Scott Webb: Concussions are common in sports and in life.

And I'm joined today by Johanna Dicks.

she's an occupational . Therapist; Brad Keck, physical therapist; and Kayla McConnell, speech language pathologist, and they're all with Franciscan Health. And they're here today to explain concussions and tell us how they can help with the symptoms and get us back to playing, working, and so on.

This is the Franciscan Health Doc Pod. I'm Scott Webb. So, I want to thank you all for joining me. I've certainly had concussions. My kids have had concussions. Many people have had concussions. But I'm not certain, Kayla, that we all know exactly what happens when we have a concussion other than maybe the symptoms which we're going to get to. So, maybe just as a baseline here, you can explain to folks what is a concussion, like what happens?

Kayla McConnell: A concussion, really people don't often realize, is actually a type of traumatic brain injury. It's often classified as like a mild traumatic brain injury. Concussions can happen, you know, all of a sudden and unexpected, either can be like a blow to the head, a jolt, even a shaking effect. Even whiplash can result under the type of concussion with like a coup and contrecoup effect. But really, it's any type of brain injury that happens because of an injury, an actual event, and then causes like just changes to the way the brain can function.

Scott Webb: Yeah, I see what you mean. And yeah, like a lot of injuries, sometimes it can be some sort of an acute blow to the head.

Kayla McConnell: Yeah, absolutely.

Scott Webb: Sometimes It can just be whiplash. And then, you know, of course, we're going to talk about the signs and the symptoms to know, you know, what is this, what's going on exactly. Before we get through though, Brad, who's most at risk? You know, who's most prone to a concussion?

Brad Keck: In the media, we all hear the primary one, which is athletes. You see this a lot in pro football. It really kind of brought concussion onto the map, so to speak, into mainstream. So, we can start there. Athletes definitely are at a higher risk of a concussion and some sports more than others. If you look at some of the latest research, football, ice hockey, soccer, lacrosse are all at the top of the list for high school sports. College professional sports, the big one, obviously football. And you know, in professional football, we actually just heard on the news that there was an uptick of concussions in the NFL last year despite all the research and R&Ds that's gone into preventing them. So, it's still a big issue in the sports sector.

Where people aren't as obvious into their concussion is people that are at risk of falls. We see a lot of people here who fall, slip on the ice, fall down the stairs; individuals who are dealing with, something called syncope where they lose consciousness, fall, hit their head from an unprotected fall; and other things like, you know, domestic abuse. We've had people with concussions from domestic abuse, repeated blows to the head, just like Kayla mentioned.

Anybody who, for whatever reason, would put themselves at a greater risk of exposure to hitting their head is at a higher risk of a concussion. And since we've started our program, we have seen and really opened our eyes into how many individuals that could be, other than the obvious one, which is athletes.

Scott Webb: Yeah. You're so right and especially about football. When you think about, as you say, all the research and development, I think about the helmets that I wore, you know, when I was a kid and played in high school, and you look at these things today and you think how, how could anyone have a head injury with something so amazing? So much money has gone into those things. But the reality is, you know, the brain and the brain banging into your skull and getting a bruise on your brain, like your brain doesn't know how much the NFL spent on those helmets, it doesn't care. And I think, Johanna, one of the things that's probably a little scary for folks, and probably scary for folks like yourself who want to help people, is that many people either may not realize they have a concussion and/or understand that there's actually things that can be done. I think the old school way was, well, you know, you lay down, you close your eyes, or you wear some sunglasses if you have the sensitivity to light or whatever it might be, and you just kind of wait it out, right? And I think we want folks to know that they don't have to suffer, they don't have to wait it out, that folks like yourself can actually help, right?

Johanna Dix: I think it is important that it's not super commonly known that some of these concussions can last a long time. But most concussions, acute concussion, they last a short amount of time. And mental, physical, emotional rest is really important for recovery. So, you know, those kind of acute, or meaning like short term right there in the moment of a few days, the typical stuff that you're going to see is having a headache, which makes sense since we banged our head into something. Some people might lose consciousness for a little bit and have a little bit of amnesia around the event. That's probably a sign it's a little bit more significant and a true mild one. Some people feel like they get foggy brain or they're like kind of feeling very cloudy in their thinking. They might feel dizzy, get like ringing in their ears, even like up to nausea and vomiting and things like that. Those are kind of our classic signs of an acute concussion. And for most people, that kind of stuff does clear up if you actually rest. Some people are like, "I can tough it out and pull myself up by my bootstraps and..."

Scott Webb: Rub some dirt on it and, you know, get back out there, yeah.

Johanna Dix: I can't even count how many people have been like, "Well, I just went straight back to work or straight back to my sport" or what have you. And that puts you at a pretty high risk to tie into, you know, who's at risk. You're at risk for having another one if you don't take care of the first one. So, it's really important to get rest. But then, there are some people where they're like, "Well, I've been waiting it out and it's been a couple of months," it's time to not wait it out anymore and it's time to take care of yourself. And some of the stuff that we see that sticks around are headaches. If they're not usually prone to having headaches before, they're not migraineurs prior, then that's something to look into. Persistent dizziness that's not normal, that needs to go. A big one is just consistent fatigue, lots and lots of fatigue, lots of sleeping at inappropriate times during the day, like sleeping way too much or having a really tough time falling asleep and being awake at 4:00 AM and wondering why. Memory issues and loss of concentration. I have a lot of people tell me like, "I feel like I'm stupid." You're not. Your brain has been injured. And then, a big one too that most people don't think about is actually vision issues, where people will have blurry vision or have a tough time reading, get headaches when they're reading. A student at school will just be really struggling with reading comprehension and not doing well on tests, but they've typically been a B/A student. So, those kind of things can be the stuff that sticks around.

And then, the other piece that a lot of people don't think about quite as much either is all the mental and emotional pieces too. Anytime our bodies undergo trauma of any type, anything that we haven't compensated for or haven't addressed previously, like if there's anything going on like anxiety or depression or any sort of diagnosed mental health disorder or a sleep disorder, et cetera, those things tend to rear their head post-trauma. And so, we find that people really benefit from either getting back into or getting involved in counseling and therapy in that regard to make sure that they're able to compensate with everything that's going on, because it's a lot.

Scott Webb: Yeah, it definitely is a lot. And Brad, so let's assume that somebody had a concussion and they did the right things, right? They took Johanna's advice. Rest, try to recover, don't just rub some dirt and get back out there. They did their part and yet the symptoms linger, whatever they may be. And as Johanna was saying, there's a multitude of them. So, what I want to have you do then is talk about the different therapies and how you can really help patients who are really suffering from, I don't know what the terminology is, but let's just say long-term concussion symptoms.

Brad Keck: That's right. Yeah. And the term that you're seeing out there now for the last several years is post-concussion syndrome. And to tie in, you know, into what Johanna was saying, we see a lot of these individuals. And what we found is developing a multidisciplinary program that involves physical medicine and rehab, at least here, that could also be neurologists that oversee this program, nurse practitioners, physician assistants, neuropsychiatrists, physical therapy, occupational therapy, speech therapy, just an entire team when these symptoms tend to become chronic over the course of weeks to months, is where we're going to get our best results.

As for each one of them and what each one does, it very much ties into what Johanna was also saying about the different symptoms. For example, I'll, you know, kind of discuss about the PT side of things. With the concussion, everybody can be different, and we've even broken up concussions into different categories. There's headache, primary headache concussions, primary dizziness concussions. There's emotional cognitive form of concussion where they have that as their primary lingering symptom.

I would say, you know, I'd ask what Johanna and Kayla think, but we tend to see where all of these things are playing a part. In particular, if these individuals had migraines prior to the concussion or maybe they had emotional cognitive problems, ADHD, PTSD, anxiety, depression, after their concussion, what we would call their chronic condition worsens. And we find that in our program, it comes back to some of those things that were preexisting and actually end up being risk factors for developing a chronic concussion or post-concussion syndrome.

As far as the physical therapy aspect of it goes, everything from treating neck problems depending on the mechanism of injury, you know, somebody could have a strained neck muscle, problems in their cervical spine, and that can also feed into their headaches. So, we can do different treatment approaches to try to reduce the cervical strain, the neck strain, the muscle tension to see how much that may help the headache aspect of things.

In addition, like Johanna said, most of these individuals have some form of dizziness, disorientation, not necessarily a spinning sensation, which is what we've commonly refer to as vertigo, but just disoriented. Also, we'll use the term as sensory overload, and what we can do in PT is try to help ground them, help them avoid or learn how to not allow that disorientation to occur. For example, the students in a choir class with a lot of noise and echoing or band or in the cafeteria or in the hallways between classes or, for adults, in the work environment, in a busy workroom or at the grocery store or at a stadium, a ballgame, they get into sensory overload, they become dizzy or disoriented. So, we'll work with them on that aspect of it, trying to educate, teach them strategies to try to learn to get control and not allow all that sensory information to disorient them.

Another thing then are your just common balance problems, instability, walking difficulties. The thing is, is a lot of times this disorientation and dizziness is what's affecting their balance and walking. So, there are a lot of times we're just working on the disorientation and the dizziness, their walking and their balance naturally improves, but we'll monitor that, we'll test it, we'll do some computerized testing to monitor that progress and make sure that they're doing well. But for like the occupational therapy side of it, I would ask Johanna if she can talk about that and Kayla, definitely the speech therapy side of it.

Johanna Dix: Yeah. We definitely call Brad the headache king over here. He does some serious magic work.

Scott Webb: And you mean that in only the most positive way, I gotcha.

Johanna Dix: Yes. No, he is not a headache, I promise. And it is really amazing to watch people come in incredibly dizzy and then see a PT for only a couple of sessions, and then they're like, "Oh my goodness, my world is now no longer moving. What a plus." Since I'm an occupational therapist, our OT side of things, I feel like definition of terms is helpful because not a lot of people are super familiar with the term occupational therapy, but it's not just returning to work or your occupation, but occupation is kind of defined as the things that occupy your time that are important to you.

And so, in OT, we are trying to get people back to the functional things in their life that they're missing right now. Whatever it is that this, you know, brain insult caused, we're trying to help move some of those things out of the way, so that they can be more functionally independent. Whether that's the simple stuff, like, "I want to get back to baking cookies for my grandkids and I can't do that right now" or whether or not that's, "I need to get back to my work," this is a Worker's Comp patient and like we are really trying to get back to work as soon as possible. Or a student trying to get back to school and back to school full-time.

I think the OT portion that we specialize in the most here in this clinic is making sure that we develop appropriate accommodations in collaboration with our sports med or physiatry or physical medicine or rehab physicians or neurologists to make sure that students, people in the workplace have good accommodations appropriate for what's going on with them, so that they can be successful at work. And then, helping to make some specific, like graduated return-to-work programs, so that people don't-- like we said earlier, you don't just jump in. Typically, if people just try to go back to school full-time or back to work full-time and they're having these post-concussion lingering things, it can sometimes set them back because their body is just not ready. And it works on overload and it doesn't have time to heal. It's spending all of its time trying to survive.

And then, in a very specific portion here at our clinic, we've developed a vision rehab program and the OTs have taken that piece. So for our people who have some visual issues, sometimes their balance and dizziness issues actually end up being vision-related. Because if your eyeballs are not telling you the correct things, it can make walking in a straight line a little hard. And so, we've developed a program in collaboration with a neuro-optometrist, who is fabulous, at the IU School of Optometry. And we've developed protocols with him, so that we can help address people's vision issues. And that typically ends up being stuff like double vision, blurry vision, headaches when reading, things like that. And so, we have some very specific treatments that we do for people with what we call binocular vision deficits, where one eye is doing something very different than the other, not sending the correct signals to the brain and not giving good brain information and not functioning appropriately. And that can show up as a cognitive issue, interestingly enough, and it looks like they're having trouble remembering what they've read. But sometimes we can solve some of those issues ahead of time if we focus on the vision. Because then once the eyeballs see what they're supposed to see, then it makes a lot more sense to the brain. So, we collaborate a lot with speech therapy who does our cognitive piece. So, I wasn't intending to do that segue, but that's a great segue to talk to Kayla about speech therapy. I didn't plan it, but I tried. So yeah, Kayla, tell us all about the cognitive piece in speech therapy.

Kayla McConnell: A lot of people don't even realize what a speech therapist does, especially in an outpatient setting, to work on, you know, like this cognitive piece because we're called speech therapists. So often, the first time I ever see a concussion patient, the first thing I say to them, is I ask them, "Do you know why you're seeing a speech therapist today?" And almost unequivocally they say no, because they don't realize that we're actually working on more of this cognitive piece, not their actual speech.

Typically when a person has a concussion, they don't have any kind of true speech impairment, but rather we're working on these cognitive aspects, things like language or word-finding, memory, attention, what we call executive functioning, which is like planning, prioritizing, having a thought, being able to organize it and like execute an action as well as some visual-spatial skills. So, those are our big goals. But the reason why those things are important is because it relates to, you know, how we do our job or how we're driving or how we manage these IADL tasks that we have, things like medication management, finances, going to school; like Johanna said, getting back to whatever it is a person wants to get back to. If that's doing word search puzzles and being able to, like Johanna said, bake cookies for their grandkids, that's a great functional goal.

So, a lot of what therapy looks like is, well, actually, we start with an evaluation on day one in the assessment that we typically use to evaluate cognition. It's called the RBANS, which stands for the Repeatable Battery for the Assessment of Neuropsychological Status. Again, that sounds like a big bunch of big, fancy words and I tell that to my patients. But really, what that means is we're going to take a look at all the cognitive aspects that I already talked about. And a lot of times honestly, with concussion, it's very, very common for an individual to take a test like the RBANS, and it is standardized, meaning it compares them to like age-matched peers. It's not a pass or a fail, like a test you might take in school. And I tell them that, because a lot of times they do end up scoring within the normal limits. And that's doesn't mean they can't benefit from speech therapy. It just means that, you know, sometimes it says they are scoring normal, but their functional complaints are a lot more severe, meaning like their true cognitive status might not be too far off their baseline and like a snapshot in time. Because a lot of times what they're really struggling with is what's called cognitive fatigue. And I tell them too what cognitive fatigue looks like. As you know, often patients are able to mentally complete a complex task, but the amount of like mental effort it takes is astronomically more than what it would've previously cost them. So, part of it is also honestly education about what's called like somatosensory tracking, kind of relating how these like physical aspects, just like Brad and Johanna already talked about, things like cognitive health and physical health, I say, are like a good marriage. They depend on each other

So, patients with PCS often mirror like a chronic illness at the point where it's like really in this post-concussion, you know, range after a few months after injury. And I tell them like, "Think back even to a time when you were sick or had the flu." It's like likely, you know, in real life you experienced like headache, fatigue, dizziness, nausea, all these really common concussion symptoms that can be ongoing. When you had the flu, obviously you didn't feel a hundred percent with your cognitive functioning, of course not. You know, that's not how our brain is functioning when we're dealing with these illness symptoms. And then, folks with concussion have that for much longer, so of course they're not functioning in their daily life at 100%, which is a great reason as to why these patients benefit from this like multidisciplinary approach. So as they make progress with, let's say your balance, make progress with their headaches, their vision, it's likely that their perceived, you know, cognitive functioning will also improve as these other aspects improve.

In the meantime, patients are like, "Okay, you're telling me that my vision and my physical health has a big impact on my cognition. So, how do I in this moment help myself remember something new or pay attention while I'm paying my bill if I still can't do those things and I'm not making good enough progress yet with these physical aspects?" So, what we do to help with that is I focus a lot on, again, what I mentioned earlier, this somatosensory tracking. So, that looks like, you know, implementing like a rating scale, like a good way to systematically track sleep, pain, activity level and headache, and then directly compare that data to their irritability, their fogginess, their worsened word-finding, whatever symptoms are most relevant to them, to see if you can find some good patterns to see how that physical and mental health are impacting their cognition, because your cognition will likely always follow suit. Having a bad day physically, you're probably going to have a bad day cognitively.

The spoon theory is a way that we do this in a little more even research way. So, the spoon theory is a type of theory to track expended mental effort and correlate this information into like balanced schedule planning around cognitive energy conservation. So really quick with that, it's kind of like taking like a proverbial spoon, representing like one unit of cognitive energy, taking that data to see if we can plan out a day more effectively, to have more mental energy throughout an entire day from beginning to end.

Johanna Dix: I feel like it's important for people to remember that like we are complex systems of a heart and mind, a body and a soul. And there's so much in us that it just all gets really tangled when there's trauma of any kind, whether or not that's physical trauma, emotional trauma. Whatever kind of trauma it is, it's a multisystem effect. And that's why I love what we do in our multidisciplinary clinic. My dream is for it also include counseling because that's the part we're missing. But that's what I think is really important about it, like "Let's look at your entire body." "I know." Nudge, nudge. "If anyone wants to talk to me about it, please call." But that is what I love about our clinic is that we're able to give more than just "You are a body container. Let's make sure, you know, your muscles feel good. And okay, bye." We are very well-rounded to be able to say, "Hey, this piece of you is affecting this piece of you is affecting this piece of you. Let's address all of you," because it's so tempting to just think of ourselves as containers of muscles and bones, and we're so much more than that.

Scott Webb: Yeah, that's perfect. I was just thinking while you were saying that, Johanna, it's that sort of mind, body, spirit, soul approach. You know, that it's not just fixing the physical ailment because what led to the physical ailment or injury, whatever it is, and how that's affecting you, not only physically, but mentally, emotionally. There's just so much going on and you guys do so much. So again, thank you all and you all stay well.

Johanna Dix: Thank you, Scott.

Brad Keck: Thank you, Scott. Thanks for having us.

Kayla McConnell: Thank you.

Scott Webb: And for more information, go to franciscanhealth.org/rehab. And if you found this podcast helpful, please share it on your social channels. And be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.