Welcome to the Deep Dive. We're the podcast where
we take stacks of dense information, really sift
through all the noise, and pull out the crucial
bits of knowledge, the surprising insights, so
you don't have to wade through it all yourself.
That's the plan. Today, we're diving into something
that affects millions, truly millions of lives
every year. But it's still often, well, quite
misunderstood. Concussions. We tend to think
of them, don't we, as just a bump on the head.
But the reality is, it's far more complex than
that. Absolutely. I mean, did you know, for instance,
that just in the US, somewhere between 1 .6 and
3 .8 million sports -related concussions get
reported each year? It's a staggering figure.
And that's just sports. If you look at Ontario,
in Canada between 2008 and 2016, over 1 % of
the entire population got a formal concussion
diagnosis each year. And the key point there
is formal diagnosis. Experts are pretty convinced
those numbers significantly underestimate how
common they actually are. So it's almost like
a hidden epidemic of the brain. And it goes way
beyond just athletes on a pitch. That's a really
crucial point to start with. Because the common
idea, you know, the one you see in films or here
in general chat, is that most people who get
a concussion, they'll just sort of shake it off.
Right. Back to normal in a few days. Exactly.
Back to baseline within days, maybe a couple
of weeks. But. As we'll unpack in this deep dive,
that's not the whole story, not by a long shot.
A significant number of people, probably far
more than we generally realize, go on to experience
what we call persisting post -concussion symptoms,
or PPCS. And these aren't just minor headaches
that linger. We're talking about a profound disruption
to someone's life. Symptoms can last for months.
sometimes even years, it can fundamentally change
how they function, day -to -day, their well -being.
It's serious. Okay, so that's our mission for
this deep dive, then, to get past those surface
-level ideas and really unpack the nuances. How
do we, whether we're healthcare professionals,
coaches, parents, or just trying to be informed,
how do we spot who might be at higher risk for
this prolonged recovery? And what does the latest
research, the really cutting -edge stuff, tell
us about how to manage this condition? Because
it is pervasive. Right. So we're going to draw
on quite a range of sources, comprehensive medical
overviews, some fascinating new scientific studies
coming out of Canada, and established sports
medicine guidelines. We'll sift through it all.
Exactly. The goal for you listening is to get
a rapid but really thorough grasp of this, hopefully
spark some aha moments, and move past the common
assumptions to a genuinely well -informed view
on concussions and this whole post -concussion
syndrome picture. Okay, so precisely. It's not
typically a structural injury you can see on
a CT or MRI. It's about how the brain is working.
And importantly, it's a specific type of mild
traumatic brain injury. or MTBI. Ah, okay. So
people use those terms interchangeably, MTBI
and concussion, but they're not quite the same.
Not technically, no. A concussion is really the
subset of MTBI. MTBI is the broader category,
which might include injuries with more structural
changes. A concussion, by definition, implies
this temporary functional disruption. Got it.
And the symptoms can vary quite a lot, can't
they? Hugely. From things that are very subtle,
maybe just feeling a bit off or foggy, to more
obvious periods of confusion or even brief laws
of consciousness, there's a whole spectrum. And
that timeline you mentioned earlier about how
long symptoms last, that seems absolutely critical
here. It really is. It helps us categorize things.
So we often talk about an acute concussion if
the symptoms resolve fairly quickly. Which is
typically how long? Generally within about 14
days, two weeks or so. But when those symptoms
stubbornly stick around for 90 days or more,
three months, That's when we start talking about
prolonged post -concussion symptoms, or PPCS.
90 days. That's the benchmark. It's a common
one? Yes. Although, it's worth noting, you sometimes
see slightly different timelines in the literature,
particularly for sports concussions, where persistent
symptoms might be defined as lasting longer than
four weeks. Right. But that distinction between
acute and prolonged, that's really important,
isn't it, for how you manage it? Absolutely vital.
Because the approach to care, the kind of resources
someone needs, their likely prognosis, it all
shifts quite dramatically once symptoms go beyond
that initial acute phase. And managing this,
especially the prolonged cases, it's not a one
-person job, is it? Definitely not. Effective
concussion care, particularly for PPCS, is inherently
interprofessional. It really does take a village.
Who's typically involved? Oh, a whole range.
Physicians, of course, but also physiotherapists,
neuropsychologists are key, occupational therapists,
sometimes speech and language therapists, social
workers. It's a team effort because the concussion
can impact so many different parts of a person's
life, physical, cognitive, emotional, social.
Okay, that makes sense. So you mentioned some
surprising research. Yes, this is where it gets
really interesting. As we unpack some of the
latest findings, especially from a big observational
study done right here in Ontario, you might find
some of the results, well, quite counterintuitive
actually. How so? Well, we're going to challenge
some perhaps deeply held assumptions about who's
most at risk for that prolonged recovery. For
instance, some factors that we've traditionally
thought were strong predictors for persistent
symptoms. Right. They might not hold up quite
as strongly when you directly compare people
with acute symptoms versus those with prolonged
ones. Really? And conversely, other factors,
maybe things that haven't been discussed as much,
seem to emerge as surprisingly significant. It
could really shift our understanding of who's
vulnerable and why. Okay, I'm intrigued now,
so we'll get into the nuts and bolts of that
study. We will. We'll explore the... the underlying
path of physiology to what's actually happening
in the brain. The metabolic changes, the structural
shifts at a cellular level after the injury,
and how knowing that is guiding new approaches.
And then the practical side, evaluation diagnosis.
Exactly. How do we effectively evaluate and diagnose
concussion? What does a structured evidence -based
recovery plan look like? including that crucial
graduated return to play protocol that's so vital
for athletes, but the principles apply more broadly
too. Okay, brilliant. It sounds like this conversation
might genuinely shift how we think about brain
injury and recovery. Let's dive in. Tell us about
this Ontario study. Right, so this study is titled,
Characterizing the Profiles of Patients with
Acute Concussion vs. Prolonged Post -Concussion
Symptoms. It was an observational study done
across multiple sites. Part of a bigger project?
Yes, part of a larger initiative called Connecting.
And they collected really rich, patient -reported
data from seven different concussion clinics
right across Ontario. And what's powerful about
that multi -site approach? It gives great diversity.
They included clinics that focused on sports,
others on acute care, and some tertiary care
centers. So it wasn't just looking at, say, elite
athletes or people only in central Toronto. Ah,
so a real mix. Geographically diverse, too. Exactly.
That geographical and functional mix is a real
strength. It gives us a much broader, more generalizable
picture of concussion in the real world, not
just in specific pockets, a much more comprehensive
view of who's getting concussions across different
settings. Makes sense. And how did they gather
the information? They were very thorough. They
collected a standardized set of data points from
everyone, usually at their first clinic visit
or within about two weeks of it. And who was
included? patients age 16 or older who had a
clinical diagnosis of concussion that lined up
with the Berlin Consensus Statement from 2017
is basically the gold standard internationally
for a diagnosis. And they had to be able to give
informed consent, obviously. Were there people
they specifically excluded? Yes. And that's important
for understanding the focus. They wanted to look
specifically at what we'd clinically call a concussion.
So. Anyone with abnormalities on CT or MRI scans,
anyone needing neurosurgery, or those with really
complex multiple injuries were out. Okay. Also
excluded were people with significant pre -existing
neurological or developmental issues, or if the
concussion -like symptoms were triggered by something
non -traumatic like a seizure or a migraine.
So they really narrowed it down to isolated,
traumatically induced concussions. Precisely.
That rigorous approach meant they could get clearer
insights into the recovery pathways specifically
for concussion without result being confounded
by more severe injuries or other conditions.
And then they split these participants into groups
for comparison. Yes, very cleverly for this analysis.
They created two distinct groups. First, the
acute concussion group people whose symptoms
had been around for 14 days or less. Okay, a
quick resolvers. Exactly. And second, the prolonged
post -concussion symptoms group, the PPCS group,
where symptoms had persisted for 90 days or more.
That three -month mark again? Right. And importantly,
to really sharpen the difference between those
two ends of the spectrum, they deliberately excluded
patients who were in the middle. The subacute
phase? Yes, those with symptoms between 15 and
89 days. Taking them out created a very clear
contrast between rapid resolution and genuinely
prolonged problems. It allowed for a much more
focused comparison. Right, that makes methodological
sense. What sort of data did they actually collect
on these people? It sounds like a lot. It was
incredibly comprehensive. They went way beyond
just basic demographics like sex and age. They
looked at marital status, education level, geographic
region where people lived, ethnicity, even annual
household income. So, a rich socioeconomic picture.
And injury details. Absolutely. Not just when
the injury happened, but how the mechanism of
injury. Now, obviously, how many days have passed
since the injury when they were assessed. What
about their medical background? A deep dive there,
too. Any prior concussions, other medical conditions
happening at the same time, vascular risk factors,
history of chronic pain, any developmental disorders.
And critically, they gather detailed information
on any history of mental health disorders and
any pre -existing problems with headaches or
migraines. Those are often cited as risk factors,
aren't they? They are indeed. They also looked
at healthcare use, how often people had been
to A &E, their GP, or seen rehabilitation specialists.
It was a truly holistic data set, capturing a
huge range of potential influences. And they
used standardized tools for assessing symptoms,
I assume, to keep things consistent? Yes, absolutely.
They used established measures, for instance,
the Sketney 5, the sport concussion assessment
tool. I've heard of that one. It's widely used.
It helps assess 22 common concussion symptoms
across different areas, physical, cognitive,
emotional fatigue. So things like headache, dizziness,
feeling foggy, irritability. Exactly, those kinds
of things. They also used the Sheehan Disability
Scale. What does that measure? That's a really
useful tool because it gets at the patient's
perception of their disability, how much the
symptoms are actually impacting their life, looking
at things like days lost from work or school,
and also days underproductive, where they might
be physically present, but just not functioning
at their usual capacity. Ah, OK. So it gives
quantifiable measures for what can feel like
a very subjective experience for the patient.
Precisely. These tools provide objective data
points. So this brings us to the study's main
goal and where you said the surprising findings
came in. Yes, this is where it really challenges
some common assumptions. The researchers initially
wanted to see if patients in the acute group
and the PPCS group differed significantly on
four specific factors, often flagged as key risk
predictors for prolonged symptoms. Which were?
Sex, having a history of mental health disorders,
having a history of headaches or migraines, and
having had previous concussions. OK, those are
the ones you often hear about. Exactly. And the
prevailing wisdom, the sort of statistic often
quoted, is that maybe only 10 % to 20 % of acute
concussions go on to become persistent. Right.
So based on that, you'd logically predict that
these known risk factors, mental health issues,
migraines, maybe being female, previous concussions
would be much more common in the PPCS group.
They should stand out as clear warning signs.
That makes sense. So what did they actually find?
Did those factors show up more in the prolonged
group? Well, this is the kicker. Quite remarkably,
And actually, contrary to what many would expect,
and indeed, contrary to the study's own initial
hypothesis, they found no statistically significant
differences between the acute group and the PPCS
group for history of mental health disorders,
pre -existing headache, or migraine history,
or sex. No difference at all. No statistically
significant difference. Let me give you the numbers.
They're quite striking. In the acute group, 37
.3 % had a history of mental health disorders.
In the PPCS group, 37 .9%. Virtually identical.
Wow. And for sex. The acute group was 61 .1 %
female. The PPCS group was 66 .3 % female. Again,
when you analyze the statistics across the whole
large group, that difference wasn't significant.
That really is eye -opening, because it seems
to fly in the face of that idea that these factors
single out the 10 -20 % who will struggle long
term. It does. It strongly implies that the baseline
vulnerability may be linked to these factors,
might be much more similar across everyone who
sustains a concussion rather than just predisposing
a small minority to poor outcomes. So what does
that mean practically for a doctor seeing a patient
or a coach? It means you can't just look at someone,
see they don't have a history of anxiety or migraines,
and assume they're automatically low risk for
prolonged symptoms. It suggests we need to perhaps
focus more on the injury itself, the immediate
symptoms, rather than relying too heavily on
these pre -existing conditions as definite predictors
of a long recovery versus a short one. Okay.
What about previous concussions? That's almost
always mentioned as a big risk factor. That also
showed no significant difference between the
two groups in this study. Really? Why might that
be? Well, the study offers a thoughtful explanation.
A history of concussions is a known risk factor,
yes, but it's a risk factor not just for developing
persistent symptoms after a new injury, but also
for sustaining another concussion in the first
place. Ah, I see. So... People in both groups
might be equally likely to have had prior concussions
just by virtue of having had a concussion now.
Exactly. It might be a characteristic shared
by many people who seek care for concussion,
whether their current symptoms resolve quickly
or not. It highlights how tricky it is to interpret
risk factors. Are they predicting future problems
or just describing the population already affected?
It's about the nuance of how these factors operate
over time. Okay, so if those factors, mental
health, migraine, sex, prior concussions, weren't
the clear dividing lines between the acute and
prolonged groups, what did stand out? What did
differentiate them? This must be where the study's
secondary aim comes in. Precisely. When they
look at the broader demographic and injury profiles,
some clear and potentially actionable differences
did emerge. Like what? Age was a big one. The
PPCS group was significantly older, on average,
than the acute concussion group. Much older.
The average age for the acute group was 32. For
the PPCS group, it jumped quite substantially
to 44. 12 years difference on average. Yes. And
when they looked at age categories, the odds
of being in an older age group, particularly
40, 49, 50, 59, and especially 60 plus, were
significantly higher for people with PPCS compared
to those aged 29 or younger. How much higher?
Dramatically higher for the oldest group. The
odds of someone age 60 or over being in the PPCS
group were over nine and a half times higher
than for someone under 30. Nine and a half times,
that's huge. So middle and older age really seems
to be a significant factor for prolonged symptoms.
This study strongly suggests so, yes. It challenges
older ideas that maybe age wasn't such a major
factor. Why might older age lead to slower or
less complete recovery? Is it biological? Well,
one common theory revolves around something called
cognitive reserve. Like the brain's backup capacity.
Sort of, yes. Think of it as your brain's ability
to cope with damage or stress. Maybe it's efficiency
or flexibility. As we age, that reserve might
naturally decrease a bit. So the brain just have
less capacity to compensate for an injury and
recover as efficiently as a younger brain might.
So it's less resilient to the disruption. Potentially,
yes. While not all previous studies have found
such a strong link, this large real -world comparison
in Ontario really points to age, especially being
40 or older, as significantly impacting how recovery
unfolds. It also makes you think about how age
interacts with other things, like education level,
which might influence your cognitive baseline
before the injury even happens. Okay, so age
is a major differentiator. What else stood out?
The way the injury happened, the mechanism of
injury, that was another critical finding. How
so? Transportation -related incidents, so car
crashes, bike accidents, motorcycle collisions,
were significantly more common in the PPCS group.
Very much so. The odds of having had a transportation
-related injury were four and a half times higher
in the PPCS group compared to the acute group
when you compare them against injuries caused
by falls or falling objects. Four and a half
times. Again, that's a massive difference. Why
would being in a crash make prolonged symptoms
so much more likely? Is it just the force involved?
That's likely part of it, certainly. The forces
in those types of collisions can be greater and
more complex. Think about the rapid acceleration
and deceleration. That can lead to more widespread
sort of shearing forces within the brain tissue.
But is it only physical? Probably not entirely.
There's also the significant psychological stress
and emotional trauma that often comes with being
in a serious accident. Post -traumatic stress.
Exactly. We know there's a considerable overlap
between symptoms of PTSD and persistent concussion
symptoms. And then there's another layer. That's
right. Litigation. Involvement in insurance claims
or legal proceedings, which is pretty common
after road traffic accidents, has also been consistently
linked with persistent symptoms. Ah, so it's
a complex mix, the physical injury, the psychological
impact, maybe even the stress of legal battles.
Precisely. It creates this really complicated
interplay that can definitely hinder and prolong
the recovery process. It's not just a bang on
the head, it's an event. with potentially wide
-ranging consequences. That makes a lot of sense.
Okay, so we have age and mechanism of injury
as clear differentiators. You mentioned geography
earlier, did where people lived show any differences?
Yes, and this pointed towards potential issues
around access to care. The geographic data showed
that patients in the PPCS group were significantly
more likely to live outside of metropolitan Toronto.
Really? In the surrounding region? Yes. The odds
of living in central Ontario, southwestern Ontario,
or other more rural or semi -urban areas were
significantly higher, around four to four and
a half times higher, for patients with PPCS compared
to those living right in Toronto. That's fascinating.
What might that be telling us? Is care better
in Toronto, or is something else going on? Well,
it raises really important questions about equitable
access to specialized concussion care. It's possible
that while Toronto, being densely populated,
might have long waiting lists for specialist
care. One study mentioned an average wait of
10 months for tertiary MTBI care there. Ten months.
Wow. Conversely, it could also mean that patients
outside the major city center just have fewer
options nearby, fewer specialist clinics, less
access to that interprofessional expertise needed
for complex cases. So if they can't get the right
help quickly enough, the symptoms might just
drag on. That's a plausible hypothesis. A lack
of timely, appropriate intervention closer to
home could contribute to symptoms becoming prolonged.
It really highlights a potential systemic issue.
How does location affect concussion care? We
need to look deeper into resource allocation
across different regions. Okay, that's a really
important system level point. Now, what about
the symptoms themselves? The study used the SCAT
T5. Did the PPCS group just have symptoms for
longer, or were the symptoms themselves different
or more severe? They were definitely more severe.
While both groups obviously had symptoms, the
PPCS group consistently reported significantly
higher perceived symptom severity across all
the SCET T5 domains. The fatigue, emotional,
cognitive, and somatic physical symptoms. So
more intense symptoms across the board. Yes.
For example, fatigue symptoms were much more
prevalent in the PPCS group. And fatigue often
goes hand in hand with emotional symptoms and
sleep problems after concussion. And emotional
symptoms like anxiety or irritability. Those
also tend to increase months after the injury
in people with prolonged issues, which aligns
with what this study found. It suggests a much
more pervasive and debilitating cluster of symptoms
in those who don't recover quickly. What about
the cognitive ones that brain fog people describe,
the trouble concentrating or remembering? Again,
consistent with other research. While cognitive
problems often get better relatively quickly
in acute cases, maybe within days, they can unfortunately
persist for years and people with PPCS. That
must have a huge impact on daily life, work,
study. Absolutely massive. And similarly, those
physical or somatic symptoms like chronic headaches,
persistent dizziness, that awful sensitivity
to light or noise, they were also significantly
more common and severe in the PPCS group. Are
any particular symptoms early on seen as predictors?
Yes. Reporting a high number of somatic symptoms,
especially headaches, right in the acute phase
after the injury is often considered one of the
better predictors that symptoms might persist
for longer. It shows how all these different
symptom types, physical, emotional, cognitive,
can weave together into this complex challenge
for patients. Makes it really hard to treat sometimes.
It really sounds like getting the right evaluation
and management right from the start could make
a big difference. Can we talk a bit about the
overall approach to assessing and managing concussions?
What are the key steps, whether it's an athlete
or someone from that car accident? Yes, absolutely.
The foundation, the absolute cornerstone, is
a thorough history and physical examination.
What does that involve? You need every detail
about the injury, how it happened, the forces
involved, was there any loss of consciousness,
however brief, and critically, any previous injuries.
Then, a detailed past medical history is vital.
Checking for those potential influencing factors.
Exactly. Previous headaches, migraines, any history
of depression, anxiety, chronic pain, dizziness.
These can all shape the recovery path, even if,
as the Ontario study showed, they didn't perfectly
distinguish the acute from the prolonged group
in that comparison. And the physical exam. A
full neurological assessment, checking cranial
nerves, vision, reflexes, muscle strength, proprioception.
That's your sense of where your body parts are
and sensation. It's about building that complete
clinical picture. For athletes, there's often
that immediate sideline check. What's crucial
there? That immediate sideline evaluation is
critical in sport. First priority is the primary
survey checking, airway, breathing, circulation,
the absolute basics. And crucially, looking for
any sign, any sign of a spinal cord injury. Neck
pain, altered sensation. Yes. If an athlete's
mental state is off or they complain of neck
pain, you must assume a cervical spine injury
until it's proven otherwise. Safety first. Are
there immediate red flags that mean straight
to hospital? Definitely. Things like a deteriorating
level of consciousness, a really severe headache
that keeps getting worse, any new focal neurological
deficits like weakness on one side, those warrant
immediate emergency transport for urgent brain
imaging. And assuming none of those red flags,
what happens next on the sideline? Then you move
to the secondary survey, focusing specifically
on cognitive function and those classic concussion
symptoms. The absolute rule here, the non -negotiable,
is that any athlete showing any signs or symptoms
suggestive of a concussion must be removed from
play immediately. No finishing the half. Absolutely
not. No return to play on the same day, full
stop. Their health is paramount. Far more important
than the game. And that's where tools like the
Scatty 5 come in useful again. Precisely. The
Scatty 5 is designed for that situation. It's
standardized, widely used for athletes age 13,
and up there's a child Scat 5 for younger ones
too. What does it involve? It has components
for immediate on -field assessment, looking for
visible signs, asking quick memory questions
like the Maddox questions, using the Glasgow
Coma Scale for consciousness level. And then
off the field? Yes. Ideally in a quiet, private
space. There's the standard assessment of concussion,
the SAC, test checking orientation, memory, concentration.
There's also the BSS test, the balance error
scoring system to objectively measure balance,
which is often affected. Are there other tools
used? Yes, things like the impact test. which
is computer -based. It looks at verbal and visual
memory, processing speed, reaction time. Often
you compare the athletes' post -injury scores
to their own baseline scores taken before the
season started. Ah, having that baseline is helpful.
Very. And the King -Devick test is another one,
looking at eye movements and concentration by
having the athlete read numbers quickly. These
tools give objective data to help the clinician
make informed decisions. So lots of assessment
tools. What about brain scans, CTs, MRIs? You
said earlier they don't diagnose concussion itself,
but when are they needed? That's a really common
point of confusion. Yeah. You're right. Generally,
advanced imaging like CT or MRI is not needed
to diagnose a concussion. Remember, it's primarily
functional. Most scans will be normal. Okay.
But imaging is absolutely essential in acute
head trauma if those red flags we mentioned pop
up. deteriorating status of your headache, focal
signs? Exactly, or a suspicion of a neck injury.
In an emergency setting, a CT scan is usually
the first choice. It's quick and good for ruling
out skull fractures, bleeding inside the head,
intracranial hemorrhage, or brain bruises, contusions.
And MRI, when would that be used? MRI gives much
more detailed pictures of the brain tissue itself.
It can pick up more subtle structural damage.
Specialized sequences like diffusion -weighted
imaging are particularly sensitive to the shearing
injuries we talked about. Can it show functional
changes, too? Functional MRI, or fMRI, can actually
show changes in blood flow patterns in the brain,
that cerebrovascular reactivity, especially in
the acute phase. And if symptoms are really dragging
on, say for more than a month, an MRI might be
done later to make sure there isn't some other
underlying neurological issue mimicking the concussion
symptoms. Okay, so imaging has a role, but it's
more about ruling out other serious problems,
not diagnosing the concussion itself. Precisely.
Diagnosis is primarily clinical, based on the
history and examination. Right. Let's talk about
treatment, then. The old advice used to be just
rest, dark room, do nothing. Has that changed?
Oh, massively. Our understanding has really evolved.
The initial step is still immediate removal from
whatever activity caused the injury or makes
symptoms worse. And definitely no same -day return
to play or demanding activity. But not weeks
of bed rest. No, absolutely not. For acute concussions,
the current recommendation is actually a very
brief period of relative cognitive and physical
rest, typically just 24 to 48 hours. Just one
or two days. Yes. This is not strict bed rest
in a dark room. We now know that prolonged complete
rest can actually be detrimental. It can lead
to worse outcomes, more anxiety, depression,
and even prolonged physical symptoms. So what
does relative rest mean then? It means minimizing
activities that actively provoke or worsen symptoms.
So maybe reducing screen time, avoiding noisy
environments, not doing strenuous physical exercise
right at the start, just taking it easy initially.
And then what? Then, that short period of initial
symptom limited rest should be followed quite
quickly by starting a carefully structured and
supervised graduated return to activity protocol.
This is fundamental to good recovery. Ah, yes,
the graduated return to play protocol. That sounds
key, especially for athletes, but you said the
principles apply more broadly. They do. It's
relevant for students returning to school, people
returning to demanding jobs. It's a structured
step -by -step approach to systematically reintroduce
physical and cognitive challenges. How does it
work? How gradual is it? Typically, each stage
lasts at least 24 hours. So assuming someone
stays symptom -free at each step, it usually
takes about a week to get through the whole protocol
and be cleared for full return to sport. A week
minimum. And why is that stepwise approach so
important? It's vital because it allows the brain
time to adapt and heal while gradually increasing
the demands placed upon it. It helps prevent
symptoms flaring up badly and reduces the risk
of getting re -injured by doing too much too
soon. Can you walk us through the stages? Sure.
It usually goes something like this. Stage one
is symptom limited activity. basically daily
activities that don't provoke symptoms. The aim
is rest from demanding tasks, less screen time,
quiet environments, maybe life's cool or work
activities if tolerated. Okay, taking it easy.
Stage two is light aerobic exercise. Once they're
symptom -free at rest, they can start things
like walking, swimming, gentle stationary cycling,
keeping the heart rate fairly low, say below
70 % of maximum, no resistance training yet.
The goal is just to increase heart rate gently
without symptoms. This actually helps brain blood
flow and recovery. Right, so activity isn't bad
if it's the right kind. Exactly. Stage three
is sport -specific exercise. More dynamic movements
now, like running drills, skating for hockey
players, throwing. Still no head impact activities
though, adding movement and agility back in.
Getting closer to the sport. Stage four is non
-contact training drills. More complex training
here. passing drills, team plays, starting some
progressive resistance training perhaps, building
exercise tolerance, coordination, cognitive load
of practice, but still no contact. Crucially,
no contact yet. Stage five is full contact practice.
This is the big step before competition. Returning
to normal training, including contact drills
appropriate for the sport, all done in a controlled
practice setting. It's about restoring confidence
and checking skills under pressure. Stage 6 is
full return to play. If and only if the individual
is completely symptom -free through all those
stages and gets clearance from a healthcare professional,
then they can return to normal games or competition.
And what if symptoms come back during one of
the stages? That's the key rule. If symptoms
return at any stage, you drop back to the last
stage where you were completely symptom -free,
rest for another 24 hours, and then try progressing
again. So listen to your body. Don't push through
symptoms. Absolutely. This patient systematic
approach is what really minimizes the risk of
prolonged problems or getting hurt again. That's
a really clear framework. What about people whose
symptoms do persist beyond that acute phase?
Someone in the PPCS group, for instance. Are
there more specific therapies beyond just gradual
activity? Yes, definitely. When symptoms persist,
the approach needs to become much more targeted.
And that interprofessional team really comes
into play. What kind of targeted therapies? Well,
medications might be considered for specific
symptoms. For persistent headaches, maybe low
-dose amitriptyline, which works on nerve pain,
or something like sopranolol, if migraines are
a feature. And for the dizziness or visual problems
people often get. Those are incredibly common
and disabling. There are specific screening tools
to pinpoint the cause. Is it the inner ear, the
stabler system, eye movements, ocular motor,
or maybe neck issues contributing? And based
on that, based on the findings, you get active
therapies, things like cervical physiotherapy
for neck pain and stiffness, specific vision
therapy exercises prescribed by an optometrist
or therapist to retrain eye tracking, focusing
and coordination, or vestibular rehabilitation
exercises from a physio to help with balance
and dizziness. These are active treatments, specific
exercises, not just passive waiting. Is there
any way to objectively know when someone's brain
is ready for more vigorous exercise, especially
if they've been struggling with symptom flare
-ups? Yes. There's a useful tool called the Buffalo
Concussion Treadmill Test. How does that work?
It's a graded exercise test, usually on a treadmill,
that helps determine the heart rate at which
symptoms start to appear or worsen. It helps
figure out a safe threshold for aerobic exercise.
So you find their symptom threshold. Exactly.
Then you can prescribe exercise just below that
threshold. The goal is to gradually increase
their exercise tolerance over time. Once a patient
can exercise for about 20 minutes at a target
heart rate, symptom free, for a few days in a
row, they're generally considered physiologically
recovered enough to handle more activity. Does
that mean they're ready to play sport again?
Not necessarily full contact sport. Physiological
recovery doesn't always perfectly align with
being ready for the cognitive demands and physical
risks of competition. But... It's a key milestone.
It allows them to get the benefits of safe aerobic
exercise, which we know aids overall recovery.
Okay. So pulling this all together beyond the
specific exercises or medications, what's the
big picture of you on managing concussion, especially
when symptoms linger and really disrupt someone's
life? The big picture, the absolute necessity,
is that interprofessional team approach we mentioned
earlier. It's not just helpful, it's essential
for truly comprehensive holistic management.
Remind us who's on that team again. It can be
a wide range, depending on the patient's needs.
Neurologists, neuropsychologists, physiotherapists,
occupational therapists, speech and language
pathologists, sometimes social workers, psychologists
or psychiatrists, if mental health is a factor.
They all need to work together. Why is that collaboration
so crucial? Because it ensures all the different
aspects of the person's recovery. The physical
symptoms, the cognitive difficulties, the emotional
impact, the social challenges, returning to work
or school are all addressed at the same time
in a coordinated way. The STATPRL source we looked
at really emphasized how much populations like
veterans and athletes benefit from this kind
of integrated care. Are there specific programs
that use this integrated approach? Yes, there
are. For instance, studies have shown that programs
like CogSmart, which combines cognitive rehabilitation
training with support for returning to employment,
can lead to quick recovery and fewer people developing
post -concussion syndrome. This seems particularly
helpful for veterans who might also have PTSD
alongside the concussion. That integrated care
is what makes the difference for long -term outcomes.
So addressing those other conditions like depression
or anxiety or PTSD is a really important part
of concussion management, too. It's not just
treating the head injury in isolation. Exactly
that. Treating those comorbidities, the conditions
happening alongside the concussion, significantly
helps recovery from the concussion symptoms themselves.
We know, for example, that getting people into
controlled exercise early on helps prevent prolonged
symptoms, partly because it reduces depression,
anxiety, and sleep problems, which are all so
common after concussion. It's a powerful non
-drug intervention. And the other absolutely
crucial factor both for preventing prolonged
symptoms and for successful treatment is patient
and family education. What kind of education?
Setting realistic expectations is huge. Explaining
that symptoms are often worse than the first
week or two, but usually do improve. Busting
myths, like the idea you need to lie in a dark
room for weeks we know now that can be harmful.
Empowering them with knowledge. Precisely. giving
patients and their families accurate information,
strategies they can use themselves, and confidence
that recovery is possible. It shifts them from
being passive sufferers to active participants
in their own healing journey. That proactive
mindset is key. Okay, so let's try and synthesize
all of this. Thinking back to the Ontario study
and everything else we've discussed, What are
the main takeaways? What does this evolving landscape
really mean for us? Well, it certainly brings
us back to those surprising findings from the
Ontario study. That direct comparison between
the acute and PPCS groups really did throw up
some counterintuitive results, didn't it? The
ones about the traditional risk factor? Yes.
The fact that sex, a history of mental health
issues, and a history of headaches or migraines
didn't show up as significantly more prevalent
in the PPCS group compared to the acute group.
especially when you think about that commonly
quoted 10 -20 % progression rate. It challenges
that idea, doesn't it? That only a small specific
group with those factors is destined for long
-term problems. It really does. It suggests the
baseline vulnerability might be much brawner,
more similar across many people who get a concussion,
regardless of those specific pre -existing conditions.
That fundamentally changes how we should think
about identifying who's at risk. So we can't
just tick those boxes, female, history of anxiety,
history of migraines, and say, ah, high risk.
It seems not. Based on this direct comparison,
it really forces us to reevaluate how we identify
people who might struggle. It suggests it's probably
a much more complex interplay of factors rather
than just a few simple predictors telling the
whole story. But some factors did clearly stand
out in the study as differentiating the groups.
Yes, absolutely. Age was significant. Patients
over 40 were at substantially higher odds of
having prolonged symptoms. And the mechanism
of injury, those transportation -related incidents
carrying much higher odds, those are things we
really need to pay close attention to right from
the initial assessment. And the geographical
finding. that finding about higher odds for PPCS
outside the major metropolitan center, that really
points towards potential access to care disparities.
That needs looking at from a healthcare system
perspective. It's not just about the individual
patient. It's about the system they're navigating.
Right. This deep dive has definitely painted
a more complex, more nuanced picture of concussion
than just a bump on the head. And it leaves us
with a really important, maybe even provocative
question for you, our listener, to think about.
If that... commonly cited figure, that only 10
-20 % of people develop persistent post -concussion
symptoms, is actually, as some research hints,
a significant underestimate, maybe closer to
50 % in some real -world settings. What does
that really mean? What are the implications for
our healthcare systems, for our communities,
for how we understand brain injury? It suggests
a much larger burden than perhaps we've acknowledged.
Exactly. This deep dive suggests many more people
might be struggling with prolonged recovery,
often without having those classic risk factors
we used to focus on. So what more do we need
to uncover about this sort of unseen burden?
And how should this evolving understanding shape
how we prevent, diagnose, and support the millions
affected? It really pushes us towards thinking
more holistically, doesn't it? Beyond single
factors, towards more integrated care models
that are accessible to everyone? Absolutely.
Well, we really hope this deep dive has given
you a fresh perspective and some valuable insights
into the complex world of concussions and prolonged
post -concussion symptoms. Hopefully some useful
takeaways. If you did find this discussion illuminating,
we'd be grateful if you could take a moment to
rate and share this deep dive with your colleagues
or anyone in your network who might benefit from
these critical insights. Thanks for joining us.
Thank you for joining us on the Deep Dive.