Making the subjective objective; how technology helps evaluate concussions

 BY: PHIL PALMER, DC

In the current climate of concussion clinics, many tools are being used to assess this type of serious injury, also known as traumatic brain injury (TBI), or acquired brain injury.

Assessments can include physical and mental status examination, Glasgow Coma Scale, Immediate Post-Concussion and Cognitive Testing (ImPACT) computer-based system, Balance Evaluation Scoring System (BESS), Inertial Sway measuring devices, and Optogait assessments. 1-3

 

Cognitive Symptoms of Concussion: difficulty remembering, feeling slowed down, feeling mentally foggy, difficulty concentrating, confused about recent events

 

Each assessment method is designed to evaluate the different aspects of the complex physical, cognitive and emotional disturbances that can result from a concussion.4

Establishing a ‘baseline’ with patients before a concussion occurs is useful in evaluating a person post-concussion to determine how the injury has affected them.1, 3, 5  This is not always possible given how and when a brain injury can occur.  An Assessment baseline can always be performed when commencing treatment and as an introduction to a rehabilitation program, and to compare against when re-evaluating a patient’s progress throughout their program.

One tool we are using to establish a patient’s baseline is the Optogait, which is considered a ‘gold-standard’ device for measuring gait (how a person walks), balance and movement symmetry.6-9

1

The simple 30-60 second test of walking on a treadmill can be recorded by a computer system using lasers to establish the individual characteristics of the patient’s gait, which can then be remeasured throughout the rehabilitation program.  This test gives objective data on all aspects of the gait cycle, as well as stability, balance and movement symmetry.

The amount you move when standing still (your postural sway), can also be measured by 3D accelerometers (which track acceleration), gyroscopes (which track orientation), and magnetometers (which, according to the journal, Karger, ‘measure the’ magnetic fields emitted by the brain, generated by neuronal activity).10 These tools allow a much precise measurement of sway  – up to 1,000 times per second more – compared to the current manual testing.

3

We also determine the speed of cognitive processing during walking by testing patients walking while counting backwards.  The movements of the eyes and head together (Vestibular Ocular Reflex) are also tested in order to determine concussive symptoms.

These tests are useful when a patient may feel that their concussion symptoms have resolved, but in fact, their cognitive processing is still poor.

The Gyko component of the protocol also tests sway, which is the movement of the centre of mass, and upper vs. lower body plus compensatory movement patterns made by the brain to return to a normal set point when standing and walking.

Screen Shot 2017-08-02 at 2.12.48 PM

These tests are blended nicely with the Optogait March in Place Tests (eyes open/eyes closed), and Gyko system to determine changes in physical functioning with changes in body position.

Most recently, a validation study was conducted to utilize the Optogait® equipment for evaluation of march-in-place tests traditionally used for vestibular (inner ear) testing, called the Fukuda or Uterberger Stepping Test. 3, 13-15

 

4

 

Using objective physical characteristics of the pathophysiology of TBI, the data collection with the OPTOGAIT equipment cannot be easily altered by the patient, thus you cannot under-estimate your symptoms with testing of gait, postural sway, or marching in place tests with your eyes open or closed.

This testing protocol provides an objective, evidence based protocol for both assessing, documenting and treating acquired brain injury.

Screen Shot 2017-08-02 at 2.13.07 PM


Dr. Philip Palmer is a chiropractor serving Toronto and the surrounding area. He is the clinical director of Genesis Rehabilitation, Physiotherapy and Sports Injury Clinic.

REFERENCES

  1. Hirsch MA, Grafton L, Runyon MS, et al. The Effect of Cognitive Task Complexity on Postural Sway in Adults Following Concussion. Archives of Physical Medicine and Rehabilitation. 2015;96(10):e51.
  2. Gaudet CE, Weyandt LL. Immediate Post-Concussion and Cognitive Testing (ImPACT): a systematic review of the prevalence and assessment of invalid performance. The Clinical neuropsychologist. 2017;31(1):43-58.
  3. Engelson MA, Bruns R, Nightingale CJ, et al. Validation of the OptoGait System for Monitoring Treatment and Recovery of Post-Concussion Athletes. Journal of chiropractic medicine.
  4. Harmon KG, Drezner JA, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. British journal of sports medicine. 2013;47(1):15-26.
  5. Alberts JL, Hirsch JR, Koop MM, et al. Using Accelerometer and Gyroscopic Measures to Quantify Postural Stability. Journal of athletic training. 2015;50(6):578-588.
  6. Lienhard K, Schneider D, Maffiuletti NA. Validity of the Optogait photoelectric system for the assessment of spatiotemporal gait parameters. Medical Engineering & Physics. 2013;35(4):500-504.
  7. Lee MM, Song CH, Lee KJ, Jung SW, Shin DC, Shin SH. Concurrent Validity and Test-retest Reliability of the OPTOGait Photoelectric Cell System for the Assessment of Spatio-temporal Parameters of the Gait of Young Adults. Journal of physical therapy science. 2014;26(1):81-85.
  8. Gomez Bernal A, Becerro-de-Bengoa-Vallejo R, Losa-Iglesias ME. Reliability of the OptoGait portable photoelectric cell system for the quantification of spatial-temporal parameters of gait in young adults. Gait & Posture. 2016;50:196-200.
  9. Ammann R, Wyss T. Comaparison of Three Gold-Standards to Measure Ground Contact Time in Runners. SPORTWISSENSCHAFTLICHE. 2011.
  10. Neville C, Ludlow C, Rieger B. Measuring postural stability with an inertial sensor: validity and sensitivity. Medical devices (Auckland, NZ). 2015;8:447-455.
  11. Iosa M, Morone G, Bini F, Fusco A, Paolucci S, Marinozzi F. The connection between anthropometry and gait harmony unveiled through the lens of the golden ratio. Neuroscience letters. 2016;612:138-144.
  12. Iosa M, Bini F, Marinozzi F, et al. Stability and Harmony of Gait in Patients with Subacute Stroke. Journal of Medical and Biological Engineering. 2016;36(5):635-643.
  13. Zhang YB, Wang WQ. Reliability of the Fukuda stepping test to determine the side of vestibular dysfunction. The Journal of international medical research. 2011;39(4):1432-1437.
  14. Honaker JA, Boismier TE, Shepard NP, Shepard NT. Fukuda stepping test: sensitivity and specificity. Journal of the American Academy of Audiology. 2009;20(5):311-314; quiz 335.
  15. Grommes C, Conway D. The stepping test: a step back in history. Journal of the history of the neurosciences. 2011;20(1):29-33.
  16. Maerlender AC, Masterson CJ, James TD, et al. Test–retest, retest, and retest: Growth curve models of repeat testing with Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). Journal of clinical and experimental neuropsychology. 2016;38(8):869-874.
  17. Schatz P, Glatts C. “Sandbagging” baseline test performance on ImPACT, without detection, is more difficult than it appears. Archives of clinical neuropsychology : the official journal of the National Academy of Neuropsychologists. 2013;28(3):236-244.

PHOTOS: Optogait Technologies Inc.

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How to best return to work following a concussion in the computer driven 21st century

BY: COLIN HARDING

One in five Canadians will experience a concussion from sport in their lifetime. Suffering a concussion can lead to a range of debilitating symptoms such as constant fatigue, changes in mood, headaches and difficulty concentrating.

Returning to work after a concussion can be challenging and if not done properly may slow recovery. There are activities and techniques that allow for the smoothest transition back to normal life and the best chance for a full recovery.

The following are some tips on how to recover from a concussion and return back to work while maintaining your health.

There are good days and bad days and accepting that things will take time is important to maintaining a high level of mental health.

Say yes to help & support

The Centre of Disease Control and Prevention recommends gathering support as an important part of recovery and may help lift the burden of a concussion off an individual’s shoulders. Support can come from many places: a partner, a family member, a healthcare professional or a manager at work.

Having open channels of communication can lead to a greater understanding and empathy during recovery. It is easier for your peers to understand your situation and support you through the process if they know what has happened.

For example, a manager who knows their co-worker has recently experienced a concussion should lessen the workload initially as the individual begins the transition from rest back to work and this may help decrease their symptoms and stress.

Woman at her desk with head in her hands
PHOTO: enerpic.com

Avoid triggers

Once someone has experienced a concussion it is important to recognize what triggers his or her symptoms. Every concussion is different and these triggers may range from person to person. The backlight on a computer screen may cause headaches, exercise may cause nausea, and conversations may cause fatigue.

Every individual has a different set of factors that will influence their symptoms. If an activity makes symptoms worse, then it is important to stop that activity and rest. For instance, if conversations’ are overwhelming, take a break from social engagements.

Manage your energy

It may sound simple, but managing symptoms and energy amongst all of the different aspects in your life can be a real challenge. Once the symptoms are resolved someone may wish to return to work. Returning with a decreased workload, taking scheduled breaks and being cognisant and respecting symptoms are helpful to ensure that transition goes smoothly.

Accepting that an injury has happened, and that it will take some time to recover from, is another important aspect to consider when living with a concussion.

Be patient

There are good days and bad days and accepting that things will take time is important to maintaining a high level of mental health. The recovery process and managing setbacks can be incredibly frustrating, and patience can be one of the most important aspects of a recovery.

A person should focus on the activities that they can control and feel like they are making progress on, as opposed to the activities that are out of their control. Light exercise (As long as a person does not experience worsening symptoms), a balanced diet, and getting enough sleep are part of the foundation to achieve health and could be part of a recovery plan.

Having a concussion can initially be draining and frustrating. Having the support from work and peers, being aware, managing symptoms, and accepting that recovery takes time can go a long way towards making the transition back to normal life successful.

 


Colin Harding is the CEO and founder of Iris Technologiesa Canadian healthcare technology company that is improving the lives of peoplewho have suffered from a mild traumatic brain injury (MTBI) or live with chronic migraines.

A version of this article originally appeared on the Iris Technologies Blog

Post Concussion Syndrome: Why giving up screen time is part of the solution & problem

LCD screens surround us. Many people stare at computer screens throughout their workdays, taking breaks only to check social media on their smartphones.

While there are far fewer concussions in the world than there are screens, the frequency with which these injuries occur has been increasingly acknowledged in the mainstream media. Athletes such as Sydney Crosby, Steve Young, and Eric Lindros just to name a few, have brought the severity of Post Concussion Syndrome (PCS) to the forefront of public discourse.

A person who suffers from PCS will experience symptoms such as dizziness, nausea and headaches for an extended period of time after the initial injury. This can last for weeks or months, and there is no clear answer as to how it can be minimized.

image of an office with a laptop and no one at the desk, next to a close up of a man who looks like he has a headache

The few treatment options that health professionals agree to are: rest, and a complete break from LCD screens.

While all cognitive activity can worsen the severity of headaches and dizziness in people with concussions, there are several reasons why the use of LCD screens in particular can exacerbate these symptoms:

  • Images that appear on LCD screens are made up of pixels that refresh at a rate of 60 times per second, even when the content on the screen is not changing.
  • The rapid movement of these pixels means when we look at screens for too long, we strain our eye muscles.
  • For someone who has suffered a brain injury, this strain can be detrimental.
  • Further, the backlighting of LCD screens can cause cognitive fatigue, headaches, dizziness and nausea in concussion patients.

22-year-old Maggie Callaghan, a varsity athlete who has suffered several sports related concussions over the past few years says she tried to avoid computer screens all together for weeks after her first concussion.

“I couldn’t look at a screen for more than a few minutes without feeling intense pain behind my eyes that would quickly evolve into a full blown migraine” Callaghan said. “I tried to avoid computer screens altogether for as long as I could.”

Maggie is one of many young concussion victims for whom the inability to study using a computer screen resulted in severe stress.

“It sort of becomes a cycle,” says Joe Ross, a 20-year-old student who, like Maggie, has suffered from concussions. “You feel sick when you use your computer to do school work, but when you aren’t able to keep up with your school work you feel anxious which can be harmful to the recovery process.”

Anxiety is just one of many mental health problems that disproportionately affects concussion patients. In fact, two out of three concussion patients experience depression following their recovery.

The social isolation that comes from being unable to communicate using computer and phone screens, as well as the stress associated with being unable to complete day-to-day tasks, are thought to be two of the primary causes of depression in concussion victims.

As difficult as it can be for students to abstain from using screens following their concussions, the struggle to recover from PCS without the use of computers can be even more intense for working adults.

“The recovery process would have been even more stressful if I had been working in a professional environment at the time of my concussions,” says Maggie. “So many jobs involve, if not completely revolve around, using computers. Being unable to work and not knowing when I would get better would be seriously nerve-wracking.”

Currently, treatment options for PCS do very little to account for the importance of screens in the average person’s everyday life. Patients have to work hard to engage in society and keep up with school or work without the use of their computer screens.

This can often be one of the most unexpected challenges of dealing with PCS.

So where does this leave people needing to return to a pre-concussion life while dealing with PCS?

While there are no solutions, one recent pilot study commissioned by the Canadian Concussion Centre indicated that people experiencing PCS were able to use a non-LCD screen, thus enabling a quicker return to school or work life.

PHOTOS via pixabay


Colin Harding is the CEO & Co-founder of Iris Technologies – a Canadian healthcare technology company that is improving the lives of people who have suffered from a mild traumatic brain injury (MTBI) or live with chronic migraines.
 
A version of this article appeared on the Iris Technologies Blog

Why didn’t my bike helmet prevent my TBI?

BY: SOPHIA VOUMVAKIS

15 per cent of the approximately 18,000 traumatic brain injuries (TBIs) that occur in a year in Ontario are a result of a cycling accident. Every year in Canada, over 11,000 people die as a result of a traumatic brain injury (TBI) – using the same 15 per cent – that’s over 1600 people in Canada who die as a result of a TBI caused by a cycling accident. 85 per cent of all cyclists’ deaths in Canada involve a brain injury.

A little over five years ago, I sustained a TBI while riding my bike. It was a beautiful spring morning, and I was riding my bike to work, as I had hundreds of times before. I remember leaving my home that morning, and then waking up in the emergency room at St. Michael’s Hospital, several hours later. I was told by the doctors in the emergency department that I had been knocked off my bike, hit the ground, passed out, and taken to the ER by ambulance. Several hours later I was diagnosed with a brain injury. To this day, I have no memory of the incident.

I was wearing a bike helmet, which I always did, but my helmet did not protect me against acquiring a TBI. I’d always wondered why, and recently I got my answer. I came across a TED Talk by bioengineer (and former football player) David Camarillo, who, along with his team at Stanford University, has been able to demonstrate what really happens to our brain during a concussion, and why bike helmets, and other sports helmets, such as football helmets are not designed to protect against concussion, but rather, they are designed and tested to determine how well they protect against skull fracture.

What happens to your brain during a concussion?

The standard thinking of what happens to your brain during a concussion is that the head moves, the brain lags behind, catches up, smashes into the skull, rebounds off the skull and then proceeds to run into the other side of the skull. This dynamic is repeated many times. This understanding of what happens to the brain during concussion suggests that the brain is damaged on the outer edges.

In his Stanford University lab, Camarillo and his team, with the aid of new technology, have looked closely at what happens to the brain when it is experiencing a concussion. Their investigations suggest that the current thinking about what occurs to the brain during a concussion is not entirely accurate. Firstly, he does not believe that the brain moves around as much as current wisdom suggests. Camarillo argues that there is very little room in our cranial cavity for movement, perhaps a few millimetres, and our cranial cavity is filled with spinal fluid, which acts as a protective layer. Secondly, he suggests that the brain does not move as a whole.

Football player with ball about to fall to the ground

Our brain is one of the softest organs in our body – the consistency of Jell-O – and as the brain moves around in our skull during a concussion, it is probably twisting and turning and contorting – the tissue is getting stretched. Concussion does not appear to be something that is happening to the outer edges of the brain, but rather it is happening somewhere much deeper, in the centre of the brain.

The Laboratory – The Stanford Football Team

To help Camarillo and his team better understand what is happening to the brain during a concussion they utilized a mouth guard equipped with sensors and a gyroscope, which most experts believe can tell us what happens to the brain during a concussion. When someone is struck in the head, the mouth guard records how the skull moves at a thousand samples per second.

The study’s laboratory is the Stanford football team, young men who regularly go out and hit their heads.  This allows for rich information to be obtained when the researchers extract the data out of the mouth guard.

When the data from the mouth guard, was combined with a finite element model of the brain, developed by Svein Kleiven in Sweden, it showed that the brain of football players, who have suffered a concussion does not smash around in the skull, as current thinking would lead us to believe, but rather twists and contorts. The data shows that the greatest amount of stretching occurs very close to the centre of the brain.

What’s there? The corpus callosum, the wiring which connects the left and right hemispheres of your brain. Camarillo believes that this might be one of the most common mechanisms of concussion, the wiring is being disrupted, which causes a disassociation between your right and left brain and could explain a lot of the symptoms one sees in concussion. This is consistent with what researchers see with Chronic Traumatic Encephalopathy (CTE) – when the corpus callosum of a middle aged, former football player is viewed, and compared to an individual who does not have CTE, his corpus callosum is greatly atrophied.

Although there is a rapid transmission of forces down to the corpus callosum when the head is struck, it does take a certain amount of time. What Camarillo and his team believe is that if we can slow the head down just enough so that the brain does not lag behind the skull, but instead moves in synchrony with the skull, then we might be able to prevent this mechanism of concussion.

How can we slow the head down?

The most currently used bicycle helmet is constructed of expanded polystyrene (EPS) foam within a thin plastic shell. The EPS liner absorbs the force of an impact by deforming, while the outer shell increases the area over which the force is dissipates. The main considerations when designing a bike helmet is the size and stiffness of the helmet, which impacts how efficiently energy is absorbed. As a result of the materials used in constructing an EPS helmet, the size of the helmet has been limited to a few inches. This does not slow down the head enough to enable the brain to move in synchrony with the skull, rather than lag behind the skull. It turns out that air, in an expandable helmet would be the ideal mechanism for slowing the head down enough during impact, so that the brain moves in synchrony with the skull, rather than lagging behind.

woman wearing a skirt standing with her bike

It turns out that a company in Sweden called Hovding, is using the principle of air to give the wearer of their ‘helmet’ some extra space to prevent concussion. Hovding has created what is essentially the world’s first airbag for cyclists. The Hovding is a collar, worn around the cyclist’s neck, that uses advanced sensors, similar to the sensors used in the mouth guards described in Camarillo’s research above, that can sense the cyclist’s movement patterns and will react in case of an accident. The airbag will then inflate, fixate your neck and provide a shock absorption. In experiments conducted by Camarillo and his team they have found that the Hovding collar can greatly reduce the risk of concussion in some scenarios, compared to a standard EPS bike helmet. The Hovding is currently for sale in Europe and Japan, and is CE labelled, which means it complies with European Union safety standards, but not for sale in the United States, and alas, Canada.

In the US, bike helmets are federally regulated by The Consumer Product Safety Commission. The Commission has jurisdiction over the type of helmets they approve. The test they use in order to grant approval to a bike helmet is testing the helmets capacity to prevent skull fractures, not whether the helmet is likely to prevent concussion. In Canada, The Canadian Standards Association accredits organizations to certify that bicycle helmets meet certain standards, such as CPSC bicycle helmet standard, which uses the tests described above by Camarillo.

I contacted Hovding and asked about the availability of their helmet in Canada – alas, it is not available here. They replied that, at this time, they have not investigated helmet certification in Canada. So it might take some time to get my head into one!

Even so, any helmet is better than no helmet, so keep wearing whatever helmet you have, and wear it properly.

 Resources

Modelling and Optimization of Airbag Helmets for Preventing Head Injuries,  published in The Annals of Biomedical Engineering in September 2016.


Since her TBI in 2011, Sophia has educated herself about TBI. She is interested in making research into TBI accessible to other survivors.

Goal setting after a brain injury

BY: ALISON

Before my concussion, I was always busy.

I worked long hours, travelled three times a year, hosted parties, played sports, volunteered and maintained a blog. I had one-year fitness goals, five-year career goals, 10-year family goals, and 30-year financial goals. After my injury, my symptoms were so debilitating and unpredictable that I couldn’t even make plans for 10 minutes in the future. I was close to giving up entirely, until I changed my perspective and approach to goal-setting.

women standing in running shoes
photo credit: 2012Vegas 676 via photopin (license)

How to Set Goals After a Brain Injury

Step 1: Change Your Perspective and Set Your Goal(s).

First you have to decide what you want your goal to be. It is imperative you don’t set yourself up for failure by having unfair expectations. If you set an unrealistic goal, you will de-motivate yourself and give up. Through accomplishing a series of challenging, yet do-able goals, you will achieve the once seemingly impossible ones.

Set simple goals that are achievable in the short term (i.e. daily and/or weekly). Then gradually work your way up to more difficult goals.

After my injury, just lifting my head off the bed to drink water was exhausting, so my first goal was to perform one task every three days. Tasks included taking a shower, folding clothes, or going to an appointment. Once I could do that, I slowly increased the frequency and difficulty of the tasks.

I then added outings to my goals, which later included running errands. Eventually, I was performing multiple tasks each day, having outings a few times per week, and running multiple errands per outing.

As my energy levels improved, I also set my first fitness goal, to walk for at least 10 minutes each day. Over time, this evolved to taking longer walks and faster-paced walks. Once I had more confidence in my capabilities, I focused on social goals. I started with phone conversations and one-on-one meetings, before working my way up to group dinners at bustling restaurants. Finally, I started hosting parties in my home.

Exercise is well-known to improve brain function, depression, anxiety, and sleeping problems. Furthermore, recent studies indicate that moderate exercise is the best treatment for concussions.

a freshly made bed
photo credit: Mazzali bedroom via photopin (license)

Step 2: Plan Out Your Goals and Take One Tiny Step at a Time.

Now that you’ve set your goal, the next step towards achieving it is to make a plan. Write your plan down on a piece of paper so you can follow it easily and cross things off as you complete them.

The best approach to planning (and executing that plan), is to take things one tiny step at a time. Break down each goal into as many small, manageable components as you can, then tackle one component at a time. The definition of ‘manageable’ is different for everyone and will change as you recover.

For example, these were the tiny, manageable steps that I planned for my goal of going for a walk:

  1. Stand up (you could break this step down further. e.g. lift head off bed, then lift head and shoulders off bed, then sit up, then sit on the side of the bed, then stand up.)
  2. Drink some water
  3. Change my clothes
  4. Gather my cell phone, keys, and health card
  5. Put walking/running shoes on
  6. Leave the house (i.e. simply step outside)
  7. Start walking (even if it’s just a few feet) and rest as needed
  8. Walk home and rest as needed
  9. Stretch
  10. Drink some water

When you start executing your plan, the most important thing to remember is to focus only on the task. Don’t even think about how you’re going to tackle the next step until you’ve completed the current one. That means, not worrying about whether or not you’ll be able to complete all of the steps, and not counting the number of steps you have left.

Taking one tiny step at a time will earn you little wins, keep you motivated, and make your goal seem less daunting. Take breaks when you need them and try again later.

It helps to have someone else’s support when you’re working towards a goal, but only if they understand the importance of taking things one step at a time. I remember one night in the winter, my partner wanted to take me to the mall to help me achieve my daily walking goal. I was fatigued and dizzy and convinced that I wouldn’t be able to do it. But he talked me through one step at a time. He said, we’re just going to get in the car and we’re just going to drive to the mall. If you’re still not feeling well when we get there, you don’t have to get out of the car, we’ll come straight home. So he helped me up off the couch and into the car. He drove me to the mall, turned the engine off, and asked if I was able to get out of the car. I was, and in that moment, we set a goal of walking to the mall entrance and back. When I got to the entrance, I felt okay, so we went inside. That night, I ended up walking for longer than my daily goal.

drinking a glass of water
photo credit: Denise via photopin (license)

So when you’re faced with a particularly daunting moment, keep repeating to yourself, “I’m just going to do this tiny task. That’s not too hard.” One and a half years of tiny steps later, I jogged 5 km in the BIST Run, Walk & Roll. I’m working towards running a 10 km race next year.

Step 3: Be Flexible and Be Kind to Yourself.

Celebrate each tiny success and never criticize or punish yourself for set-backs. Goal-setting after a brain injury requires time and practice through trial and error, so be patient with yourself, do what you can, and be flexible with changes to your plans. If something’s not working for you, try again and then try something different. You might need to re-evaluate your goals, revisit them at a later time, or break certain steps into smaller components. Don’t be afraid to ask someone for help.

Step 4: Set New Goals and Keep Challenging Yourself.

As your symptoms improve, you’ll be able to accomplish more each day. When you’re further along in your recovery process, gradually increase the breadth and difficulty of your steps. Soon, you’ll be working on various goals (e.g. fitness, cognitive, financial and social) simultaneously.

Eventually, your goals will become more and more challenging, complex, and long-term. No matter what your physical barriers are, there’s always something to learn, something to improve, and new ways to challenge yourself. As long as you take things one step at a time, you’ll look back one day and surprise yourself with how far you’ve come.


‘Mind Yourself with Alison’ is a collection of self-help tips, research, and personal experiences dedicated to helping people thrive after brain injury (or other trauma). Check out Alison’s other BIST Blog articles Women and Brain Injury: What you need to know and How to be a Good Friend to a Survivor.

 

 

Concussions: the missing piece of the puzzle

BY: KAROLINA URBAN

Its been over two years since my last concussion, which I got while playing hockey. I still have difficulty focusing and remembering small details. I have anxiety and, at times, I feel down.

Although I no longer have a concussion, I don’t feel exactly the same as I did before my brain injury, and that is exactly what has captivated me for over the past several years as a researcher.

hockey skates on ice
photo credit: Week One:Skate via photopin (license)

I continually ask myself, why is it that we can’t fully understand what is going on after a concussion? What is the piece of the puzzle we are missing and how do we get people recovered to a point where they can get back to doing what they love without any consequences? How can we find a way to assess concussions that don’t rely on subjective symptom reporting? More importantly, how do we educate people about brain injuries so they make an informed decision?

These are just some of questions that go through my head.

I think most athletes can say they have lied about aches or pains they have had occur in games or practices. Many have played through broken bones, torn or sprained muscles or joints.

This is part of the team-first culture, where blocking shots, taking a hit to make the play, or playing through an injury is idolized. However, there is a huge difference between injuries to the body and injuries and injuries to the brain.

Injured hockey player
photo credit: Learning the hard way via photopin (license)

The brain is truly extraordinary. It makes it possible for us to do the things we love, such as communicate, learn, share joy and many other things. How we achieve tasks such as skating, or how we understand situations and make decisions involves complex processes with many thousands of connections, millions of neurons firing, tens of millions support cells and all of this is completed at an incredible speed.

And yet sometimes we treat the brain as just another tool in our body, a sacrifice to the team.

When I think of it from another perspective I realize this is the wrong way to look at it!

The brain is what gives us the team-first attitude, what helps us make the correct decisions, and to achieve specific skills. Without it functioning properly we can not be the best we can be. And this is the perspective I know have taken on when I talk to young athletes who have sustained a mild traumatic brain injury. But is this enough to keep them from playing is yet to be seen.

Recently I became an assistant coach for a competitive female hockey team. One of the players was tripped up and hit her head on the end boards. She came off upset, emotional, in pain and clearly could have sustained a concussion. After the ice clean she came back out and wanted to play. Despite all my knowledge about brain injuries, I found it extremely difficult to tell her she needed to sit out the rest of the game.

It is hard to tell an athlete they can’t go back out there and that they need to rests especially when its all they have known their whole life.

16447977753_17dffab6b1
photo credit: Young Athletes via photopin (license)

“Get knocked down, get back up.”

“No pain, no gain.”

“Sacrifice your body to win the game.”

But how can we change this? How can we ensure our trainers, who are responsible for pulling the players out of the game, feel comfortable and believe that it is the right decision? Or can we make the athletes realize they need to be more accountable for their own health and long-term development? Maybe it’s the combination of both?

I can’t say I have the answer, but I can touch on some ways to change this problem.

Mentors

We need mentors, we need people such as Sidney Crosby or Jennifer Botterill speaking about their injuries and what they could have done or should have done to prevent those months of symptoms.

We all know that players are more likely to listen to those who have gone through similar situations, especially when their idols. I can  say I probably wouldn’t have thought about the injury any differently if a doctor, teacher came up and told me not to do something or to be honest about the injury. I mean they told me not to play through a torn tendon in my knee in playoffs, which I completely ignored.

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photo credit: Jordan Reed via photopin (license)

Education

Despite the media constantly speaking about concussions, there is a lack of knowledge about the injury, symptoms, possible long term impact, what to do when you have a concussion, and what resources are available.

One example of a recent partnership is between the Greater Toronto Hockey League (GTHL) and Holland Bloorview Kids Rehab Hospital Concussion Centre. This partnership is an example of how leagues are hoping to educate their players, parents, referees and coaches.

The brain is one of the most complex systems in our body, yet there is little time allocated to teaching about the brain, diagnosis, and rehabilitation.

Many medical schools only spend about an hour or so covering concussions. Physiotherapists have limited education on the subject, which is concerning as they deal with many athletes.

We need to develop supports and education for all stakeholders – parents, coaches and trainers.

 Karolina Urban is a former University of Toronto and Canadian Women’s Hockey League player. Currently she is a PhD student at the Concussion Centre in Holland Bloorview Kids Rehab Hospital

Exploring Concussions with Dr. Anne W. Hunt of the Concussion Centre at Holland Bloorview

On April 7th, BIST is hosting a FREE talk on Exploring Concussions:
Concussion Facts & Myths AND The latest Research Findings
 – featuring speakers Dr. Lesley Ruttan of Main St. Psychological Centre and Toronto Rehab; Dr. Carmela Tartaglia, Assistant Professor at the University of Toronto Tanz Centre for Research in Neurodegenerative Disease and Dr. Anne W. Hunt, Manager, On TRACK concussion program Concussion Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital.
Our writer Karolina Urban spoke to Dr. Hunt about her upcoming talk with BIST.

KU:  What are some of the pieces of advice you have for those who have sustained a brain injury in terms of recovery?

AH:  Work as hard as your body and brain will let you; be open to doing things differently; keep in mind that recovery may continue for many years. I’ve seen survivors make significant changes many years after injury.

Dr. Anne W. Hunt
Dr. Anne W. Hunt

KU:  Can you tell me about the importance of time management and prioritization and how to best manage every day life? How important is goal setting? exercise? Doing the things you love?

AH: All of these things are important! It’s important for health and well-being in general to be engaged in activities every day that have purpose and meaning to each person.

Time management and prioritization are important skills that can help us to find time to do activities we need and want to do. Using calendars to schedule activities, using ‘to do’ lists, setting alarm reminders are strategies that may be helpful in managing time. Goal setting is helpful for some people, it is important to set goals that are specific, meaningful and relevant. Setting time frames for goal achievement can be tricky as sometimes following brain injury it can be challenging to know how long it might take to do something. Instead, think about what you might accomplish today and consider how you will accomplish that-make plans and then do it!

Exercise is good for health overall and contributes to optimal brain function. I encourage people with brain injury to participate in exercise that they enjoy, but to do this in a way that doesn’t make symptoms worse. This may mean doing the activity at a less intense level, for a shorter period of time or in a less stimulating environment.

BIST Exploring Concussions Talk
KU: In terms of mental health and dealing with the accident itself, can you speak to some of the tips and/or advice you have for someone who is dealing with persistent issues?

AH: Good mental health is important for well-being. Following brain injury, people may feel more emotional, this may include feeling sad, anxious, scared, angry, overwhelmed, and less confident to name a few. It’s important to develop a support network to help you through difficult times. Consider who your network is-who can you turn to for support-this might be a professional (e.g. therapist), a family member, or friend. If you are uncertain, community organizations like BIST may be able to provide some direction.

KU: Dr. Hunt can you tell me about some of your current or recent research and outcomes?

AH: As an occupational therapist by profession, I’m most interested in developing interventions to enable individuals with brain injury to participate optimally in meaningful activities.

Recently, I’ve been studying how self-management problem solving interventions can help adults and youth with mild traumatic brain injuries. Results from our initial work are very positive. People like these interventions and they are useful in helping people get back to doing activities as well as improving their mood. Our work is in very early stages though so more research is needed.

I’ve also been investigating how vision is affected following brain injury. Visual issues are not uncommon following brain injury. We think that in some people visual issues may be contributing to symptoms like headache and fatigue. Currently we are focusing on understanding and identifying these visual changes in youth following concussion.

KU: Where do you see research fitting in to rehabilitation and assisting recovery or helping to get people back to their daily lives?

AH: Research is very important in brain injury rehabilitation. We need to develop evidence to help us understand what interventions work for specific individuals-no two people with brain injury are alike! Participating in research may have benefits for brain injury survivors. By participating in an intervention study for example, there is the potential to benefit from the intervention itself, plus research participants typically feel good about participating in general because they are contributing to research and ultimately helping others with brain injury.

Although intervention studies may be hard to find, I encourage anyone who may have an interest to contact their local hospital’s research program. Being a research participant can be a very rewarding experience.

Find out more about BIST’s Exploring Concussions Speaker Series HERE

Register by March 31st at info@bist.ca

BIST Exploring Concussions Talk


 Karolina Urban is a former University of Toronto and Canadian Women’s Hockey League player. Currently she is a PhD student at the Concussion Centre in Holland Bloorview Kids Rehab Hospital