
Speaker 2:It's sport dependent. So I think NFL ice hockey there's evidence to suggest that it's a good that with the impact they have. Yeah, for Aussie rules. There is no evidence to suggest that having a helmet is. We talked earlier about the pathophys of concussion and it being a shaking in the brain If you have a. If you have a carton of eggs and you put it in a box and you drop the box, the same thing happens to the eggs. So what we find it's interesting what you say about the forces and the weight of the helmet. What we find in, especially in kids, is that they don't learn to tackle well, they put a helmet on and think they're invincible but it doesn't change.
Speaker 2:So you're better off teaching your kid to, or your child to tackle well and learn how to how and have you know tackle and learn how to play, rather than putting a helmet on. There's emerging evidence in Canada about mouth guards that we just don't know. But yeah, it's sport dependent. We wear a helmet when we cycle because the impact of hitting the asphalt will crack your skull and facial injuries, but for a lot of local sports, yeah it's. I wouldn't be recommending helmets from what I know.
Speaker 1:Can I ask you again? I'm not sure whether this is even known, but do we know how much force is applied to the head with, say, headring the soccer ball or being hit from a certain distance?
Speaker 2:I've been making it up.
Speaker 1:So is there no studies there?
Speaker 2:There are studies that have looked at. So there are studies using accelerometers looking at testing that and looking at impact and then prolonged symptoms and I don't know how conclusive they've been and I could point you in the right direction, but I can't if I've been making it up.
Speaker 1:Sure.
Speaker 2:Said something.
Speaker 2:Because again what we do know is we talked about multiple concussions, like when I've been involved in making decisions about people retiring or returning to play, which we do because, you know, you do see people that have generally a lot of the people that we've worked, that I've worked with might have three or four, five, six concussions. They recover through their playing career juniors, inter seniors they recover within a week. They don't think much of it and then they have, maybe have some of it later in life or later in their career and all of a sudden the impact of the injury that they're experiencing is not as great and the recovery patterns are longer. So, you know, I might see an elite person at concussion number six and I'll see them and I'll treat them for two or three weeks and I'll go back to play and then I might see them again down the track. They've had concussion seven and if you look at the video you look oh, you got the impact of that wasn't so big.
Speaker 2:So what we think we're seeing, you know, as as their career goes on, is that it's less of an impact to have more of a more of an impact on recovery, and that forms part of your you know decision about whether you're weighing up the risks right of what life is like after football and what, the whether they play on going and what, yes, so yeah, from an impact point of view, I don't know. It's more than like sort of risk factors of like the deciding whether you're going to have present with concussion symptoms that are prolonged is not just about impact. Yeah, okay, preexisting mental health like anxiety, depression, learning difficulties, whether you had when motion sick or had a sensitivity to your vestibular system, whether you have a history of migraines, whether, like, for female generally tend to be more affected than males. So whether that's hormonal, we can. Next, we just don't know. But there's not a lot of correlation between loss of consciousness and being stretched it off the field? Yeah, or even having seizure activity on the field and prolonged symptoms. So it's more than just the impact.
Speaker 1:Right, so that immediate response is not indicative of the severity of the concussive injury. Okay, that's important to know. Yeah, hey, I've got to tell you a scenario. A very, very good friend of mine used to play for an AFL team back in the 90s, played full back, and a couple of times he told me that he was sent back out. And he remembers standing in the goal square, thinking, right, I actually shouldn't be here. And the ball comes down and he's just like, yeah, I definitely shouldn't be here. But that's what happened back then.
Speaker 2:Yeah, and that's not a little understand. We know that's not good.
Speaker 1:Tap him on the back and you'll be fine. Don't worry about the headache. Take a few panadol, you'll be fine.
Speaker 2:And then turn up to probably have a carton of beer and turn up to training on Monday morning and do it all again. It's a different world. We're not saying your friend did that. No, it's a different world now and I think we've moved in the right way.
Speaker 1:Well, I know we've moved in the right direction.
Speaker 2:There's so much evidence to support that the guidelines are better in place and the removal from play is the right thing.
Speaker 1:Yeah, I think the messages you've passed on are very strong, though, that concussive head injuries are treatable. Yes, and there might be outliers there, for sure. That might be much more serious, but at the end of the day they're much more treatable. What we see as a first response is not indicative of the severity, but people have to be aware of the things you mentioned about headache, fatigue, emotional being emotional, the fogginess you mentioned and the physical or the visual acuity signs are indicative that someone needs to take it easy for, as you mentioned that, 14 to 21 days at least. But obviously people need to see people like yourself and sports physicians to really be assessed and also learn.
Speaker 2:If it's lingering. Yeah, I think a massive part of our role is educating people that it is treatable, that you can do something about it. But it doesn't mean, if you've had one concussion you should stop contact sport forever.
Speaker 1:I think the issue with the media is we just, you know, someone of high profile gets a head injury and it's on the front page of the media and everyone's like oh my God, you know this sport or that head injury is a disaster. That's the biggest issue. There's no sort of really objective conveyance is there of information.
Speaker 2:Yeah, yeah, or understanding what's happening in their life, and sometimes they can make it worse. If you're treating someone and they're seeing themselves, you know all over the paper with a few people and what they should do. It's pretty hard when you think about it. I explained about concussion being emotional, cognitive, you know, physical. Like what's that doing to the emotional side of things when they're seeing, yeah, it's just, yeah, it's frustrating because it's you just want to wrap them up and put them in a safe house for a few weeks to treat them.
Speaker 2:But you talk about like the serious ones, that don't necessarily and there are, there are. I'm not denying that. There are people that sustain a concussion and it's very difficult to treat and they have long lasting symptoms, like that's real. But it's a small, small population of what we see. But you would get that in a musk population where you're treating an ankle and you're doing all the right things but they can't get back to running and they've got pain you can't explain. Yeah.
Speaker 2:And you know like it's a similar sort of thing I would show that sensual sensitization of pain, that you know, it's sort of that space in the concussion world. They have ongoing headaches, yeah. And it becomes difficult, but for the most, most of the time, you treat an ankle and you do all the right things and they go back to running.
Speaker 1:They'll be fine. Yes, yeah, exactly, you're right. Yeah, I get it. I know you do a fair bit of education through the neurological rehab group that you direct. Are those education courses for practitioners and like patients or families as well? Because I can see that people's understanding of if someone gets injured, a head injury, the people around them, like family, particularly have to have some level of understanding. Yeah, so is that something you do as well, or you sort of bring people in for meetings?
Speaker 2:No, we run a two day course which is based for practitioners, to understand exactly what I'm talking about tonight and how to treat. But we I've got I've got the most unbelievable group of staff and I've, you know my concussion team are so passionate in what we do. Yeah, they just want to spread the word. So they are pretty keen on organizing. We organize information evenings, usually at the beginning, and it's great because they do a lot of this, they do a lot of it, and I just sit there and introduce them and take questions. But yeah, the idea of that is it's a free evening, it's based in Mount Waibley and we usually write in one of the neuropsychs we work with and the whole idea is to educate families, schools.
Speaker 2:We often invite school nurses, trainers, people so that we can explain exactly what we're explaining to you that it's treatable, that you can do things. It's about recognition. It's about recognizing, grading their recovery, recognizing when it's recognizing someone has a concussion, knowing what to do post concussion with a graded, you know, grading everything. And then recognizing when they're not recovering well and what to do about that.
Speaker 1:That's what I was thinking of, because obviously the people around that athlete, or whoever it is that has an injury it's obviously the parents or other family members or friends or, you know, partner of someone who's going to recognize, you know, some sort of change, or is he or she, you know, not recovering that well? So I was just thinking that, you know, it's obviously in the peripheral of the athlete. That's going to be really important.
Speaker 2:And we often get them to come in on sessions when we do our initial assessment and say this is why you know you've got someone who can't go to work, who's struggling in busy environments, having trouble on the computer, and all of a sudden you do really simple visual stuff and they struggle and you're like this is why you can't look between two points for repetition. Well, you can't focus on something as it comes towards you. You know one thing you can't Coke in life.
Speaker 1:Yeah.
Speaker 2:Peel back life, give you rehab and all of a sudden, like a lot of my patients say, I wish I look fine. No one thinks like I don't look like anything's wrong with me and I wish I could put a bandage around their head and yeah. Bit of blood on it.
Speaker 1:Yeah.
Speaker 2:They're really struggling, and so for the person that is living with them or understands them, to see them struggle and here I say you are struggling visually or you can't turn your head and focus on something your vestibular system is working. That's why you can't sit in class, that's why you? Can't do this. It really it sort of the penny drops and yeah everyone's on board, yeah.
Speaker 1:Put a bandage around them. Just put a bandage on everyone. I've got to ask you. I had a conversation with a physio and ex football in Sydney and he was telling me his story. He was telling me his story about successive concussive injuries and he went to the neurologist and I can't remember the name of the test but he was told to stand there and walk with his hands out forward. And he had done and he took a few paces forward. He did a complete 180 degree change in direction but thought he was moving forward and the neurologist said right, that's it, that's the end of your football career. I can't remember the name of the test, but it just sounded so severe and so hideous that he had no orientation.
Speaker 2:Sounds like he lost function in one of his vestibular system. That's a sounds like the Faduka step test. Is that what it?
Speaker 1:was the Faduka step test. That's it. That's it Exactly.
Speaker 2:We sometimes do it, but we used to do it. People used to do it back to test whether you've got any hypo function or a vestibular system that's not working. So that's a pretty severe reaction, yeah.
Speaker 1:So the vestibular system is in our ears. It's all about balance and I suppose that's spatial awareness.
Speaker 2:Correct yeah.
Speaker 1:There are problems that people get like many years and things like that.
Speaker 2:Yeah, so everyone comes and thinks they've got the crystals. So you can get BPVV in the inner ear, bpvv, bpvv, which is in the inner ear.
Speaker 1:Yeah.
Speaker 2:And it's these crystals of calcium. It's common form of dizziness in the older population, right. So a lot of people think they've got that, and often we've got patients that can have vestibular migraines, so they can feel they get vertigo and their migraines don't present as pain, they present as dizziness or a sense of imbalance in the world. And then there's many ears. Probably we don't see as much many as in our clinic.
Speaker 2:Head injuries contribute to this Down the trash, I think, compassion oh look, if you've got, if you have a peripheral problem on top of a central problem, like on top of a head injury, it's pretty. It can be pretty. These patients don't know where they are in space. It can be pretty bad.
Speaker 2:So, often if we have a concussion presentation, we want to make sure they don't have a peripheral injury. But my impression of this lack of concussion is it's a central processing vestibular problem. So, generally speaking, the inner ear is intact and, from what I my experience and if they have a BPBV the crystals in the inner ear you want to treat it and manage it so that you so that you're working with a stable sort of peripheral system while you treat the concussion.
Speaker 1:Yeah, right, yeah, I've got you. Yeah, so it's all about what comes in has to be processed.
Speaker 2:Yep. So you have the vestibular system in the inner ear. It's encased in bone and it's part of our peripheral system, so it's like touching their skin on your hand. It's part of your peripheral system, travels through peripheral nerves into the brain.
Speaker 1:Yeah.
Speaker 2:It just doesn't have to travel very far because it's in our ear and then it's processed centrally in the brain. So it's a sensory organ with balance. So, your vestibular system, your vision and your somatosensory system makes up your balance. So it's a really but it's a really important part of our balance system.
Speaker 1:Hey, thanks so much for coming on and speaking to me about this huge and really really important messages. So good, massive, anything you want to pass on Finally.
Speaker 2:I think just that. I think that it's treatable that you that concussion isn't very man-gloom. There's a lot of positivity that can come out of what we do. Participation is so important in sport. I think we need to treat the individual and make sure we're making the right cause for the individuals and treating concussion as it can be treated.
Speaker 1:As I said, really clear, powerful messages that we need to hear from people like you about.
Speaker 2:Thank you.
Speaker 1:Because we don't hear this stuff. This, the headache and fatigue and all the signs should be on the front page of the morning paper, not the dude who goes down and hits the ground and, oh my God, it's always catastrophised, isn't it?
Speaker 2:Yeah, that's what I think, yeah.
Speaker 1:So clear in what goes on and hopefully the jockies can stay a little bit upright. Hey, it's amazing yeah. I would never have thought you got me on that quiz. All right, katie. Thanks so much.
Speaker 2:Thanks so much, Jason.
Speaker 1:The Australian Sports Commission, in conjunction with the Australian Institute of Sport, the Physiotherapy Association, sports Medicine Australia and the Australasian College of Sports Physicians have their concussion and brain health position statement accessible to read and can be found at wwwconcussioninsport or one word dot, gov, dot au, concussioninsportgovau. I did look at some of the research in heading the soccer ball and the studies I looked at concluded that the force to the head during the soccer and heading the ball at different velocities did not approach the forces that cause a concussive injury. Thanks for tuning into this episode. More details and links, including those for Katty Davies and the Neuro Rehab Group, can be found on the show notes, where you can also follow and support this show. You can follow this show on Instagram at the underscore champion within. Thanks for listening and I'll speak to you soon.
