Getting a-head of concussions

Transcript

Transcript

[Pulse sound]

[Music]

Megan Beahen: Hi and welcome to Healthy Canadians, your space for nuanced conversations and expert insights about the health topics that matter to all of us. I'm your host, Megan Beahen. Today I’m talking about concussions with Dr. Ryan D’Arcy, Co-Founder of HealthTech Connex Inc., and professor at Simon Frasier University, as well as Stephanie Cowle, Director of Knowledge Translation at Parachute. We’re going to talk about prevention, risk, treatment and what headway they’re making in this field.
Although Healthy Canadians is brought to you by Health Canada and the Public Health Agency of Canada, what we discuss won't always reflect the official positions or policies of the Government of Canada, but that's okay. These are conversations, not news releases.
Okay, let’s talk about concussions.

[Pulse sound]

Megan: Hi Stephanie and Ryan, thanks for joining me today.

Stephanie Cowle: Hi Megan.

Ryan D'Arcy: Hi Megan, thanks for having us.

Megan: Okay so I will admit I have never had a concussion myself, but I think we all know people who have had them, and it seems like lately I'm hearing more and more about concussions. Are there more concussions happening now or is it a bigger problem, or are we just understanding more and hearing about it more now? I'll throw it to Ryan first.

Ryan: Yes, I think there are, the prevalence of concussions are going up over the last while. It depends on how you kind of look at it but it's roughly around 10%, it can be in childhood like 5%, and then when you look over your lifespan it can rise up to about 20%.

Megan: Wow as in like 10% of children have had concussions?

Ryan: The estimates vary but that's a good number to use as a ballpark, yeah.

Megan: That's pretty high. And so that's increased in Canada?

Ryan: There is a trend right now that suggests that it is increasing, yes. But that's certainly just a trend in current times, we're always trying to get them to decrease.

Stephanie: It's true but there is also increased awareness and so we know that there are more people going to get concussions checked out. So, when we look at emergency department visits and we see those increasing I think the kind of sense is that it's a bit of both. But awareness is really contributing to people going to the doctor.

I know that in Ontario when we look at some of the changes since there's been concussion legislation in the province and more awareness, we saw kind of a spike in visits to emergency departments and doctor's offices that's starting to plateau now, which is a great thing. Hopefully we've kind of reached that peak where there's new cases, increased awareness, and hopefully we'll keep level or go down from here.

Ryan: Yeah, it's a really good point, and also another point on that- one emergency physician that I've worked with quotes "if you think you have a concussion you probably do". So, I think the threshold of where we're defining concussions is also increasing a bit and driving that, so we now even talk about the concept of subconcussive impacts...

Megan: Oh wow.

Ryan: ... which aren't an official diagnosis of concussion but are actually exposure to concussive impacts.

Megan: Okay, that's a good takeaway. We might need to repeat that again before the end of the episode, if you think you have a concussion you probably do. So, who is most likely to get concussions? Obviously, we know like in sports it's more likely. Are there certain sports where people are having head trauma? Are there certain people or parts of life where people are more apt to get a concussion?

Ryan: Stephanie that sounds like one for you.

Stephanie: Yeah I'm happy to start there. So, when we look at rates of concussion overall from all causes, we're more likely to see higher rates in young children, likely under the age of six and older adults, so those you know 65 and older. And then we also, again, see high rates in youth, so it really is across the lifespan.

When we dig into certain causes of concussion by age group that's where we start to see a lot of differences. So, youth maybe around 10 to 19 years old are most likely to get a sport and recreation related concussion. Older adults and young kids are most likely to get a fall related concussion, so it is really important that we look at different populations and how concussions are happening and see how different people are affected.

Ryan: Absolutely. The other two categories are motor vehicle accidents and, in fact, in terms of looking at where the research activities are directed, in addition to that would be partner abuse as well.

Megan: Oh, wow okay. So, a variety of reasons and causes. And what happens when you get a concussion, like what physically happens? I'll throw it to Ryan first.

Ryan: Yeah, so to break it into the basics, your brain is this incredibly sophisticated and fragile supercomputer that resides between your ears. And it's encased in your skull which is not only hard and bony but it actually internally it has kind of- it's not smooth inside. So, when you sustain a hit to your head, your brain moves back and forth, and a number of things happen.

Number one, it can actually impact your skull both in the forward motion and the backward motion, but it also can sort of tear and shear the fibers, both from that that sort of shift and also from the rotation. So, what we want to do is reduce any, basically the bottom line is, any impacts to your head cause sort of a translation of an impact to your brain and we want to reduce that.

Megan: How would I know if I had a concussion? What are the symptoms? I keep hearing stories of people who are only finding out way later they had one, or perhaps some of the symptoms were like a bit sneaky and they didn't notice them right away. What are the common things to look out for?

Stephanie: Well you know sorry Ryan so nicely explained the brain as being this complex computer. So, we've probably learned early on in your school years what the brain does, and it does everything. So, think about the brain controlling everything: your vision, your memory, your personality, your mood, your concentration, your balance and movement, all of those things. So, a concussion is an injury to the way the brain is working, which means all those things could potentially be affected.

So, you can have physical symptoms, like a headache. You can have emotional symptoms, thinking symptoms, and it can even affect your sleep. Now not everyone with a concussion is going to get all these things. You could get one symptom; you could get many symptoms. So, a lot of doctors that we work with in this space say if you've seen one concussion, you've seen one concussion. It can come out in so many different ways.

So, it is really important, one of the most critical things we want people to be able to do is know and learn many of the signs and symptoms of concussions so that you can recognize it in yourself or someone else. That's something that absolutely everyone can do to help make a difference. And we know which symptoms are most common. So, the most commonly reported symptom is headache or feeling pressure in your head, and the second most common is dizziness.

Megan: And would you feel the symptoms right away?

Ryan: You can. What we tend to look for right away would be things like if you if you had an alteration in consciousness, or a loss of consciousness, that's certainly something that would put a flag up. Another thing would be if you had problems with your memory, your immediate memory around the event, that would definitely be something that we would be concerned about.

And in general if you've hit your head we're also concerned immediately whether or not that's caused bleeding inside your skull and so that's why the recommendation is if you have a concern for a concussion, seek medical advice right away so that some of these very sort of critical aspects can be ruled out. And then after that the question usually shifts to whether or not you experience symptoms over a longer period of time. Because symptoms will generally resolve, but if they don't resolve then that's where to continue to sort of seek medical help and guidance.

Stephanie: And those symptoms can come up right away, but they can also be delayed. So, we generally say watch for up to 48 hours to see if symptoms appear. I'm fortunate that I've only had one concussion. I call myself fortunate because I know we hear it's so common. And it was almost 24 hours later that I really started to get a headache and all of a sudden started to get worse. So, it really can take a bit of time, so we don't want to rush dismissing the notion that you might have a concussion.

Megan: That's good advice. So, if you did hit your head, you had some of these symptoms, advice is to go see a health care provider. I also want to pick up on what you said Stephanie about, like friends and family involvement. Like you want to look out for yourself but if you know a friend or family member who got in the head you want to look at those symptoms and signs as well right? For your loved one.

But when you see a healthcare provider what are the types of treatment? And I feel like the treatment is quite wide and varied, but Ryan maybe you could jump in and talk a little bit about what are the typical treatments someone might see?

Ryan: Sure. Concussion's actually quite frustrating from a health care provider perspective. If for example you end up in the emergency with a concussion, one of the first things that typically a provider would be thinking about is getting some sort of brain scan, like a CT scan, really if they're concerned to rule out that there's bleeding in your brain. Bleeding in your brain can turn quite serious quite quickly, so that's kind of one of the very first things that tends to be looked at.

It's also to understand the severity of it. So, if for example they see that there's signs of a greater extent of injury. The way we identify concussion, it actually formally falls in what we call mild traumatic brain injury. And mild traumatic brain injury is on a spectrum of traumatic brain injury, so you can have mild, moderate or severe. So often a provider, if you've landed in the emergency, is really trying to understand "is this mild. moderate or severe? And is there anything that's immediately life-threatening?"

Above and beyond that it gets very frustrating from a from a treatment point of view because there's historic sort of treatment, and then there's what's becoming increasingly more kind of contemporary treatment. We now know that, for example, recovery within the next 48 hours is important but it also used to be that the idea was to limit your activity and maybe stay in a dark room...

Megan: Yeah, that's what I was just going to say, don't you stay in a dark room?

Ryan: Yeah, now that's actually being overwritten.

Megan: Oh wow.

Ryan: We actually for example know that exercise can be quite good for you if it's non-impact-based exercise, and that you want to kind of return to your activities in a way that is not necessarily exacerbating. So, for example, if your headaches get worse, you stop. But you would try a gradual return to your activity or your sport, or whatever it is you're doing, with kind of monitoring how your symptoms are going. If they're getting worse then you'd back it off sort of thing so, it has changed, and it is changing now.

Stephanie: Yeah, it's such an important point to talk about how this has changed because a lot of people, especially maybe if you're a parent, will remember how concussion was dealt with years ago. Which was either to be completely ignored or this old way of "let's shove you in a dark room and you're just going to rest till you're better", and surprise! Lots of people didn't get better that way. Lots of people developed depression, anxiety, stress from that method of treatment, but it's what we knew at the time.

So as Ryan said now we're looking at people getting rest in the first couple of days but you can still go about things you have to do at home in terms of you can still cook your dinner, you can still shower, do kind of those low-level daily things, you don't have to hide yourself away. And then we gradually add back in activities, and I think this is a really good news story to help people be less afraid of maybe admitting or seeking help for a concussion, that you're not going to be stored away and told you can't do anything.

The other thing that we've progressed on is in the first 48 hours it's shown that there's some benefit to limiting the time you're spending with screens, so your phone, your TV, your computer. But after that first 48 Hours it can kind of go based on how you feel, aside from you know most people will get better with following those graduated steps to return to activity. Most people do not need any type of specialized treatment.

But some people's symptoms might last longer and mainly the treatment for that is to look at "how can we help people manage the symptoms that they have and make sure that those aren't disrupting their life so much?" So, "how do we manage the fact that you have a chronic headache every day, you're feeling dizzy, and kind of target those individual symptoms?"

Megan: So, we talk about management of symptoms, does that mean there's a chance some people are going to have concussions and they're going to have symptoms for the rest of their life?

Stephanie: It's possible. So, the most people, there's a variety of estimates in the research but probably about 70 to 85% of people typically get better in about a month's time which is...

Megan: Okay, that's a good statistic.

Stephanie: Pretty good, right?

Megan: That's pretty good, yeah!

Stephanie: And then there's kind of another number of people that maybe will last three to six months ish and then we see another incremental increase in people getting completely better. But people can experience concussion symptoms for several years, and there could be lasting effects over the course of your life. Especially if you have multiple concussions or multiple impacts to the head so coming back to that subconcussion idea Ryan mentioned.

We're looking to understand that, whether that's you know individual factors people that have, or sometimes it may be the matter that they didn't get the right help and advice early on that could have reduced the lasting nature of their symptoms.

Megan: That's exactly what I was just going to ask because I hear over and over again people saying, "well I've had many concussions before so it's just like a foregone conclusion that I will continue to have them". Is that true, it's just the nature of what they do in their life but also perhaps they didn't get the treatment that they needed to begin with?

Stephanie: I think Ryan can talk more about the brain science there.

Ryan: Yeah.

Megan: Yeah, give us a science perspective on that. How does that work Ryan?

Ryan: Yeah, for sure. It's interesting because I remember when, for example, Sydney Crosby had concussions, and it became quite a catalytic event around sort of 2010. And I remember thinking as a neuroscientist who works, specialized, in brain injury who had written actually in 2000 about papers where that the idea of a concussion was controversial, we just wanted to dismiss it right. I was like wow this is going to be a problem that's going to take a long time before we see some improvements. There's been a lot of breakthroughs in the past, even if you go back five years, towards chronic symptoms in concussion.

So, what we're seeing, I'll give you a couple of examples, for individuals who have chronic what we call post concussive syndrome there have been, we've done clinical trials on a way to stimulate your brain by stimulating the nerves that go into your brain. So, this is completely non-invasive. It's not a medication, it's not surgery. We can pair it with things like rehabilitation and it actually has quite a successful, in terms of the published science, outcomes. So, the outcomes of improving sort of chronic symptoms, not just problems with balance and dizziness, but actually also cognitive and mental health aspects that also tend to pile on.

So, what we've seen, and just an example with this what's called neurostimulation, when you pair it with rehabilitation. Our clinic specializes in treating individuals with those sort of chronic situations and we're actually having now clinically greater than 80% treatment outcome success with this combined neurostimulation. So, we are making headway in treating those with new science and technology advances.

And on the other end of the spectrum, which is also quite encouraging, still early but it's definitely promising. So, in medicine there's this long-standing axiom of you can't treat what you can't measure. So, we focused a lot on getting a sensitive measurement through our technology NeuroCatch, and that's allowed us to actually characterize subconcussive impacts. And through leading institutions like the Mayo Clinic, they've come up with actually things you can change in your diet that address the consequence of concussion, such that you can start to give promotional kind of protective brain health supplements.

And we've done studies on these in ice hockey for example, and we're showing that you can actually sort of create a protective environment that causes these repetitive subconcussive impacts to be not neutralized but basically not detectable.

Stephanie: One of the things we just want to remind people too is that these specialized and individualized services aren't necessarily for everyone, right? And I think it this is really exciting to hear about, and it's so important that people like Ryan are doing science to innovate for folks who are not finding the help that they need. We do want to reassure the average person with concussion, again that that's 70 to 85%, will do okay with kind of typical management.

And so, the reason that I bring this up is because we've also heard stories of people searching around especially searching on the internet finding private clinics that charge a lot of money for treatments that aren't necessarily based in science or proven to work. Unfortunately, not everyone is as thorough as folks like Ryan or others that we know are really committed to following science and practice guidelines. And unfortunately, with the explosion of concussion and the attention there also is now an industry around concussion. So, there might be products for sale claiming to prevent concussion or treatments that that folks claim to work. And not to scare people, but just to help people think about really looking into anyone that you're seeking help from and kind of checking that it's a credible source and looking into what they're basing on and how they can articulate the work that they're doing.

One other great resource for people, coming back to the advocacy point and peer support is important, is brain injury associations. And we have Brain Injury Canada, and there's local associations in I think pretty much every province and territory as well as in regions. They're not treatment centers, but they offer help whether it's connecting you with peer groups, getting you information, just giving you emotional and mental support. Also, if you're a caregiver for someone with brain injury including concussion, they're a wonderful resource that's available.

Megan: Thank you for adding that Stephanie. I will say yeah everyone I know who's had a concussion, everyone has said that they have received like such amazing support from peer groups.

Stephanie: Yeah, yeah and it's cool that now you know between social media and digital platforms, virtual meeting platforms, there's so many ways that that support can be provided across the country.

Megan: Love that.

Ryan: Yeah.

Megan: So obviously the ideal scenario is you don't ever get a concussion, and we don't have to talk about treatment. Maybe Stephanie you can start by talking about some of the preventative measures.

Stephanie: Yeah, absolutely. This is another area where unfortunately the quick-fix response isn't going to be there. I can't tell you go out and buy this product and you'll prevent concussions, unfortunately. But there's so much that we can do. So really the principle behind prevention is we want to look, "what's causing the injury and where can we intervene?" So that's why we really look to understand how people are getting concussions and that's why that data and research is so important. Because otherwise, we don't know where to focus for prevention. So obviously some of the leading causes such as car crashes and falls, we really want to prevent those from happening. But that's a bigger question of you...

Megan: Right.

Stephanie:...know don't get in a car crash. There's a whole field in understanding that so you know reducing your speeds, all those good things are going to apply. Most of the research that's done in concussion prevention is focused on sport related concussions...

Megan: Okay.

Stephanie:...and so there's many different things we can look at for preventing sport related concussions. We can look at the environment that athletes are participating in, or any participant even if we're talking about phys-ed class at a school.

Megan: Oh wow.

Stephanie: You know, what's the floor situation like? Have we cleaned off water to you know get rid of slips and trips? Is there correct padding around? In outdoor fields what's the surface like? So, we can look at all those environmental factors. We can also look at how people are training. So, we want people to be training in skills that are appropriate for their level of development. There's also some more strengthening research around practices in contact sports.

So, for example, in youth football research supports that when there's less contact practice, so either fewer practices with contact or shorter durations of contact, that's proving to reduce the risk of concussion. We also have studies show showing that less body checking or later age of body checking in hockey reduces risk of concussion. So, the way that we go about participating in sports, creating rule changes, those are really important. So, there's so many different ways that we can prevent concussions. I want to address kind of elephant in the room when it comes to concussion prevention, which is the concept of helmets.

Megan: I know I thought that was going to be the first thing on your list. I didn't know it was an elephant in the room.

Stephanie: It's the easiest, and maybe people don't know that, so I'm going to pull that trunk and bring it right out. That's the first thing people think about, "okay let me protect my head I'll put on a helmet". It's also maybe the simplest thing we can think of. Helmets are really important. I work for an injury prevention organization; we really support helmets. The evidence supports helmets for lots of types of head injuries. They protect your skull, they protect you from serious brain injuries. What they are not at this point proven to do is necessarily prevent concussions.

Megan: Okay.

Stephanie: It comes back to that movement of the brain inside the head. You put a helmet on, that can't hold your brain still. It can't prevent that sudden start and stop movement of the brain. So logically it may not be the best way to try and prevent a concussion. So, helmets are great, wear helmets in hockey, wear helmets cycling, wear helmets in football. "If you wear a helmet, are you not going to get a concussion", we can't say that.

Megan: Okay thank you. Ryan go ahead.

Ryan: Yeah, I would piggyback on to that. I think helmets are an essential protective piece of equipment, particularly if you are in an activity that you think is going to involve contact with your head. And what we know is the threshold for concussive impact. So, I want to separate between a diagnosed concussion and concussive impact, because those are different, right? You can still sustain concussive impact without necessarily having the experience of symptoms that lead you to a diagnosed concussion. And that's really the essence of what Stephanie's saying is, to simplify it, you would not want to think "I put a helmet on therefore I will not get a concussion or concussive impact".

You put a helmet on which protected your head and your brain for sure, but that doesn't necessarily- it's not a cure all in that way. I think in sports concussion, usually for listeners who are let's say parents or even the kids that are in sports concussion, we do know that you want to... I'll go into some interesting science. So, we measured the exposure to impact by putting sensors on helmets in both Junior A and Bantom hockey players and we actually compared that to youth football players. What we could show is that the number of impacts as recorded by those sensors was very, very highly correlated with the cognitive impairment that we measured in our brain waves.

So, in general, over the course of a a contact season the more exposure to impact you see, the more you have some impacts to how your brain is processing information. So, it is really, the moral of the story is you want to think about your exposure to impact and you want to try and reduce your exposure to impact. It's not just about a diagnosed concussion and put a helmet on and you won't have one.

Megan: Right.

Ryan: It's about trying to minimize how much your brain is moving around inside your skull. I also wanted to quickly just talk, because I imagine many listeners are also, let's say getting on in their lifespan and are older adults. And the concept of falls, I think the latest stat I'm sure they're updated now but more than a third of falls can result in concussive impacts and concussions.

Megan: Wow.

Ryan: And so there are things you can do in those circumstances too, for instance, our brain has this wonderful concept of we learn all our life and we do that by rewiring new circuits and from a science point of view we call that neuroplasticity. And let's say there's an individual who's worried about falls and worried about hitting their head there, we actually do have the capability to train for example our balance and our gate.

And there are exercises you can do as you're getting on in life to actually proactively try to keep your balance in an improved realm which will reduce the chances of a fall, and therefore the chances of a concussion. So, there are a number of things, again similar to the conversation we just had, that are effective and proving effective to reduce the chances of concussive injury.

Megan: And I want to pick up on this theme of optimism, and we have to wrap up and I feel like I could talk to you both forever about this. But I want to end on a note of optimism because there's been lots of threads of optimism throughout this. Looking forward, question for both of you, Stephanie you can start. What are you optimistic about in the future, what's new, what are you looking forward to in the space?

Stephanie: We know more now about concussion and the brain than we ever have in history. A few years ago, there was a conference, an international conference is held every few years where they kind of take stock of all of the current international research. And in two years they found as many published papers on concussion as they had for the entire decade prior.

Megan: Wow.

Stephanie: So, it's moving at a fast pace. We're learning more and we're doing better with that knowledge, in the way that we're changing our thinking about treatment. So, I'm excited about that. I'm excited that I think we're listening more to people with concussion and brain injuries. We can do all the science in the world, but if it isn't improving people's health and lives, what's really the point?

Megan: Thank you. Ryan?

Ryan: Sure, well I mean I'm a neuroscientist and a neuroimager specifically, right?

Megan: Yeah.

Ryan: So, my entire career is dedicated towards translating the science into tangible things that improve brain health for Canadians and worldwide. I remember when we did- I've also had the privilege of course of inventing and developing the NeuroCatch scanner which is one of the world's first portable objective measurements of a brain function. And I remember when we did our subconcussive work in, we've done it in hockey and football and MMA and high school sports, and what have you. Always pointing out that it's not a pessimistic thing to show that you know the thresholds of what we thought were concussive injury are much lower.

You know a lot of people would be like "oh goodness, so then it's more of a problem?" And I would always point out, like I mentioned, the axiom in medicine is you cannot treat what you can't measure. So, I'm so, like, freaking excited because we can now measure and find treatments at a rate that is like mind-blowing. Now we're finding all these things that are actually making a difference. Our job is once we find them to make sure they get that people get access to them. And that's why you know organizations like parachute and brain injury societies and that sort of thing are critical because that allows people to get connected into all the amazing things that are coming down the pipe, so I'm very optimistic about what the future looks like for how we manage concussion.

Megan: I love that. Thank you! Thank you, Stephanie. Thank you, Ryan. Thank you for your optimism, your excitement even, and all this practical information. It's been a pleasure talking to you today.

Ryan: Awesome, thank you for having us.

[Pulse sound]

[Music]

Megan: Thanks for tuning in to Healthy Canadians. If you're watching on YouTube, don’t forget to click the like button below and subscribe to stay up to date on future episodes. Find us wherever you get your podcasts and leave us a review if you like what you’ve heard. For more information on the health topics that matter to you, visit canada.ca/health.

[Music]

Learn more

• Concussion: Symptoms and treatment - Canada.ca
• Concussion: Prevention and risks - Canada.ca
• HealthTech Connex - How's Your Brain Doing Today?
• Parachute – Preventing Injuries. Saving Lives.
• Concussion resources - Canada.ca
• Brain Health and Cognitive Impairment in Aging Research Initiative - CIHR
• Concussion in Sport - Canada.ca
• After a concussion: Return-to-school strategy (PDF, 327 KB)

Visit our Healthy Canadians podcast gallery to browse through previous episodes.