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Dr. Michael Smith (Host): Although some sports have higher instances of concussion such as football, hockey, soccer, concussions can happen in any sport or recreational activity. Welcome to The GW Hospital HealthCast. I’m Dr. Mike Smith, and today’s topic managing concussions. My guest is Dr. Gobindveer Sahi. Dr. Sahi is a primary care sports medicine and concussion specialist. Dr. Sahi, welcome to the show.

Dr. Gobindveer Sahi (Guest): Thank you Dr. Smith. Good to be here.

Host: So more and more I think my audience is hearing about concussions. I know it comes up a lot during football season. I know the NFL is focusing more on how to prevent concussions and manage that, so I think that most people understand the idea of a concussion, but maybe not fully what it is, so how about let’s start with what actually is a concussion?

Dr. Sahi: Sure, so for the general audience, you can sort of attribute a concussion to a contusion of the brain without actually having a mark. It’s a temporary change in the internal brain chemistry as well as hormones. There’s a complex cascade that goes on. Most of the time, over 95% of the time, imaging studies are going to be normal. It is a transient period. Most concussions will resolve in about 4-6 weeks, give or take a few weeks on each end and they are going to be temporary changes in brain chemistry, which will cause a variety of symptoms with regards to thinking problems, physical symptoms such as a headache or nausea, you can have mood problems like irritability and sadness, problems with sleep, affecting interpersonal relationships; so that’s sort of the general definition of a concussion.

Host: So how is it – are concussions rated? Obviously some may be a little bit more severe than others. Is there – if you are diagnosing it, is there a rating system for this?

Dr. Sahi: Well there used to be but there isn’t anymore. The analogy I give my patients, if you or a loved one heaven forbid have a heart attack, was it mild, was it moderate, was it severe, or was it a heart attack that we have to deal with. It’s sort of the same thing with concussions. We don’t really classify them as mild, moderate, or severe. Right now, it’s either you have a concussion or you don’t, and if your symptoms last for a period longer than about 6 weeks, then you can transition into what we would call a post-concussion syndrome.

Host: So how common is this? How often do you as a sports medicine specialist and a concussion specialist, how often do you treat concussions?

Dr. Sahi: Everyday, all day every day. It’s unfortunate but with our active population, or with the military population, people in the workforce, bad weather, any sort of slip or direct or indirect trauma to the head or the neck can result in a concussion, and I think it’s important to educate the population of certain warning signs, what might take place, but I have at least a few concussions everyday in clinic. I would say probably at least 30% of my sports medicine practice right now is dealing with concussions.

Host: Right and it’s not just from sports, as you mentioned, it could be a fall, a slip, a car accident, etc. I think sometimes the general audience might hear the word concussions and they automatically think you know, football, but it can happen in everyday life. You mentioned something that I think is important, like what are those warning signs? Let’s say we have a listener who fell, hit their head. What are some of the signs and symptoms they should look for that might tell them they have a concussion?

Dr. Sahi: So obviously a headache that wouldn’t go away with rest or hydration and/or Tylenol. Some danger signs if it’s worsening concussion also would be nausea or severe projectile vomiting. If you’re having fluid or blood dripping out of your nose or your ears or your mouth and sort of the most splitting headache of your life, those are danger signs which would mean you’d probably want to go to the emergency room. If you’re not experiencing those, you still would definitely want to follow up with a concussion specialist, and/or urgent care or your primary care physician, but we usually breakdown the concussion symptoms via an aid questionnaire. There’s four main symptoms, headings that we look for. One of them is problems with thinking. Obviously if you’re feeling a little slowed down, problems concentrating or remembering things, sort of functioning at your normal level. Physical symptoms would obviously be headache, as we said nausea or vomiting, problems with balance is a big one, changes or blurriness in vision, feeling fatigued and having sensitivity to light or noise. The mood problems would be if you’re sad or emotional or more nervous than normal. There can also be some sleep problems, if you’re sleeping more or less, problems falling asleep, so those are sort of the general symptoms to look for with a concussion.

Host: When do you suggest if somebody has a few of those. Obviously some of them sound a little bit more severe, like the blood issue or something, but other ones maybe not so, the mood issues, maybe just some of the muddled thinking. At what point does somebody actually seek help? Or should – or if you get a head injury of any type, should you always just go see help?

Dr. Sahi: You know if you’re standing up – it sort of obviously depends on the individual presentation and the individual patient. You know if you stand up and hit your head on a shelf like I did earlier this morning, hopefully you aren’t concussed, but if you do have one of those significant mechanisms of injury we talked about and you’re experiencing mainly a headache and any of the other symptoms, I would probably recommend going and seeking medical care immediately. Especially if it’s in one of our youth population and/or athletes, what we say is any sort of hit to the head or neck which causes any of these symptoms of the patient or the athlete would have to be pulled out of the game at once, evaluated on the sideline by a trainer, athletic trainer or another professional and then follow up with a physician. So again if you’re in a motor vehicle accident, you slip and hit your head, you’re horsing around or you’re a weekend warrior and you’re experiencing maybe more than two or three of those symptoms, I would probably recommend going in sooner rather than later. The reason for that is that it’s important to engage in about 48 hours brain rest, brain and physical rest for give or take two days, which means basically don’t do anything physical beyond walking and stretching and try to minimize the noxious external stimuli like light, noise, stress, re-injury. One of the important things about concussion is, it’s different from sports injuries. You know if you sprain your ankle, you can tape it up, take an ibuprofen, ice it, kind of gut through it, maybe your ligaments will be a little bit looser later on in life, but you know it’s an ankle. We got two of those, but you only get one brain, so if you push through your symptoms and the symptom is getting worse, that’s one of the – sort of the brain’s way of telling you, hey I need some rest and you should probably seek medical attention from your primary care physician, a concussion specialist, urgent care, that sort of thing.

Host: Is brain rest pretty much all we do or is there other treatments you might do based on the severity of the concussion?

Dr. Sahi: There’s quite a few different treatment options, and in the acute setting we would recommend – if the headache is bad you can take regular over the counter Tylenol or acetaminophen. We tend to stay away from steroids and/or the anti-inflammatories like Aleve, naproxen, Motrin, ibuprofen and whatnot. Just for the reason that if you overdue those, you can sort of get what we call a rebound headache. Sort of if you or me don’t have a cup of coffee in the morning, you might get a headache. The same concept is it thins the blood a little bit, so if there is a 2% chance of a bleed, you don’t want to have it bleeding more. So you would wear sunglasses to avoid the light, polarized sunglasses for outdoor light, blue tinted sunglasses for indoor light and screens. You obviously would want to put away anything with a screen, your iPad, phone, computer, tablets, whatnot. You wouldn’t want to over read too much. Obviously you would try not to overstretch things. One of the problems we find is that especially here in DC, we have quite a few intelligent high functioning individuals, so telling them to not overthink or overanalyze their symptoms and to just let your brain and body heal on its own, that can be a bit of a challenge as well. And then just the normal things, get good sleep, 8-10 hours of sleep at night, one hour nap in the afternoon. Again, don’t oversleep because you can get rebound headaches from that as well. Hydration is really important. Things with electrolytes, like any of the aids, Gatorade, Powerade, Pedialyte, water; good nutrition, getting your proteins and carbohydrates in. This is kind of relaxation. We don’t want to do complete social isolation so depending on the individual concussion and physician level of comfort, I normally allow my patients to walk a little bit, stretch a little bit. If they have a family dog, they can take them for a walk and just kind of observe them. Those are sort of the things we would do in the acute settings.

Host: So what if there’s continued problems. If you get through the acute setting and somebody continues to have headaches here and there, maybe the mood issues, does that tell you something else needs to be done?

Dr. Sahi: Well a lot of times with concussions, there’s also underlying – if somebody has an underlying disease process that can complicate things a little bit. Sort of like you said if somebody has an underlying anxiety and depression or learning disability or if they have a history of chronic headaches or migraine headaches, any previous history of neurological phenomenon, multiple sclerosis; those can sort of mimic symptoms of concussion. We need to weed through all of those things with history taking as well as the physical exam and kind of get to the bottom of things, but if we have ongoing symptoms with headache, balance, eye tracking, one of the nice newer things we have is, there’s actually physical therapy for concussions now where they’ll work on your eye tracking, your balance. A lot of times I’ll send patients to see a therapist for if they’re having mood problems because it’s very normal to be a little angry and sad after a concussion. So with the therapy and the physical therapy, those are a couple other things that we can do. If symptoms are lasting more than 6 weeks, there’s obviously medication we can use to aid with that and normally we don’t tend to image the brain until it’s 4-6 weeks out because, like I said, probably at least 98% of all the imaging is normal and in the acute phase if you’re worried about a brain bleed, obviously we would do a CT scan. Now that has radiation so you need to be careful about that, especially in the pediatric population. Later on if it’s subacute like we talked about 4-6 weeks out, we can always consider doing an MRI of the brain because there’s no radiation there. Maybe even a functional MRI or a functional EEG, we can check to see how the neurons are actually firing to see if there’s diminished activity in the parietal lobe, the occipital lobe, frontotemporal. There’s a lot of things we can do actually.

Host: So lots of information covered here. Fantastic information, Dr. Sahi. Let’s end this way, what would you like my listening audience to know about concussion?

Dr. Sahi: Well I think they’re very serious and any sort of trauma to the head or neck, and if you’re experiencing headaches and symptoms, I would definitely seek medical attention as soon as possible with your primary care physician, the sports medicine docs here at GW and one of the most important things is to keep a positive outlook on things because if you’re positive and you let your body and brain health with time. Most concussions will resolve within about a month. Don’t overthink things. See the professionals, and hopefully all will be well soon.

Host: Excellent summary. Dr. Sahi, I want to thank you for the work that you’re doing and thank you for coming on the show today. You’re listening to The GW Hospital HealthCast. For more information, go to gwdocs.com, that’s gwdocs.com. I’m Dr. Mike Smith, thanks for listening.