WEBVTT 00:00:00.000 --> 00:00:02.640 Welcome to the Deep Dive. We're the podcast where 00:00:02.640 --> 00:00:05.480 we take stacks of dense information, really sift 00:00:05.480 --> 00:00:08.000 through all the noise, and pull out the crucial 00:00:08.000 --> 00:00:10.400 bits of knowledge, the surprising insights, so 00:00:10.400 --> 00:00:11.900 you don't have to wade through it all yourself. 00:00:12.080 --> 00:00:14.480 That's the plan. Today, we're diving into something 00:00:14.480 --> 00:00:16.960 that affects millions, truly millions of lives 00:00:16.960 --> 00:00:20.440 every year. But it's still often, well, quite 00:00:20.440 --> 00:00:24.399 misunderstood. Concussions. We tend to think 00:00:24.399 --> 00:00:26.379 of them, don't we, as just a bump on the head. 00:00:26.539 --> 00:00:29.100 But the reality is, it's far more complex than 00:00:29.100 --> 00:00:31.339 that. Absolutely. I mean, did you know, for instance, 00:00:31.800 --> 00:00:34.859 that just in the US, somewhere between 1 .6 and 00:00:34.859 --> 00:00:37.759 3 .8 million sports -related concussions get 00:00:37.759 --> 00:00:40.100 reported each year? It's a staggering figure. 00:00:40.179 --> 00:00:42.659 And that's just sports. If you look at Ontario, 00:00:42.820 --> 00:00:47.119 in Canada between 2008 and 2016, over 1 % of 00:00:47.119 --> 00:00:49.759 the entire population got a formal concussion 00:00:49.759 --> 00:00:52.079 diagnosis each year. And the key point there 00:00:52.079 --> 00:00:55.399 is formal diagnosis. Experts are pretty convinced 00:00:55.399 --> 00:00:57.759 those numbers significantly underestimate how 00:00:57.759 --> 00:00:59.579 common they actually are. So it's almost like 00:00:59.579 --> 00:01:02.179 a hidden epidemic of the brain. And it goes way 00:01:02.179 --> 00:01:04.620 beyond just athletes on a pitch. That's a really 00:01:04.620 --> 00:01:06.900 crucial point to start with. Because the common 00:01:06.900 --> 00:01:09.120 idea, you know, the one you see in films or here 00:01:09.120 --> 00:01:11.359 in general chat, is that most people who get 00:01:11.359 --> 00:01:13.120 a concussion, they'll just sort of shake it off. 00:01:13.219 --> 00:01:15.099 Right. Back to normal in a few days. Exactly. 00:01:15.260 --> 00:01:17.239 Back to baseline within days, maybe a couple 00:01:17.239 --> 00:01:20.540 of weeks. But. As we'll unpack in this deep dive, 00:01:20.879 --> 00:01:23.780 that's not the whole story, not by a long shot. 00:01:24.019 --> 00:01:26.900 A significant number of people, probably far 00:01:26.900 --> 00:01:29.859 more than we generally realize, go on to experience 00:01:29.859 --> 00:01:32.459 what we call persisting post -concussion symptoms, 00:01:33.180 --> 00:01:37.099 or PPCS. And these aren't just minor headaches 00:01:37.099 --> 00:01:40.000 that linger. We're talking about a profound disruption 00:01:40.000 --> 00:01:43.159 to someone's life. Symptoms can last for months. 00:01:43.469 --> 00:01:46.370 sometimes even years, it can fundamentally change 00:01:46.370 --> 00:01:49.489 how they function, day -to -day, their well -being. 00:01:49.810 --> 00:01:52.469 It's serious. Okay, so that's our mission for 00:01:52.469 --> 00:01:54.530 this deep dive, then, to get past those surface 00:01:54.530 --> 00:01:57.510 -level ideas and really unpack the nuances. How 00:01:57.510 --> 00:01:59.090 do we, whether we're healthcare professionals, 00:01:59.290 --> 00:02:01.670 coaches, parents, or just trying to be informed, 00:02:02.150 --> 00:02:04.109 how do we spot who might be at higher risk for 00:02:04.109 --> 00:02:06.569 this prolonged recovery? And what does the latest 00:02:06.569 --> 00:02:08.909 research, the really cutting -edge stuff, tell 00:02:08.909 --> 00:02:11.110 us about how to manage this condition? Because 00:02:11.110 --> 00:02:12.990 it is pervasive. Right. So we're going to draw 00:02:12.990 --> 00:02:15.930 on quite a range of sources, comprehensive medical 00:02:15.930 --> 00:02:18.409 overviews, some fascinating new scientific studies 00:02:18.409 --> 00:02:21.169 coming out of Canada, and established sports 00:02:21.169 --> 00:02:23.250 medicine guidelines. We'll sift through it all. 00:02:23.389 --> 00:02:27.389 Exactly. The goal for you listening is to get 00:02:27.389 --> 00:02:30.590 a rapid but really thorough grasp of this, hopefully 00:02:30.590 --> 00:02:33.729 spark some aha moments, and move past the common 00:02:33.729 --> 00:02:36.590 assumptions to a genuinely well -informed view 00:02:36.590 --> 00:02:39.030 on concussions and this whole post -concussion 00:02:39.030 --> 00:02:42.189 syndrome picture. Okay, so precisely. It's not 00:02:42.189 --> 00:02:44.169 typically a structural injury you can see on 00:02:44.169 --> 00:02:47.409 a CT or MRI. It's about how the brain is working. 00:02:47.949 --> 00:02:51.409 And importantly, it's a specific type of mild 00:02:51.409 --> 00:02:55.550 traumatic brain injury. or MTBI. Ah, okay. So 00:02:55.550 --> 00:02:58.389 people use those terms interchangeably, MTBI 00:02:58.389 --> 00:03:00.789 and concussion, but they're not quite the same. 00:03:01.270 --> 00:03:03.710 Not technically, no. A concussion is really the 00:03:03.710 --> 00:03:06.889 subset of MTBI. MTBI is the broader category, 00:03:07.189 --> 00:03:09.110 which might include injuries with more structural 00:03:09.110 --> 00:03:12.210 changes. A concussion, by definition, implies 00:03:12.210 --> 00:03:14.710 this temporary functional disruption. Got it. 00:03:14.909 --> 00:03:16.710 And the symptoms can vary quite a lot, can't 00:03:16.710 --> 00:03:19.009 they? Hugely. From things that are very subtle, 00:03:19.150 --> 00:03:22.330 maybe just feeling a bit off or foggy, to more 00:03:22.330 --> 00:03:24.669 obvious periods of confusion or even brief laws 00:03:24.669 --> 00:03:26.629 of consciousness, there's a whole spectrum. And 00:03:26.629 --> 00:03:28.569 that timeline you mentioned earlier about how 00:03:28.569 --> 00:03:30.870 long symptoms last, that seems absolutely critical 00:03:30.870 --> 00:03:33.349 here. It really is. It helps us categorize things. 00:03:33.729 --> 00:03:36.150 So we often talk about an acute concussion if 00:03:36.150 --> 00:03:38.090 the symptoms resolve fairly quickly. Which is 00:03:38.090 --> 00:03:40.490 typically how long? Generally within about 14 00:03:40.490 --> 00:03:43.509 days, two weeks or so. But when those symptoms 00:03:43.509 --> 00:03:46.110 stubbornly stick around for 90 days or more, 00:03:46.150 --> 00:03:48.900 three months, That's when we start talking about 00:03:48.900 --> 00:03:51.780 prolonged post -concussion symptoms, or PPCS. 00:03:51.979 --> 00:03:54.300 90 days. That's the benchmark. It's a common 00:03:54.300 --> 00:03:57.539 one? Yes. Although, it's worth noting, you sometimes 00:03:57.539 --> 00:03:59.819 see slightly different timelines in the literature, 00:04:00.419 --> 00:04:03.180 particularly for sports concussions, where persistent 00:04:03.180 --> 00:04:05.280 symptoms might be defined as lasting longer than 00:04:05.280 --> 00:04:07.879 four weeks. Right. But that distinction between 00:04:07.879 --> 00:04:10.360 acute and prolonged, that's really important, 00:04:10.439 --> 00:04:12.639 isn't it, for how you manage it? Absolutely vital. 00:04:12.969 --> 00:04:15.430 Because the approach to care, the kind of resources 00:04:15.430 --> 00:04:18.769 someone needs, their likely prognosis, it all 00:04:18.769 --> 00:04:21.550 shifts quite dramatically once symptoms go beyond 00:04:21.550 --> 00:04:24.290 that initial acute phase. And managing this, 00:04:24.370 --> 00:04:26.670 especially the prolonged cases, it's not a one 00:04:26.670 --> 00:04:29.870 -person job, is it? Definitely not. Effective 00:04:29.870 --> 00:04:32.769 concussion care, particularly for PPCS, is inherently 00:04:32.769 --> 00:04:34.889 interprofessional. It really does take a village. 00:04:35.009 --> 00:04:37.009 Who's typically involved? Oh, a whole range. 00:04:37.490 --> 00:04:39.709 Physicians, of course, but also physiotherapists, 00:04:39.910 --> 00:04:42.829 neuropsychologists are key, occupational therapists, 00:04:43.410 --> 00:04:46.009 sometimes speech and language therapists, social 00:04:46.009 --> 00:04:49.610 workers. It's a team effort because the concussion 00:04:49.610 --> 00:04:51.810 can impact so many different parts of a person's 00:04:51.810 --> 00:04:54.589 life, physical, cognitive, emotional, social. 00:04:54.750 --> 00:04:57.449 Okay, that makes sense. So you mentioned some 00:04:57.449 --> 00:04:59.670 surprising research. Yes, this is where it gets 00:04:59.670 --> 00:05:01.730 really interesting. As we unpack some of the 00:05:01.730 --> 00:05:04.370 latest findings, especially from a big observational 00:05:04.370 --> 00:05:06.930 study done right here in Ontario, you might find 00:05:06.930 --> 00:05:09.750 some of the results, well, quite counterintuitive 00:05:09.750 --> 00:05:12.149 actually. How so? Well, we're going to challenge 00:05:12.149 --> 00:05:15.410 some perhaps deeply held assumptions about who's 00:05:15.410 --> 00:05:18.509 most at risk for that prolonged recovery. For 00:05:18.509 --> 00:05:20.870 instance, some factors that we've traditionally 00:05:20.870 --> 00:05:22.750 thought were strong predictors for persistent 00:05:22.750 --> 00:05:25.250 symptoms. Right. They might not hold up quite 00:05:25.250 --> 00:05:27.569 as strongly when you directly compare people 00:05:27.569 --> 00:05:30.250 with acute symptoms versus those with prolonged 00:05:30.250 --> 00:05:32.850 ones. Really? And conversely, other factors, 00:05:33.310 --> 00:05:35.069 maybe things that haven't been discussed as much, 00:05:35.470 --> 00:05:38.350 seem to emerge as surprisingly significant. It 00:05:38.350 --> 00:05:40.430 could really shift our understanding of who's 00:05:40.430 --> 00:05:43.050 vulnerable and why. Okay, I'm intrigued now, 00:05:43.149 --> 00:05:45.009 so we'll get into the nuts and bolts of that 00:05:45.009 --> 00:05:48.170 study. We will. We'll explore the... the underlying 00:05:48.170 --> 00:05:50.149 path of physiology to what's actually happening 00:05:50.149 --> 00:05:52.829 in the brain. The metabolic changes, the structural 00:05:52.829 --> 00:05:54.970 shifts at a cellular level after the injury, 00:05:55.350 --> 00:05:58.129 and how knowing that is guiding new approaches. 00:05:58.290 --> 00:06:01.009 And then the practical side, evaluation diagnosis. 00:06:01.310 --> 00:06:04.410 Exactly. How do we effectively evaluate and diagnose 00:06:04.410 --> 00:06:07.569 concussion? What does a structured evidence -based 00:06:07.569 --> 00:06:10.930 recovery plan look like? including that crucial 00:06:10.930 --> 00:06:13.470 graduated return to play protocol that's so vital 00:06:13.470 --> 00:06:16.029 for athletes, but the principles apply more broadly 00:06:16.029 --> 00:06:18.470 too. Okay, brilliant. It sounds like this conversation 00:06:18.470 --> 00:06:21.050 might genuinely shift how we think about brain 00:06:21.050 --> 00:06:24.009 injury and recovery. Let's dive in. Tell us about 00:06:24.009 --> 00:06:26.939 this Ontario study. Right, so this study is titled, 00:06:27.300 --> 00:06:29.000 Characterizing the Profiles of Patients with 00:06:29.000 --> 00:06:31.519 Acute Concussion vs. Prolonged Post -Concussion 00:06:31.519 --> 00:06:33.920 Symptoms. It was an observational study done 00:06:33.920 --> 00:06:35.779 across multiple sites. Part of a bigger project? 00:06:35.959 --> 00:06:38.360 Yes, part of a larger initiative called Connecting. 00:06:38.839 --> 00:06:41.500 And they collected really rich, patient -reported 00:06:41.500 --> 00:06:44.240 data from seven different concussion clinics 00:06:44.240 --> 00:06:47.060 right across Ontario. And what's powerful about 00:06:47.060 --> 00:06:50.060 that multi -site approach? It gives great diversity. 00:06:50.519 --> 00:06:52.560 They included clinics that focused on sports, 00:06:52.779 --> 00:06:55.819 others on acute care, and some tertiary care 00:06:55.819 --> 00:06:58.980 centers. So it wasn't just looking at, say, elite 00:06:58.980 --> 00:07:02.579 athletes or people only in central Toronto. Ah, 00:07:02.800 --> 00:07:06.000 so a real mix. Geographically diverse, too. Exactly. 00:07:06.180 --> 00:07:08.740 That geographical and functional mix is a real 00:07:08.740 --> 00:07:12.199 strength. It gives us a much broader, more generalizable 00:07:12.199 --> 00:07:15.199 picture of concussion in the real world, not 00:07:15.199 --> 00:07:18.160 just in specific pockets, a much more comprehensive 00:07:18.160 --> 00:07:20.680 view of who's getting concussions across different 00:07:20.680 --> 00:07:22.699 settings. Makes sense. And how did they gather 00:07:22.699 --> 00:07:24.899 the information? They were very thorough. They 00:07:24.899 --> 00:07:27.160 collected a standardized set of data points from 00:07:27.160 --> 00:07:29.300 everyone, usually at their first clinic visit 00:07:29.300 --> 00:07:31.500 or within about two weeks of it. And who was 00:07:31.500 --> 00:07:34.540 included? patients age 16 or older who had a 00:07:34.540 --> 00:07:37.120 clinical diagnosis of concussion that lined up 00:07:37.120 --> 00:07:39.420 with the Berlin Consensus Statement from 2017 00:07:39.420 --> 00:07:41.620 is basically the gold standard internationally 00:07:41.620 --> 00:07:44.160 for a diagnosis. And they had to be able to give 00:07:44.160 --> 00:07:46.279 informed consent, obviously. Were there people 00:07:46.279 --> 00:07:48.860 they specifically excluded? Yes. And that's important 00:07:48.860 --> 00:07:51.300 for understanding the focus. They wanted to look 00:07:51.300 --> 00:07:54.279 specifically at what we'd clinically call a concussion. 00:07:55.040 --> 00:07:58.790 So. Anyone with abnormalities on CT or MRI scans, 00:07:59.290 --> 00:08:01.810 anyone needing neurosurgery, or those with really 00:08:01.810 --> 00:08:04.829 complex multiple injuries were out. Okay. Also 00:08:04.829 --> 00:08:07.709 excluded were people with significant pre -existing 00:08:07.709 --> 00:08:11.569 neurological or developmental issues, or if the 00:08:11.569 --> 00:08:13.930 concussion -like symptoms were triggered by something 00:08:13.930 --> 00:08:16.449 non -traumatic like a seizure or a migraine. 00:08:16.550 --> 00:08:18.790 So they really narrowed it down to isolated, 00:08:19.129 --> 00:08:21.889 traumatically induced concussions. Precisely. 00:08:22.230 --> 00:08:24.410 That rigorous approach meant they could get clearer 00:08:24.410 --> 00:08:26.810 insights into the recovery pathways specifically 00:08:26.810 --> 00:08:29.209 for concussion without result being confounded 00:08:29.209 --> 00:08:31.470 by more severe injuries or other conditions. 00:08:31.649 --> 00:08:33.789 And then they split these participants into groups 00:08:33.789 --> 00:08:36.690 for comparison. Yes, very cleverly for this analysis. 00:08:37.029 --> 00:08:39.799 They created two distinct groups. First, the 00:08:39.799 --> 00:08:41.519 acute concussion group people whose symptoms 00:08:41.519 --> 00:08:43.740 had been around for 14 days or less. Okay, a 00:08:43.740 --> 00:08:46.840 quick resolvers. Exactly. And second, the prolonged 00:08:46.840 --> 00:08:49.460 post -concussion symptoms group, the PPCS group, 00:08:49.840 --> 00:08:52.120 where symptoms had persisted for 90 days or more. 00:08:52.259 --> 00:08:55.000 That three -month mark again? Right. And importantly, 00:08:55.320 --> 00:08:56.960 to really sharpen the difference between those 00:08:56.960 --> 00:08:59.620 two ends of the spectrum, they deliberately excluded 00:08:59.620 --> 00:09:01.720 patients who were in the middle. The subacute 00:09:01.720 --> 00:09:04.460 phase? Yes, those with symptoms between 15 and 00:09:04.460 --> 00:09:08.179 89 days. Taking them out created a very clear 00:09:08.179 --> 00:09:11.379 contrast between rapid resolution and genuinely 00:09:11.379 --> 00:09:14.120 prolonged problems. It allowed for a much more 00:09:14.120 --> 00:09:16.519 focused comparison. Right, that makes methodological 00:09:16.519 --> 00:09:19.639 sense. What sort of data did they actually collect 00:09:19.639 --> 00:09:21.659 on these people? It sounds like a lot. It was 00:09:21.659 --> 00:09:24.059 incredibly comprehensive. They went way beyond 00:09:24.059 --> 00:09:26.919 just basic demographics like sex and age. They 00:09:26.919 --> 00:09:29.820 looked at marital status, education level, geographic 00:09:29.820 --> 00:09:32.679 region where people lived, ethnicity, even annual 00:09:32.679 --> 00:09:35.899 household income. So, a rich socioeconomic picture. 00:09:36.259 --> 00:09:38.659 And injury details. Absolutely. Not just when 00:09:38.659 --> 00:09:41.080 the injury happened, but how the mechanism of 00:09:41.080 --> 00:09:42.960 injury. Now, obviously, how many days have passed 00:09:42.960 --> 00:09:44.799 since the injury when they were assessed. What 00:09:44.799 --> 00:09:46.980 about their medical background? A deep dive there, 00:09:47.019 --> 00:09:50.200 too. Any prior concussions, other medical conditions 00:09:50.200 --> 00:09:53.100 happening at the same time, vascular risk factors, 00:09:53.620 --> 00:09:56.779 history of chronic pain, any developmental disorders. 00:09:57.340 --> 00:10:00.360 And critically, they gather detailed information 00:10:00.360 --> 00:10:02.980 on any history of mental health disorders and 00:10:02.980 --> 00:10:05.659 any pre -existing problems with headaches or 00:10:05.659 --> 00:10:07.919 migraines. Those are often cited as risk factors, 00:10:07.980 --> 00:10:10.519 aren't they? They are indeed. They also looked 00:10:10.519 --> 00:10:12.460 at healthcare use, how often people had been 00:10:12.460 --> 00:10:15.980 to A &E, their GP, or seen rehabilitation specialists. 00:10:16.460 --> 00:10:19.240 It was a truly holistic data set, capturing a 00:10:19.240 --> 00:10:21.860 huge range of potential influences. And they 00:10:21.860 --> 00:10:24.620 used standardized tools for assessing symptoms, 00:10:24.700 --> 00:10:27.580 I assume, to keep things consistent? Yes, absolutely. 00:10:27.759 --> 00:10:29.460 They used established measures, for instance, 00:10:29.659 --> 00:10:32.000 the Sketney 5, the sport concussion assessment 00:10:32.000 --> 00:10:34.120 tool. I've heard of that one. It's widely used. 00:10:34.360 --> 00:10:36.700 It helps assess 22 common concussion symptoms 00:10:36.700 --> 00:10:39.039 across different areas, physical, cognitive, 00:10:39.159 --> 00:10:42.600 emotional fatigue. So things like headache, dizziness, 00:10:43.039 --> 00:10:45.360 feeling foggy, irritability. Exactly, those kinds 00:10:45.360 --> 00:10:47.519 of things. They also used the Sheehan Disability 00:10:47.519 --> 00:10:49.750 Scale. What does that measure? That's a really 00:10:49.750 --> 00:10:52.110 useful tool because it gets at the patient's 00:10:52.110 --> 00:10:54.730 perception of their disability, how much the 00:10:54.730 --> 00:10:56.529 symptoms are actually impacting their life, looking 00:10:56.529 --> 00:10:59.429 at things like days lost from work or school, 00:10:59.429 --> 00:11:02.289 and also days underproductive, where they might 00:11:02.289 --> 00:11:05.029 be physically present, but just not functioning 00:11:05.029 --> 00:11:07.649 at their usual capacity. Ah, OK. So it gives 00:11:07.649 --> 00:11:10.210 quantifiable measures for what can feel like 00:11:10.210 --> 00:11:12.350 a very subjective experience for the patient. 00:11:12.690 --> 00:11:15.529 Precisely. These tools provide objective data 00:11:15.529 --> 00:11:18.200 points. So this brings us to the study's main 00:11:18.200 --> 00:11:20.519 goal and where you said the surprising findings 00:11:20.519 --> 00:11:22.980 came in. Yes, this is where it really challenges 00:11:22.980 --> 00:11:25.950 some common assumptions. The researchers initially 00:11:25.950 --> 00:11:28.029 wanted to see if patients in the acute group 00:11:28.029 --> 00:11:31.149 and the PPCS group differed significantly on 00:11:31.149 --> 00:11:34.649 four specific factors, often flagged as key risk 00:11:34.649 --> 00:11:36.570 predictors for prolonged symptoms. Which were? 00:11:36.870 --> 00:11:39.190 Sex, having a history of mental health disorders, 00:11:39.549 --> 00:11:41.649 having a history of headaches or migraines, and 00:11:41.649 --> 00:11:43.649 having had previous concussions. OK, those are 00:11:43.649 --> 00:11:46.129 the ones you often hear about. Exactly. And the 00:11:46.129 --> 00:11:48.710 prevailing wisdom, the sort of statistic often 00:11:48.710 --> 00:11:52.549 quoted, is that maybe only 10 % to 20 % of acute 00:11:52.549 --> 00:11:55.309 concussions go on to become persistent. Right. 00:11:55.590 --> 00:11:58.490 So based on that, you'd logically predict that 00:11:58.490 --> 00:12:01.210 these known risk factors, mental health issues, 00:12:01.570 --> 00:12:04.269 migraines, maybe being female, previous concussions 00:12:04.269 --> 00:12:06.509 would be much more common in the PPCS group. 00:12:06.570 --> 00:12:08.490 They should stand out as clear warning signs. 00:12:08.789 --> 00:12:11.110 That makes sense. So what did they actually find? 00:12:11.250 --> 00:12:13.149 Did those factors show up more in the prolonged 00:12:13.149 --> 00:12:16.509 group? Well, this is the kicker. Quite remarkably, 00:12:16.759 --> 00:12:19.139 And actually, contrary to what many would expect, 00:12:19.620 --> 00:12:21.720 and indeed, contrary to the study's own initial 00:12:21.720 --> 00:12:24.980 hypothesis, they found no statistically significant 00:12:24.980 --> 00:12:27.820 differences between the acute group and the PPCS 00:12:27.820 --> 00:12:29.820 group for history of mental health disorders, 00:12:30.299 --> 00:12:32.399 pre -existing headache, or migraine history, 00:12:32.679 --> 00:12:35.059 or sex. No difference at all. No statistically 00:12:35.059 --> 00:12:36.519 significant difference. Let me give you the numbers. 00:12:36.519 --> 00:12:39.279 They're quite striking. In the acute group, 37 00:12:39.279 --> 00:12:41.720 .3 % had a history of mental health disorders. 00:12:41.720 --> 00:12:45.700 In the PPCS group, 37 .9%. Virtually identical. 00:12:45.899 --> 00:12:49.639 Wow. And for sex. The acute group was 61 .1 % 00:12:49.639 --> 00:12:54.000 female. The PPCS group was 66 .3 % female. Again, 00:12:54.139 --> 00:12:55.980 when you analyze the statistics across the whole 00:12:55.980 --> 00:12:58.000 large group, that difference wasn't significant. 00:12:58.779 --> 00:13:00.860 That really is eye -opening, because it seems 00:13:00.860 --> 00:13:03.860 to fly in the face of that idea that these factors 00:13:03.860 --> 00:13:06.879 single out the 10 -20 % who will struggle long 00:13:06.879 --> 00:13:09.879 term. It does. It strongly implies that the baseline 00:13:09.879 --> 00:13:12.350 vulnerability may be linked to these factors, 00:13:12.830 --> 00:13:15.049 might be much more similar across everyone who 00:13:15.049 --> 00:13:17.830 sustains a concussion rather than just predisposing 00:13:17.830 --> 00:13:20.669 a small minority to poor outcomes. So what does 00:13:20.669 --> 00:13:24.389 that mean practically for a doctor seeing a patient 00:13:24.389 --> 00:13:27.490 or a coach? It means you can't just look at someone, 00:13:27.570 --> 00:13:30.549 see they don't have a history of anxiety or migraines, 00:13:30.710 --> 00:13:33.509 and assume they're automatically low risk for 00:13:33.509 --> 00:13:36.529 prolonged symptoms. It suggests we need to perhaps 00:13:36.529 --> 00:13:39.389 focus more on the injury itself, the immediate 00:13:39.389 --> 00:13:42.070 symptoms, rather than relying too heavily on 00:13:42.070 --> 00:13:45.049 these pre -existing conditions as definite predictors 00:13:45.049 --> 00:13:47.070 of a long recovery versus a short one. Okay. 00:13:47.210 --> 00:13:49.149 What about previous concussions? That's almost 00:13:49.149 --> 00:13:51.250 always mentioned as a big risk factor. That also 00:13:51.250 --> 00:13:52.990 showed no significant difference between the 00:13:52.990 --> 00:13:54.950 two groups in this study. Really? Why might that 00:13:54.950 --> 00:13:57.690 be? Well, the study offers a thoughtful explanation. 00:13:58.139 --> 00:14:01.220 A history of concussions is a known risk factor, 00:14:01.460 --> 00:14:05.059 yes, but it's a risk factor not just for developing 00:14:05.059 --> 00:14:07.720 persistent symptoms after a new injury, but also 00:14:07.720 --> 00:14:09.620 for sustaining another concussion in the first 00:14:09.620 --> 00:14:13.000 place. Ah, I see. So... People in both groups 00:14:13.000 --> 00:14:15.720 might be equally likely to have had prior concussions 00:14:15.720 --> 00:14:18.480 just by virtue of having had a concussion now. 00:14:18.799 --> 00:14:20.919 Exactly. It might be a characteristic shared 00:14:20.919 --> 00:14:22.980 by many people who seek care for concussion, 00:14:23.299 --> 00:14:25.080 whether their current symptoms resolve quickly 00:14:25.080 --> 00:14:27.840 or not. It highlights how tricky it is to interpret 00:14:27.840 --> 00:14:30.779 risk factors. Are they predicting future problems 00:14:30.779 --> 00:14:33.059 or just describing the population already affected? 00:14:33.379 --> 00:14:35.539 It's about the nuance of how these factors operate 00:14:35.539 --> 00:14:38.159 over time. Okay, so if those factors, mental 00:14:38.159 --> 00:14:41.440 health, migraine, sex, prior concussions, weren't 00:14:41.440 --> 00:14:43.820 the clear dividing lines between the acute and 00:14:43.820 --> 00:14:47.200 prolonged groups, what did stand out? What did 00:14:47.200 --> 00:14:49.779 differentiate them? This must be where the study's 00:14:49.779 --> 00:14:52.360 secondary aim comes in. Precisely. When they 00:14:52.360 --> 00:14:54.899 look at the broader demographic and injury profiles, 00:14:55.299 --> 00:14:57.519 some clear and potentially actionable differences 00:14:57.519 --> 00:15:00.419 did emerge. Like what? Age was a big one. The 00:15:00.419 --> 00:15:03.779 PPCS group was significantly older, on average, 00:15:04.039 --> 00:15:06.000 than the acute concussion group. Much older. 00:15:06.190 --> 00:15:09.029 The average age for the acute group was 32. For 00:15:09.029 --> 00:15:11.210 the PPCS group, it jumped quite substantially 00:15:11.210 --> 00:15:15.110 to 44. 12 years difference on average. Yes. And 00:15:15.110 --> 00:15:17.549 when they looked at age categories, the odds 00:15:17.549 --> 00:15:19.429 of being in an older age group, particularly 00:15:19.429 --> 00:15:23.750 40, 49, 50, 59, and especially 60 plus, were 00:15:23.750 --> 00:15:26.850 significantly higher for people with PPCS compared 00:15:26.850 --> 00:15:29.350 to those aged 29 or younger. How much higher? 00:15:29.789 --> 00:15:31.860 Dramatically higher for the oldest group. The 00:15:31.860 --> 00:15:35.039 odds of someone age 60 or over being in the PPCS 00:15:35.039 --> 00:15:37.679 group were over nine and a half times higher 00:15:37.679 --> 00:15:40.360 than for someone under 30. Nine and a half times, 00:15:40.440 --> 00:15:43.960 that's huge. So middle and older age really seems 00:15:43.960 --> 00:15:46.159 to be a significant factor for prolonged symptoms. 00:15:46.360 --> 00:15:48.919 This study strongly suggests so, yes. It challenges 00:15:48.919 --> 00:15:51.379 older ideas that maybe age wasn't such a major 00:15:51.379 --> 00:15:54.559 factor. Why might older age lead to slower or 00:15:54.559 --> 00:15:57.419 less complete recovery? Is it biological? Well, 00:15:57.720 --> 00:15:59.700 one common theory revolves around something called 00:15:59.700 --> 00:16:02.360 cognitive reserve. Like the brain's backup capacity. 00:16:02.860 --> 00:16:05.919 Sort of, yes. Think of it as your brain's ability 00:16:05.919 --> 00:16:08.980 to cope with damage or stress. Maybe it's efficiency 00:16:08.980 --> 00:16:12.659 or flexibility. As we age, that reserve might 00:16:12.659 --> 00:16:15.940 naturally decrease a bit. So the brain just have 00:16:15.940 --> 00:16:18.480 less capacity to compensate for an injury and 00:16:18.480 --> 00:16:20.519 recover as efficiently as a younger brain might. 00:16:20.740 --> 00:16:23.259 So it's less resilient to the disruption. Potentially, 00:16:23.519 --> 00:16:26.029 yes. While not all previous studies have found 00:16:26.029 --> 00:16:29.330 such a strong link, this large real -world comparison 00:16:29.330 --> 00:16:33.110 in Ontario really points to age, especially being 00:16:33.110 --> 00:16:36.210 40 or older, as significantly impacting how recovery 00:16:36.210 --> 00:16:38.649 unfolds. It also makes you think about how age 00:16:38.649 --> 00:16:40.950 interacts with other things, like education level, 00:16:41.289 --> 00:16:43.350 which might influence your cognitive baseline 00:16:43.350 --> 00:16:45.610 before the injury even happens. Okay, so age 00:16:45.610 --> 00:16:48.309 is a major differentiator. What else stood out? 00:16:48.429 --> 00:16:50.809 The way the injury happened, the mechanism of 00:16:50.809 --> 00:16:52.370 injury, that was another critical finding. How 00:16:52.370 --> 00:16:54.850 so? Transportation -related incidents, so car 00:16:54.850 --> 00:16:56.850 crashes, bike accidents, motorcycle collisions, 00:16:57.309 --> 00:16:59.750 were significantly more common in the PPCS group. 00:17:00.309 --> 00:17:03.029 Very much so. The odds of having had a transportation 00:17:03.029 --> 00:17:05.890 -related injury were four and a half times higher 00:17:05.890 --> 00:17:08.789 in the PPCS group compared to the acute group 00:17:08.789 --> 00:17:10.849 when you compare them against injuries caused 00:17:10.849 --> 00:17:13.289 by falls or falling objects. Four and a half 00:17:13.289 --> 00:17:16.299 times. Again, that's a massive difference. Why 00:17:16.299 --> 00:17:18.859 would being in a crash make prolonged symptoms 00:17:18.859 --> 00:17:21.400 so much more likely? Is it just the force involved? 00:17:21.619 --> 00:17:24.160 That's likely part of it, certainly. The forces 00:17:24.160 --> 00:17:26.539 in those types of collisions can be greater and 00:17:26.539 --> 00:17:29.279 more complex. Think about the rapid acceleration 00:17:29.279 --> 00:17:32.519 and deceleration. That can lead to more widespread 00:17:32.519 --> 00:17:34.680 sort of shearing forces within the brain tissue. 00:17:34.900 --> 00:17:37.930 But is it only physical? Probably not entirely. 00:17:38.529 --> 00:17:40.890 There's also the significant psychological stress 00:17:40.890 --> 00:17:43.210 and emotional trauma that often comes with being 00:17:43.210 --> 00:17:45.390 in a serious accident. Post -traumatic stress. 00:17:45.630 --> 00:17:47.930 Exactly. We know there's a considerable overlap 00:17:47.930 --> 00:17:50.390 between symptoms of PTSD and persistent concussion 00:17:50.390 --> 00:17:52.890 symptoms. And then there's another layer. That's 00:17:52.890 --> 00:17:56.369 right. Litigation. Involvement in insurance claims 00:17:56.369 --> 00:17:58.250 or legal proceedings, which is pretty common 00:17:58.250 --> 00:18:01.690 after road traffic accidents, has also been consistently 00:18:01.690 --> 00:18:04.650 linked with persistent symptoms. Ah, so it's 00:18:04.650 --> 00:18:08.289 a complex mix, the physical injury, the psychological 00:18:08.289 --> 00:18:11.009 impact, maybe even the stress of legal battles. 00:18:11.490 --> 00:18:13.630 Precisely. It creates this really complicated 00:18:13.630 --> 00:18:16.529 interplay that can definitely hinder and prolong 00:18:16.529 --> 00:18:18.869 the recovery process. It's not just a bang on 00:18:18.869 --> 00:18:21.470 the head, it's an event. with potentially wide 00:18:21.470 --> 00:18:23.609 -ranging consequences. That makes a lot of sense. 00:18:24.009 --> 00:18:26.430 Okay, so we have age and mechanism of injury 00:18:26.430 --> 00:18:30.049 as clear differentiators. You mentioned geography 00:18:30.049 --> 00:18:32.970 earlier, did where people lived show any differences? 00:18:33.529 --> 00:18:35.569 Yes, and this pointed towards potential issues 00:18:35.569 --> 00:18:38.450 around access to care. The geographic data showed 00:18:38.450 --> 00:18:41.289 that patients in the PPCS group were significantly 00:18:41.289 --> 00:18:43.950 more likely to live outside of metropolitan Toronto. 00:18:44.109 --> 00:18:46.809 Really? In the surrounding region? Yes. The odds 00:18:46.809 --> 00:18:49.309 of living in central Ontario, southwestern Ontario, 00:18:49.589 --> 00:18:52.430 or other more rural or semi -urban areas were 00:18:52.430 --> 00:18:54.490 significantly higher, around four to four and 00:18:54.490 --> 00:18:57.390 a half times higher, for patients with PPCS compared 00:18:57.390 --> 00:19:00.029 to those living right in Toronto. That's fascinating. 00:19:00.549 --> 00:19:02.750 What might that be telling us? Is care better 00:19:02.750 --> 00:19:04.789 in Toronto, or is something else going on? Well, 00:19:04.849 --> 00:19:06.990 it raises really important questions about equitable 00:19:06.990 --> 00:19:10.299 access to specialized concussion care. It's possible 00:19:10.299 --> 00:19:12.799 that while Toronto, being densely populated, 00:19:13.259 --> 00:19:15.480 might have long waiting lists for specialist 00:19:15.480 --> 00:19:18.000 care. One study mentioned an average wait of 00:19:18.000 --> 00:19:21.579 10 months for tertiary MTBI care there. Ten months. 00:19:21.940 --> 00:19:24.500 Wow. Conversely, it could also mean that patients 00:19:24.500 --> 00:19:26.799 outside the major city center just have fewer 00:19:26.799 --> 00:19:30.019 options nearby, fewer specialist clinics, less 00:19:30.019 --> 00:19:32.500 access to that interprofessional expertise needed 00:19:32.500 --> 00:19:34.920 for complex cases. So if they can't get the right 00:19:34.920 --> 00:19:37.660 help quickly enough, the symptoms might just 00:19:37.660 --> 00:19:40.700 drag on. That's a plausible hypothesis. A lack 00:19:40.700 --> 00:19:43.079 of timely, appropriate intervention closer to 00:19:43.079 --> 00:19:45.940 home could contribute to symptoms becoming prolonged. 00:19:46.539 --> 00:19:48.660 It really highlights a potential systemic issue. 00:19:49.000 --> 00:19:51.579 How does location affect concussion care? We 00:19:51.579 --> 00:19:53.400 need to look deeper into resource allocation 00:19:53.400 --> 00:19:55.160 across different regions. Okay, that's a really 00:19:55.160 --> 00:19:57.359 important system level point. Now, what about 00:19:57.359 --> 00:19:59.940 the symptoms themselves? The study used the SCAT 00:19:59.940 --> 00:20:02.720 T5. Did the PPCS group just have symptoms for 00:20:02.720 --> 00:20:05.160 longer, or were the symptoms themselves different 00:20:05.160 --> 00:20:07.500 or more severe? They were definitely more severe. 00:20:07.799 --> 00:20:11.019 While both groups obviously had symptoms, the 00:20:11.019 --> 00:20:14.480 PPCS group consistently reported significantly 00:20:14.480 --> 00:20:17.619 higher perceived symptom severity across all 00:20:17.619 --> 00:20:20.819 the SCET T5 domains. The fatigue, emotional, 00:20:21.039 --> 00:20:23.519 cognitive, and somatic physical symptoms. So 00:20:23.519 --> 00:20:26.440 more intense symptoms across the board. Yes. 00:20:26.940 --> 00:20:28.920 For example, fatigue symptoms were much more 00:20:28.920 --> 00:20:31.920 prevalent in the PPCS group. And fatigue often 00:20:31.920 --> 00:20:34.460 goes hand in hand with emotional symptoms and 00:20:34.460 --> 00:20:36.720 sleep problems after concussion. And emotional 00:20:36.720 --> 00:20:39.339 symptoms like anxiety or irritability. Those 00:20:39.339 --> 00:20:41.819 also tend to increase months after the injury 00:20:41.819 --> 00:20:44.240 in people with prolonged issues, which aligns 00:20:44.240 --> 00:20:46.680 with what this study found. It suggests a much 00:20:46.680 --> 00:20:49.200 more pervasive and debilitating cluster of symptoms 00:20:49.200 --> 00:20:51.079 in those who don't recover quickly. What about 00:20:51.079 --> 00:20:53.599 the cognitive ones that brain fog people describe, 00:20:53.660 --> 00:20:56.279 the trouble concentrating or remembering? Again, 00:20:56.500 --> 00:20:58.920 consistent with other research. While cognitive 00:20:58.920 --> 00:21:01.099 problems often get better relatively quickly 00:21:01.099 --> 00:21:04.200 in acute cases, maybe within days, they can unfortunately 00:21:04.200 --> 00:21:06.630 persist for years and people with PPCS. That 00:21:06.630 --> 00:21:09.329 must have a huge impact on daily life, work, 00:21:09.490 --> 00:21:13.170 study. Absolutely massive. And similarly, those 00:21:13.170 --> 00:21:16.130 physical or somatic symptoms like chronic headaches, 00:21:16.990 --> 00:21:19.609 persistent dizziness, that awful sensitivity 00:21:19.609 --> 00:21:23.369 to light or noise, they were also significantly 00:21:23.369 --> 00:21:26.519 more common and severe in the PPCS group. Are 00:21:26.519 --> 00:21:29.319 any particular symptoms early on seen as predictors? 00:21:29.640 --> 00:21:32.359 Yes. Reporting a high number of somatic symptoms, 00:21:32.640 --> 00:21:34.579 especially headaches, right in the acute phase 00:21:34.579 --> 00:21:37.079 after the injury is often considered one of the 00:21:37.079 --> 00:21:39.000 better predictors that symptoms might persist 00:21:39.000 --> 00:21:41.750 for longer. It shows how all these different 00:21:41.750 --> 00:21:44.269 symptom types, physical, emotional, cognitive, 00:21:44.529 --> 00:21:46.609 can weave together into this complex challenge 00:21:46.609 --> 00:21:49.250 for patients. Makes it really hard to treat sometimes. 00:21:49.509 --> 00:21:51.470 It really sounds like getting the right evaluation 00:21:51.470 --> 00:21:53.589 and management right from the start could make 00:21:53.589 --> 00:21:56.170 a big difference. Can we talk a bit about the 00:21:56.170 --> 00:21:58.730 overall approach to assessing and managing concussions? 00:21:58.890 --> 00:22:00.589 What are the key steps, whether it's an athlete 00:22:00.589 --> 00:22:03.210 or someone from that car accident? Yes, absolutely. 00:22:03.349 --> 00:22:05.630 The foundation, the absolute cornerstone, is 00:22:05.630 --> 00:22:07.589 a thorough history and physical examination. 00:22:07.710 --> 00:22:10.099 What does that involve? You need every detail 00:22:10.099 --> 00:22:12.599 about the injury, how it happened, the forces 00:22:12.599 --> 00:22:14.980 involved, was there any loss of consciousness, 00:22:15.200 --> 00:22:18.099 however brief, and critically, any previous injuries. 00:22:18.660 --> 00:22:22.180 Then, a detailed past medical history is vital. 00:22:22.500 --> 00:22:24.980 Checking for those potential influencing factors. 00:22:25.160 --> 00:22:28.220 Exactly. Previous headaches, migraines, any history 00:22:28.220 --> 00:22:31.160 of depression, anxiety, chronic pain, dizziness. 00:22:31.839 --> 00:22:34.500 These can all shape the recovery path, even if, 00:22:34.519 --> 00:22:37.079 as the Ontario study showed, they didn't perfectly 00:22:37.079 --> 00:22:39.740 distinguish the acute from the prolonged group 00:22:39.740 --> 00:22:42.400 in that comparison. And the physical exam. A 00:22:42.400 --> 00:22:44.480 full neurological assessment, checking cranial 00:22:44.480 --> 00:22:47.940 nerves, vision, reflexes, muscle strength, proprioception. 00:22:48.299 --> 00:22:50.019 That's your sense of where your body parts are 00:22:50.019 --> 00:22:52.599 and sensation. It's about building that complete 00:22:52.599 --> 00:22:54.819 clinical picture. For athletes, there's often 00:22:54.819 --> 00:22:57.240 that immediate sideline check. What's crucial 00:22:57.240 --> 00:22:59.720 there? That immediate sideline evaluation is 00:22:59.720 --> 00:23:01.880 critical in sport. First priority is the primary 00:23:01.880 --> 00:23:04.119 survey checking, airway, breathing, circulation, 00:23:04.279 --> 00:23:06.799 the absolute basics. And crucially, looking for 00:23:06.799 --> 00:23:09.839 any sign, any sign of a spinal cord injury. Neck 00:23:09.839 --> 00:23:13.579 pain, altered sensation. Yes. If an athlete's 00:23:13.579 --> 00:23:15.819 mental state is off or they complain of neck 00:23:15.819 --> 00:23:18.640 pain, you must assume a cervical spine injury 00:23:18.640 --> 00:23:21.400 until it's proven otherwise. Safety first. Are 00:23:21.400 --> 00:23:23.480 there immediate red flags that mean straight 00:23:23.480 --> 00:23:26.390 to hospital? Definitely. Things like a deteriorating 00:23:26.390 --> 00:23:28.529 level of consciousness, a really severe headache 00:23:28.529 --> 00:23:32.549 that keeps getting worse, any new focal neurological 00:23:32.549 --> 00:23:36.069 deficits like weakness on one side, those warrant 00:23:36.069 --> 00:23:38.750 immediate emergency transport for urgent brain 00:23:38.750 --> 00:23:40.970 imaging. And assuming none of those red flags, 00:23:41.069 --> 00:23:43.609 what happens next on the sideline? Then you move 00:23:43.609 --> 00:23:46.289 to the secondary survey, focusing specifically 00:23:46.289 --> 00:23:49.329 on cognitive function and those classic concussion 00:23:49.329 --> 00:23:52.369 symptoms. The absolute rule here, the non -negotiable, 00:23:52.769 --> 00:23:55.210 is that any athlete showing any signs or symptoms 00:23:55.210 --> 00:23:57.650 suggestive of a concussion must be removed from 00:23:57.650 --> 00:24:00.230 play immediately. No finishing the half. Absolutely 00:24:00.230 --> 00:24:02.509 not. No return to play on the same day, full 00:24:02.509 --> 00:24:05.559 stop. Their health is paramount. Far more important 00:24:05.559 --> 00:24:07.359 than the game. And that's where tools like the 00:24:07.359 --> 00:24:09.859 Scatty 5 come in useful again. Precisely. The 00:24:09.859 --> 00:24:12.599 Scatty 5 is designed for that situation. It's 00:24:12.599 --> 00:24:15.059 standardized, widely used for athletes age 13, 00:24:15.339 --> 00:24:17.539 and up there's a child Scat 5 for younger ones 00:24:17.539 --> 00:24:19.680 too. What does it involve? It has components 00:24:19.680 --> 00:24:21.920 for immediate on -field assessment, looking for 00:24:21.920 --> 00:24:24.319 visible signs, asking quick memory questions 00:24:24.319 --> 00:24:26.759 like the Maddox questions, using the Glasgow 00:24:26.759 --> 00:24:28.799 Coma Scale for consciousness level. And then 00:24:28.799 --> 00:24:32.000 off the field? Yes. Ideally in a quiet, private 00:24:32.000 --> 00:24:34.900 space. There's the standard assessment of concussion, 00:24:35.599 --> 00:24:38.539 the SAC, test checking orientation, memory, concentration. 00:24:39.380 --> 00:24:42.380 There's also the BSS test, the balance error 00:24:42.380 --> 00:24:44.799 scoring system to objectively measure balance, 00:24:44.900 --> 00:24:47.099 which is often affected. Are there other tools 00:24:47.099 --> 00:24:50.240 used? Yes, things like the impact test. which 00:24:50.240 --> 00:24:52.759 is computer -based. It looks at verbal and visual 00:24:52.759 --> 00:24:55.579 memory, processing speed, reaction time. Often 00:24:55.579 --> 00:24:57.900 you compare the athletes' post -injury scores 00:24:57.900 --> 00:25:00.440 to their own baseline scores taken before the 00:25:00.440 --> 00:25:03.000 season started. Ah, having that baseline is helpful. 00:25:03.200 --> 00:25:05.680 Very. And the King -Devick test is another one, 00:25:05.920 --> 00:25:08.039 looking at eye movements and concentration by 00:25:08.039 --> 00:25:10.569 having the athlete read numbers quickly. These 00:25:10.569 --> 00:25:12.630 tools give objective data to help the clinician 00:25:12.630 --> 00:25:14.589 make informed decisions. So lots of assessment 00:25:14.589 --> 00:25:18.029 tools. What about brain scans, CTs, MRIs? You 00:25:18.029 --> 00:25:20.049 said earlier they don't diagnose concussion itself, 00:25:20.049 --> 00:25:22.309 but when are they needed? That's a really common 00:25:22.309 --> 00:25:24.650 point of confusion. Yeah. You're right. Generally, 00:25:24.849 --> 00:25:28.089 advanced imaging like CT or MRI is not needed 00:25:28.089 --> 00:25:31.069 to diagnose a concussion. Remember, it's primarily 00:25:31.069 --> 00:25:33.569 functional. Most scans will be normal. Okay. 00:25:33.950 --> 00:25:37.109 But imaging is absolutely essential in acute 00:25:37.109 --> 00:25:39.690 head trauma if those red flags we mentioned pop 00:25:39.690 --> 00:25:42.640 up. deteriorating status of your headache, focal 00:25:42.640 --> 00:25:45.039 signs? Exactly, or a suspicion of a neck injury. 00:25:46.200 --> 00:25:48.859 In an emergency setting, a CT scan is usually 00:25:48.859 --> 00:25:51.680 the first choice. It's quick and good for ruling 00:25:51.680 --> 00:25:54.440 out skull fractures, bleeding inside the head, 00:25:54.640 --> 00:25:57.539 intracranial hemorrhage, or brain bruises, contusions. 00:25:57.680 --> 00:26:00.440 And MRI, when would that be used? MRI gives much 00:26:00.440 --> 00:26:02.339 more detailed pictures of the brain tissue itself. 00:26:02.559 --> 00:26:04.740 It can pick up more subtle structural damage. 00:26:05.319 --> 00:26:07.039 Specialized sequences like diffusion -weighted 00:26:07.039 --> 00:26:09.440 imaging are particularly sensitive to the shearing 00:26:09.440 --> 00:26:11.240 injuries we talked about. Can it show functional 00:26:11.240 --> 00:26:15.299 changes, too? Functional MRI, or fMRI, can actually 00:26:15.299 --> 00:26:17.579 show changes in blood flow patterns in the brain, 00:26:18.160 --> 00:26:20.960 that cerebrovascular reactivity, especially in 00:26:20.960 --> 00:26:24.359 the acute phase. And if symptoms are really dragging 00:26:24.359 --> 00:26:26.980 on, say for more than a month, an MRI might be 00:26:26.980 --> 00:26:28.660 done later to make sure there isn't some other 00:26:28.660 --> 00:26:31.299 underlying neurological issue mimicking the concussion 00:26:31.299 --> 00:26:34.349 symptoms. Okay, so imaging has a role, but it's 00:26:34.349 --> 00:26:37.250 more about ruling out other serious problems, 00:26:37.609 --> 00:26:40.509 not diagnosing the concussion itself. Precisely. 00:26:40.769 --> 00:26:43.029 Diagnosis is primarily clinical, based on the 00:26:43.029 --> 00:26:45.289 history and examination. Right. Let's talk about 00:26:45.289 --> 00:26:48.029 treatment, then. The old advice used to be just 00:26:48.029 --> 00:26:50.490 rest, dark room, do nothing. Has that changed? 00:26:50.609 --> 00:26:53.450 Oh, massively. Our understanding has really evolved. 00:26:53.750 --> 00:26:56.410 The initial step is still immediate removal from 00:26:56.410 --> 00:26:58.630 whatever activity caused the injury or makes 00:26:58.630 --> 00:27:01.950 symptoms worse. And definitely no same -day return 00:27:01.950 --> 00:27:04.309 to play or demanding activity. But not weeks 00:27:04.309 --> 00:27:07.369 of bed rest. No, absolutely not. For acute concussions, 00:27:07.589 --> 00:27:09.329 the current recommendation is actually a very 00:27:09.329 --> 00:27:11.710 brief period of relative cognitive and physical 00:27:11.710 --> 00:27:14.529 rest, typically just 24 to 48 hours. Just one 00:27:14.529 --> 00:27:17.509 or two days. Yes. This is not strict bed rest 00:27:17.509 --> 00:27:21.180 in a dark room. We now know that prolonged complete 00:27:21.180 --> 00:27:24.660 rest can actually be detrimental. It can lead 00:27:24.660 --> 00:27:27.400 to worse outcomes, more anxiety, depression, 00:27:27.880 --> 00:27:30.140 and even prolonged physical symptoms. So what 00:27:30.140 --> 00:27:33.339 does relative rest mean then? It means minimizing 00:27:33.339 --> 00:27:36.599 activities that actively provoke or worsen symptoms. 00:27:37.319 --> 00:27:40.299 So maybe reducing screen time, avoiding noisy 00:27:40.299 --> 00:27:43.039 environments, not doing strenuous physical exercise 00:27:43.039 --> 00:27:45.180 right at the start, just taking it easy initially. 00:27:45.319 --> 00:27:48.339 And then what? Then, that short period of initial 00:27:48.339 --> 00:27:50.759 symptom limited rest should be followed quite 00:27:50.759 --> 00:27:52.960 quickly by starting a carefully structured and 00:27:52.960 --> 00:27:55.880 supervised graduated return to activity protocol. 00:27:56.400 --> 00:27:58.480 This is fundamental to good recovery. Ah, yes, 00:27:58.640 --> 00:28:00.880 the graduated return to play protocol. That sounds 00:28:00.880 --> 00:28:03.319 key, especially for athletes, but you said the 00:28:03.319 --> 00:28:05.640 principles apply more broadly. They do. It's 00:28:05.640 --> 00:28:07.599 relevant for students returning to school, people 00:28:07.599 --> 00:28:10.240 returning to demanding jobs. It's a structured 00:28:10.240 --> 00:28:13.140 step -by -step approach to systematically reintroduce 00:28:13.140 --> 00:28:15.569 physical and cognitive challenges. How does it 00:28:15.569 --> 00:28:18.130 work? How gradual is it? Typically, each stage 00:28:18.130 --> 00:28:21.109 lasts at least 24 hours. So assuming someone 00:28:21.109 --> 00:28:22.890 stays symptom -free at each step, it usually 00:28:22.890 --> 00:28:24.970 takes about a week to get through the whole protocol 00:28:24.970 --> 00:28:27.369 and be cleared for full return to sport. A week 00:28:27.369 --> 00:28:30.269 minimum. And why is that stepwise approach so 00:28:30.269 --> 00:28:32.630 important? It's vital because it allows the brain 00:28:32.630 --> 00:28:35.650 time to adapt and heal while gradually increasing 00:28:35.650 --> 00:28:38.390 the demands placed upon it. It helps prevent 00:28:38.390 --> 00:28:41.029 symptoms flaring up badly and reduces the risk 00:28:41.029 --> 00:28:43.569 of getting re -injured by doing too much too 00:28:43.569 --> 00:28:46.240 soon. Can you walk us through the stages? Sure. 00:28:46.680 --> 00:28:48.759 It usually goes something like this. Stage one 00:28:48.759 --> 00:28:51.099 is symptom limited activity. basically daily 00:28:51.099 --> 00:28:53.880 activities that don't provoke symptoms. The aim 00:28:53.880 --> 00:28:56.940 is rest from demanding tasks, less screen time, 00:28:57.059 --> 00:28:59.480 quiet environments, maybe life's cool or work 00:28:59.480 --> 00:29:01.700 activities if tolerated. Okay, taking it easy. 00:29:02.119 --> 00:29:05.000 Stage two is light aerobic exercise. Once they're 00:29:05.000 --> 00:29:06.539 symptom -free at rest, they can start things 00:29:06.539 --> 00:29:08.920 like walking, swimming, gentle stationary cycling, 00:29:09.559 --> 00:29:11.900 keeping the heart rate fairly low, say below 00:29:11.900 --> 00:29:14.700 70 % of maximum, no resistance training yet. 00:29:15.259 --> 00:29:17.200 The goal is just to increase heart rate gently 00:29:17.200 --> 00:29:19.609 without symptoms. This actually helps brain blood 00:29:19.609 --> 00:29:22.309 flow and recovery. Right, so activity isn't bad 00:29:22.309 --> 00:29:25.309 if it's the right kind. Exactly. Stage three 00:29:25.309 --> 00:29:28.930 is sport -specific exercise. More dynamic movements 00:29:28.930 --> 00:29:31.549 now, like running drills, skating for hockey 00:29:31.549 --> 00:29:34.769 players, throwing. Still no head impact activities 00:29:34.769 --> 00:29:36.930 though, adding movement and agility back in. 00:29:37.069 --> 00:29:39.490 Getting closer to the sport. Stage four is non 00:29:39.490 --> 00:29:42.430 -contact training drills. More complex training 00:29:42.430 --> 00:29:45.740 here. passing drills, team plays, starting some 00:29:45.740 --> 00:29:48.359 progressive resistance training perhaps, building 00:29:48.359 --> 00:29:51.359 exercise tolerance, coordination, cognitive load 00:29:51.359 --> 00:29:54.420 of practice, but still no contact. Crucially, 00:29:54.940 --> 00:29:58.299 no contact yet. Stage five is full contact practice. 00:29:58.859 --> 00:30:01.740 This is the big step before competition. Returning 00:30:01.740 --> 00:30:04.000 to normal training, including contact drills 00:30:04.000 --> 00:30:06.400 appropriate for the sport, all done in a controlled 00:30:06.400 --> 00:30:08.579 practice setting. It's about restoring confidence 00:30:08.579 --> 00:30:12.079 and checking skills under pressure. Stage 6 is 00:30:12.079 --> 00:30:15.420 full return to play. If and only if the individual 00:30:15.420 --> 00:30:17.420 is completely symptom -free through all those 00:30:17.420 --> 00:30:20.000 stages and gets clearance from a healthcare professional, 00:30:20.339 --> 00:30:22.380 then they can return to normal games or competition. 00:30:22.579 --> 00:30:24.519 And what if symptoms come back during one of 00:30:24.519 --> 00:30:27.160 the stages? That's the key rule. If symptoms 00:30:27.160 --> 00:30:29.920 return at any stage, you drop back to the last 00:30:29.920 --> 00:30:31.940 stage where you were completely symptom -free, 00:30:32.440 --> 00:30:35.160 rest for another 24 hours, and then try progressing 00:30:35.160 --> 00:30:37.769 again. So listen to your body. Don't push through 00:30:37.769 --> 00:30:40.970 symptoms. Absolutely. This patient systematic 00:30:40.970 --> 00:30:44.150 approach is what really minimizes the risk of 00:30:44.150 --> 00:30:46.569 prolonged problems or getting hurt again. That's 00:30:46.569 --> 00:30:49.269 a really clear framework. What about people whose 00:30:49.269 --> 00:30:52.589 symptoms do persist beyond that acute phase? 00:30:52.670 --> 00:30:54.569 Someone in the PPCS group, for instance. Are 00:30:54.569 --> 00:30:57.630 there more specific therapies beyond just gradual 00:30:57.630 --> 00:31:00.250 activity? Yes, definitely. When symptoms persist, 00:31:00.369 --> 00:31:02.170 the approach needs to become much more targeted. 00:31:02.430 --> 00:31:04.670 And that interprofessional team really comes 00:31:04.670 --> 00:31:07.690 into play. What kind of targeted therapies? Well, 00:31:07.789 --> 00:31:09.450 medications might be considered for specific 00:31:09.450 --> 00:31:11.809 symptoms. For persistent headaches, maybe low 00:31:11.809 --> 00:31:13.990 -dose amitriptyline, which works on nerve pain, 00:31:14.329 --> 00:31:16.289 or something like sopranolol, if migraines are 00:31:16.289 --> 00:31:18.710 a feature. And for the dizziness or visual problems 00:31:18.710 --> 00:31:21.009 people often get. Those are incredibly common 00:31:21.009 --> 00:31:23.970 and disabling. There are specific screening tools 00:31:23.970 --> 00:31:26.849 to pinpoint the cause. Is it the inner ear, the 00:31:26.849 --> 00:31:29.930 stabler system, eye movements, ocular motor, 00:31:30.329 --> 00:31:32.720 or maybe neck issues contributing? And based 00:31:32.720 --> 00:31:34.880 on that, based on the findings, you get active 00:31:34.880 --> 00:31:37.519 therapies, things like cervical physiotherapy 00:31:37.519 --> 00:31:40.720 for neck pain and stiffness, specific vision 00:31:40.720 --> 00:31:43.240 therapy exercises prescribed by an optometrist 00:31:43.240 --> 00:31:46.079 or therapist to retrain eye tracking, focusing 00:31:46.079 --> 00:31:49.319 and coordination, or vestibular rehabilitation 00:31:49.319 --> 00:31:51.819 exercises from a physio to help with balance 00:31:51.819 --> 00:31:54.859 and dizziness. These are active treatments, specific 00:31:54.859 --> 00:31:57.920 exercises, not just passive waiting. Is there 00:31:57.920 --> 00:32:01.220 any way to objectively know when someone's brain 00:32:01.220 --> 00:32:03.539 is ready for more vigorous exercise, especially 00:32:03.539 --> 00:32:05.339 if they've been struggling with symptom flare 00:32:05.339 --> 00:32:08.140 -ups? Yes. There's a useful tool called the Buffalo 00:32:08.140 --> 00:32:10.220 Concussion Treadmill Test. How does that work? 00:32:10.480 --> 00:32:12.819 It's a graded exercise test, usually on a treadmill, 00:32:13.380 --> 00:32:15.599 that helps determine the heart rate at which 00:32:15.599 --> 00:32:18.220 symptoms start to appear or worsen. It helps 00:32:18.220 --> 00:32:20.559 figure out a safe threshold for aerobic exercise. 00:32:20.720 --> 00:32:22.319 So you find their symptom threshold. Exactly. 00:32:22.700 --> 00:32:25.059 Then you can prescribe exercise just below that 00:32:25.059 --> 00:32:28.039 threshold. The goal is to gradually increase 00:32:28.039 --> 00:32:31.180 their exercise tolerance over time. Once a patient 00:32:31.180 --> 00:32:33.440 can exercise for about 20 minutes at a target 00:32:33.440 --> 00:32:35.880 heart rate, symptom free, for a few days in a 00:32:35.880 --> 00:32:38.059 row, they're generally considered physiologically 00:32:38.059 --> 00:32:40.319 recovered enough to handle more activity. Does 00:32:40.319 --> 00:32:42.359 that mean they're ready to play sport again? 00:32:42.859 --> 00:32:45.859 Not necessarily full contact sport. Physiological 00:32:45.859 --> 00:32:47.740 recovery doesn't always perfectly align with 00:32:47.740 --> 00:32:50.579 being ready for the cognitive demands and physical 00:32:50.579 --> 00:32:53.690 risks of competition. But... It's a key milestone. 00:32:54.210 --> 00:32:56.390 It allows them to get the benefits of safe aerobic 00:32:56.390 --> 00:32:59.349 exercise, which we know aids overall recovery. 00:32:59.730 --> 00:33:02.730 Okay. So pulling this all together beyond the 00:33:02.730 --> 00:33:05.430 specific exercises or medications, what's the 00:33:05.430 --> 00:33:08.650 big picture of you on managing concussion, especially 00:33:08.650 --> 00:33:11.210 when symptoms linger and really disrupt someone's 00:33:11.210 --> 00:33:13.849 life? The big picture, the absolute necessity, 00:33:14.329 --> 00:33:16.309 is that interprofessional team approach we mentioned 00:33:16.309 --> 00:33:18.609 earlier. It's not just helpful, it's essential 00:33:18.609 --> 00:33:21.150 for truly comprehensive holistic management. 00:33:21.250 --> 00:33:23.109 Remind us who's on that team again. It can be 00:33:23.109 --> 00:33:25.849 a wide range, depending on the patient's needs. 00:33:26.609 --> 00:33:29.369 Neurologists, neuropsychologists, physiotherapists, 00:33:29.650 --> 00:33:32.089 occupational therapists, speech and language 00:33:32.089 --> 00:33:34.829 pathologists, sometimes social workers, psychologists 00:33:34.829 --> 00:33:37.150 or psychiatrists, if mental health is a factor. 00:33:37.730 --> 00:33:40.390 They all need to work together. Why is that collaboration 00:33:40.390 --> 00:33:43.970 so crucial? Because it ensures all the different 00:33:43.970 --> 00:33:46.589 aspects of the person's recovery. The physical 00:33:46.589 --> 00:33:49.569 symptoms, the cognitive difficulties, the emotional 00:33:49.569 --> 00:33:52.710 impact, the social challenges, returning to work 00:33:52.710 --> 00:33:55.509 or school are all addressed at the same time 00:33:55.509 --> 00:33:58.710 in a coordinated way. The STATPRL source we looked 00:33:58.710 --> 00:34:01.490 at really emphasized how much populations like 00:34:01.490 --> 00:34:03.910 veterans and athletes benefit from this kind 00:34:03.910 --> 00:34:06.390 of integrated care. Are there specific programs 00:34:06.390 --> 00:34:08.750 that use this integrated approach? Yes, there 00:34:08.750 --> 00:34:10.670 are. For instance, studies have shown that programs 00:34:10.670 --> 00:34:13.610 like CogSmart, which combines cognitive rehabilitation 00:34:13.610 --> 00:34:16.110 training with support for returning to employment, 00:34:16.510 --> 00:34:19.090 can lead to quick recovery and fewer people developing 00:34:19.090 --> 00:34:21.929 post -concussion syndrome. This seems particularly 00:34:21.929 --> 00:34:24.210 helpful for veterans who might also have PTSD 00:34:24.210 --> 00:34:27.650 alongside the concussion. That integrated care 00:34:27.650 --> 00:34:29.550 is what makes the difference for long -term outcomes. 00:34:29.789 --> 00:34:32.329 So addressing those other conditions like depression 00:34:32.329 --> 00:34:35.489 or anxiety or PTSD is a really important part 00:34:35.489 --> 00:34:37.929 of concussion management, too. It's not just 00:34:37.929 --> 00:34:40.769 treating the head injury in isolation. Exactly 00:34:40.769 --> 00:34:43.869 that. Treating those comorbidities, the conditions 00:34:43.869 --> 00:34:46.889 happening alongside the concussion, significantly 00:34:46.889 --> 00:34:49.710 helps recovery from the concussion symptoms themselves. 00:34:50.039 --> 00:34:52.659 We know, for example, that getting people into 00:34:52.659 --> 00:34:55.539 controlled exercise early on helps prevent prolonged 00:34:55.539 --> 00:34:57.960 symptoms, partly because it reduces depression, 00:34:58.219 --> 00:35:00.519 anxiety, and sleep problems, which are all so 00:35:00.519 --> 00:35:04.659 common after concussion. It's a powerful non 00:35:04.659 --> 00:35:07.340 -drug intervention. And the other absolutely 00:35:07.340 --> 00:35:09.920 crucial factor both for preventing prolonged 00:35:09.920 --> 00:35:12.599 symptoms and for successful treatment is patient 00:35:12.599 --> 00:35:14.920 and family education. What kind of education? 00:35:15.119 --> 00:35:18.239 Setting realistic expectations is huge. Explaining 00:35:18.239 --> 00:35:19.900 that symptoms are often worse than the first 00:35:19.900 --> 00:35:22.440 week or two, but usually do improve. Busting 00:35:22.440 --> 00:35:24.860 myths, like the idea you need to lie in a dark 00:35:24.860 --> 00:35:26.940 room for weeks we know now that can be harmful. 00:35:27.239 --> 00:35:30.300 Empowering them with knowledge. Precisely. giving 00:35:30.300 --> 00:35:32.900 patients and their families accurate information, 00:35:33.420 --> 00:35:35.960 strategies they can use themselves, and confidence 00:35:35.960 --> 00:35:38.980 that recovery is possible. It shifts them from 00:35:38.980 --> 00:35:41.659 being passive sufferers to active participants 00:35:41.659 --> 00:35:44.460 in their own healing journey. That proactive 00:35:44.460 --> 00:35:49.280 mindset is key. Okay, so let's try and synthesize 00:35:49.280 --> 00:35:52.139 all of this. Thinking back to the Ontario study 00:35:52.139 --> 00:35:54.320 and everything else we've discussed, What are 00:35:54.320 --> 00:35:56.739 the main takeaways? What does this evolving landscape 00:35:56.739 --> 00:35:59.039 really mean for us? Well, it certainly brings 00:35:59.039 --> 00:36:01.099 us back to those surprising findings from the 00:36:01.099 --> 00:36:04.280 Ontario study. That direct comparison between 00:36:04.280 --> 00:36:07.239 the acute and PPCS groups really did throw up 00:36:07.239 --> 00:36:09.360 some counterintuitive results, didn't it? The 00:36:09.360 --> 00:36:11.400 ones about the traditional risk factor? Yes. 00:36:11.860 --> 00:36:14.440 The fact that sex, a history of mental health 00:36:14.440 --> 00:36:16.940 issues, and a history of headaches or migraines 00:36:16.940 --> 00:36:19.300 didn't show up as significantly more prevalent 00:36:19.300 --> 00:36:21.780 in the PPCS group compared to the acute group. 00:36:21.960 --> 00:36:24.019 especially when you think about that commonly 00:36:24.019 --> 00:36:26.539 quoted 10 -20 % progression rate. It challenges 00:36:26.539 --> 00:36:29.039 that idea, doesn't it? That only a small specific 00:36:29.039 --> 00:36:31.320 group with those factors is destined for long 00:36:31.320 --> 00:36:34.800 -term problems. It really does. It suggests the 00:36:34.800 --> 00:36:37.559 baseline vulnerability might be much brawner, 00:36:37.679 --> 00:36:40.639 more similar across many people who get a concussion, 00:36:40.880 --> 00:36:43.280 regardless of those specific pre -existing conditions. 00:36:44.179 --> 00:36:46.400 That fundamentally changes how we should think 00:36:46.400 --> 00:36:48.889 about identifying who's at risk. So we can't 00:36:48.889 --> 00:36:51.909 just tick those boxes, female, history of anxiety, 00:36:52.170 --> 00:36:54.289 history of migraines, and say, ah, high risk. 00:36:54.909 --> 00:36:57.750 It seems not. Based on this direct comparison, 00:36:58.349 --> 00:37:01.329 it really forces us to reevaluate how we identify 00:37:01.329 --> 00:37:04.010 people who might struggle. It suggests it's probably 00:37:04.010 --> 00:37:06.650 a much more complex interplay of factors rather 00:37:06.650 --> 00:37:08.429 than just a few simple predictors telling the 00:37:08.429 --> 00:37:10.909 whole story. But some factors did clearly stand 00:37:10.909 --> 00:37:13.150 out in the study as differentiating the groups. 00:37:13.469 --> 00:37:16.449 Yes, absolutely. Age was significant. Patients 00:37:16.449 --> 00:37:18.949 over 40 were at substantially higher odds of 00:37:18.949 --> 00:37:21.289 having prolonged symptoms. And the mechanism 00:37:21.289 --> 00:37:24.230 of injury, those transportation -related incidents 00:37:24.230 --> 00:37:26.449 carrying much higher odds, those are things we 00:37:26.449 --> 00:37:28.110 really need to pay close attention to right from 00:37:28.110 --> 00:37:30.010 the initial assessment. And the geographical 00:37:30.010 --> 00:37:33.590 finding. that finding about higher odds for PPCS 00:37:33.590 --> 00:37:36.050 outside the major metropolitan center, that really 00:37:36.050 --> 00:37:38.650 points towards potential access to care disparities. 00:37:39.289 --> 00:37:41.070 That needs looking at from a healthcare system 00:37:41.070 --> 00:37:43.150 perspective. It's not just about the individual 00:37:43.150 --> 00:37:45.250 patient. It's about the system they're navigating. 00:37:45.710 --> 00:37:47.469 Right. This deep dive has definitely painted 00:37:47.469 --> 00:37:50.510 a more complex, more nuanced picture of concussion 00:37:50.510 --> 00:37:53.250 than just a bump on the head. And it leaves us 00:37:53.250 --> 00:37:55.969 with a really important, maybe even provocative 00:37:55.969 --> 00:37:58.070 question for you, our listener, to think about. 00:37:59.010 --> 00:38:01.949 If that... commonly cited figure, that only 10 00:38:01.949 --> 00:38:04.590 -20 % of people develop persistent post -concussion 00:38:04.590 --> 00:38:07.590 symptoms, is actually, as some research hints, 00:38:07.789 --> 00:38:09.869 a significant underestimate, maybe closer to 00:38:09.869 --> 00:38:12.650 50 % in some real -world settings. What does 00:38:12.650 --> 00:38:14.409 that really mean? What are the implications for 00:38:14.409 --> 00:38:16.510 our healthcare systems, for our communities, 00:38:16.670 --> 00:38:18.969 for how we understand brain injury? It suggests 00:38:18.969 --> 00:38:21.369 a much larger burden than perhaps we've acknowledged. 00:38:21.599 --> 00:38:25.179 Exactly. This deep dive suggests many more people 00:38:25.179 --> 00:38:27.599 might be struggling with prolonged recovery, 00:38:28.000 --> 00:38:30.360 often without having those classic risk factors 00:38:30.360 --> 00:38:33.599 we used to focus on. So what more do we need 00:38:33.599 --> 00:38:36.039 to uncover about this sort of unseen burden? 00:38:36.440 --> 00:38:39.119 And how should this evolving understanding shape 00:38:39.119 --> 00:38:42.579 how we prevent, diagnose, and support the millions 00:38:42.579 --> 00:38:45.030 affected? It really pushes us towards thinking 00:38:45.030 --> 00:38:47.230 more holistically, doesn't it? Beyond single 00:38:47.230 --> 00:38:50.110 factors, towards more integrated care models 00:38:50.110 --> 00:38:52.469 that are accessible to everyone? Absolutely. 00:38:52.969 --> 00:38:54.809 Well, we really hope this deep dive has given 00:38:54.809 --> 00:38:57.429 you a fresh perspective and some valuable insights 00:38:57.429 --> 00:39:00.610 into the complex world of concussions and prolonged 00:39:00.610 --> 00:39:02.750 post -concussion symptoms. Hopefully some useful 00:39:02.750 --> 00:39:05.429 takeaways. If you did find this discussion illuminating, 00:39:05.530 --> 00:39:07.570 we'd be grateful if you could take a moment to 00:39:07.570 --> 00:39:09.710 rate and share this deep dive with your colleagues 00:39:09.710 --> 00:39:11.849 or anyone in your network who might benefit from 00:39:11.849 --> 00:39:14.170 these critical insights. Thanks for joining us. 00:39:14.309 --> 00:39:15.869 Thank you for joining us on the Deep Dive.