injury management

July 13, 2016 by Marla Shapiro Leave a Comment

“What do you say to athletes about concussions?”

I had a wonderful chance encounter this morning with a local high school football coach. When I told him that I enjoy talking to athletes about sports-related concussions, he asked me what, exactly, I talk about. My answer? “Common sense.”

July in Georgia marks the start of another football season and with that, a likely surge in the hysteria, folklore, and marketing dollars that have become part of the sports-concussion landscape. One of the most important parts of my job in managing concussions is to help spread accurate information – about what, exactly, concussions are and how best to manage them, so that when they do occur, the secondary fallout is minimized and youth athletes are able to return to the classrooms and playing fields as quickly and safely as possible.

So what, exactly, do I say?

First, I want to make sure we’re all speaking the same language and that athletes actually know what a concussion is. Despite the mandatory concussion education for GA high school athletes since 2013, I still find that injured athletes – many of whom see a few other healthcare providers before they get to my office – still don’t know what, exactly, a concussion is. And, if they don’t know what it is, how are they supposed to be able to manage it well?

When I explain what a concussion is, I also include discussion of how it affects the athlete.. for example, how an offensive lineman’s quality of play can be impacted by slowed reaction time… or what happens to a quarterback when dizziness spikes with rapid head and eye movements… or how about that cheerleading flyer who’s dizzy and thinking more slowly than usual? Add to that the increased pressure of a few AP classes and the cumulative effects of only 5-6 hours of sleep/night, and athletes can start to see that hiding their symptoms may not be the way to stay in the game longer or to continue support their teammates.

Concomitantly, I also talk about the role of an athlete’s common sense, self-awareness, and self-control in minimizing symptom increase during recovery, along with the importance of workload and classroom management. I acknowledge how our typical suck-it-up-and-play approach to sports-injury management can be counter-productive in facilitating recovery from concussion, and how we manage concussions very differently than we manage other sports injuries.

Finally, I also talk about risk management, and what athletes can do to minimize their own risk of concussion and prolonged recoveries. This can include some discussion of things like heads-up tackling, equipment and field conditions, for example. I also emphasize the importance of sleep, hydration, and good conditioning, what it means to “listen to your body,” and how to truly look out for teammates. Coaches and athletic trainers play key roles here, too, in creating and maintaining a culture that promotes player safety in addition to the competitive edge.

In a perfect world, conversations like this would be starting again across our state’s locker rooms, playing fields and gyms as pre-season practices begin. Let me know how I can help start the conversation for your team.

March 12, 2016 by Marla Shapiro Leave a Comment

Concussions and Persistent Dizziness

Why do some people experience persistent dizziness after a concussion? Good question, and while we are continuing to learn more about who is most likely to experience persistent dizziness post-injury, we do know that some people experience persistent symptoms associated with vestibular system dysfunction that will not improve without intervention – specifically, vestibular therapy.

The vestibular system is the sensory system that contributes the most to our sense of balance and spatial orientation for the purpose of coordinating movement with balance. This system includes the eyes, senses, and vestibular centers in the ears.

From the Vestibular Disorders Association: “Trauma to the brain can result in abnormal vestibular system functioning, and the brain can receive abnormal signals regarding the position and movement of the head in space. When vestibular information is inaccurate, the brain most often relies on visual input to stabilize the head on the body. This means that the visual system becomes the most reliable system to quickly assess one’s position in space and to remain balanced. Relying upon vision alone as the primary source of balance often leads to fatigue and difficulty performing routine daily activities. Reliance on the visual system for balance can result in eyestrain and tension headaches. If the vestibular system is delivering inaccurate information to the brain about the head’s position in space, the brain must rely on visual input and joint sensors (proprioception) to feel the body in space. Failure to effectively compensate with use of visual references and being aware of the surface on which on is sitting or standing results in dizziness and a sense of instability. Dizziness encourages a person to refrain from moving the head, and leads to neck stiffness and headaches. Presence of a whiplash associated with the concussion further complicates the diagnosis and suddenly symptoms limit the ability to participate in life activities. Activities involving rapid head and eye movements, sudden positional changes, complex visual environments, and removing visual input (e.g., dark room, eyes closed) can lead to increased symptoms such as headache, dizziness, and nausea.

Physical evaluation by a physical therapist with specific expertise in the vestibular system will include examination of balance activities that involve the vestibular, vision and proprioceptive systems, which reveals how the brain interprets movement of the body and head relative to space and the visual surround. A cervical examination determines if neck sprain or dizziness from the neck is contributing to symptoms and perpetuating headaches.”

Based on examination findings, customized exercises will be prescribed to use at home to rehabituate, to tolerate increasingly rapid and complex movements, until symptoms are fully resolved. With good compliance with the home exercise program and other lifestyle adjustments as recommended by the treating neuropsychologist, most people achieve full recovery within 6 weeks, though additional risk factors and medical conditions can prolong recovery.

Not all physical therapists have specific expertise in vestibular therapy, however, and not all vestibular therapists have specific expertise in working with individuals with concussions, so be sure that your provider has the appropriate training.

In addition to working with a skilled vestibular therapist, the following recommendations may also be helpful in minimizing persistent symptoms until recovery is complete:

For persistent dizziness, change positions slowly, and sit down if you feel too unsteady to walk. Increase surface contact – back to wall or chair, for example. Hold the rail while walking up or down stairs; if using stairs in a crowded school hallway, ask a friend to walk with you. Do not shower unattended, and be sure to have something to hold onto (a rail, or if not sit down), when closing your eyes. Find a stable reference point when walking – that is, focus on small objects 10-15 feet away. Avoid busy “box stores” and malls, crowded places such as school hallways between classes, and take walks in quiet areas without a rush of scenery.

For nausea, take cool sips of water, and apply a cool cloth to pulse points (e.g., wrist, neck). Ginger and sniffs of essential peppermint oil offer natural nausea remedies, too.

For light sensitivity, dim lights, and adjust computer and cell-phone brightness. Wear sunglasses inside and outside, and especially if bright lights inside can be a problem. Better to watch TV in a lit room with sunglasses than to turn off the lights, since the harsh contrast of a bright screen in a dark room can be a problem.

When rapid head and eye movements trigger worsening of symptoms, avoid driving or watching sporting events with a lot of back-and-forth movement (or sit far enough away that you can keep head and eyes steady). Video games can be problematic, too.

The most important thing that you can do to facilitate recovery is to do your home exercises as prescribed, and follow all of your doctors’ advice. When in doubt, or when symptoms do not improve, let us know so that we can help you get better!

For more information, go to www.vestibular.org and www.dizzy.com.

February 13, 2016 by Marla Shapiro Leave a Comment

So what does properly managed really mean?

After my last blog, a colleague messaged me privately and said that one thing he might add is, what does properly managed really mean?

Great question! While there is no gold-standard credential that denotes appropriate training or care, I’ll provide some ideas below, as well as red flags to watch for….

Do look for…

Providers with expertise with concussion management specific to the target age range – individuals who see all kinds of problems across all age ranges tend not to have the specialized training needed for concussion management in particular. See the membership list for the Sports Neuropsychology Society for neuropsychologists in particular with this kind of expertise http://www.sportsneuropsychologysociety.com/find-a-doctor/ .
Providers who work collaboratively with other specialists, and who don’t try to do everything themselves – concussions are multi-faceted injuries, and so you need a group of providers with different areas of expertise to assess different aspects of the injury, according to their own areas of expertise. As a neuropsychologist, for example, my expertise is brain-behavior relationships, so my training and expertise is in managing behavior, symptoms of brain injury, functional impact on learning and the return-to-learn, and in administering and interpreting tests of neurocognitive functioning. I also function as a case-manager, coordinating referrals among related healthcare providers which may include:
- PCP – keeping your primary care physician informed, and consulting as indicated
- Sports medicine specialist to evaluate physical – not the cognitive! – aspect of the injury (typically orthopedist or primary care sports-medicine physician, or athletic trainer)
- Physical therapist – evaluating or treating cervicogenic, balance-related, and vestibular aspects of the injury
- Neurology – for headache management, and ruling out more serious brain injury
- Behavioral psychologist – to facilitate stress management and sleep

Sometimes these providers work for the same facility, but not always – the important thing is a collaborative, interdisciplinary approach that transcends institutional boundaries.

It can also be helpful to know “red flags” that may signal less than optimal care. The science and practice of concussion management is a rapidly evolving field, and it can be difficult for non-specialists to keep up with changes in practice standards.

Some of the common myths and mistruths that we hear that suggest that a provider may not have the most updated knowledge or requisite training and experience include the following:

Primary reliance on computerized testing like ImPACT to assess recovery, and administration and interpretation by non-neuropsychologists. This is neuropsychological testing, and you want the experts in that interpreting results. Plus, it should only be one piece of the evaluation approach, and I really don’t need formal testing to confirm that someone is feeling badly and functioning poorly. I will use ImPACT, and a number of other evaluation tools, as needed to help inform clinical decision-making, but decisions to use these tools, and which tools to use, are made on an individual basis.

Providers who discuss ImPACT in terms of passing or failing scores – there’s no such thing.

Recommendations to remain at home until symptoms resolve or significantly improve – there is increasing evidence that prolonged bedrest and withdrawal from routine activities do not facilitate recovery and can even be associated with a worsening of symptoms.

Grading of concussions – concussions are no longer graded, or rated.

Providers who explain the injury by saying that the brain is bruised – an actual bruise is a more serious injury. Symptoms of concussion are associated with the metabolic (chemical) changes associated with a hard bump or jolt to the brain, and not a bruise.

Hearing that “it just takes time,” for weeks on end – 80-85% of young adults should recover fully in 2-3 weeks, if their injuries are appropriately managed, with 90% recovering fully within a month. Even when specialized vestibular therapy is needed, most experts tell me that full symptom resolution is typically attained within 6 weeks or so with compliance with the prescribed home exercise program, and in the context of a comprehensive management plan that typically includes lifestyle adjustments as well.

It is not necessary to carbo load, remove all electronics, remain home for set periods of time, or return to school in a scripted way – recommendations for concussion management should be highly individualized, based on the individual’s history, symptoms, risk factors and settings. Moreover, school-related recommendations need to involve adjustments to demands and workload that are specific to the individual’s symptoms, setting and history. While reduced screen-time is often recommended, it’s based on the person’s symptom threshold and how long screen use can be tolerated before symptoms worsen.

There is no such thing as “3 strikes and you’re out” – there is absolutely no medical or scientific basis for this, and decisions about retirement from sport are, like general injury management, highly individualized and based on many factors.

Neuropsychologists who insist on long batteries of neuropsychological tests without first ruling out other factors to treat – I rarely need to administer extended testing batteries, since I can usually identify areas needing intervention that might provide more plausible and treatable explanations of prolonged symptoms. Most often I see prolonged symptoms due to migraines (for which I refer to neurologists), vestibular deficits (for which I refer to vestibular therapists), or poor stress management, cognitive overload, inadequate sleep and/or hydration, which I address in a treatment plan or for which I provide referrals to behavioral psychologists if additional help is needed. Unless a child or adolescent athlete has a very complex medical or concussion history, hours of testing should not be needed, and especially not before other avenues of evaluation and treatment are explored.

February 12, 2016 by Marla Shapiro Leave a Comment

Media Attention & Concussions –-
Too Much of a Good Thing?

The steady increase of media attention to concussions has largely been a good thing – with increased awareness comes increased scrutiny and education. The downside, though, is that it also seems to bring with it a lot of inaccurate information that is frequently sensationalized to grab headlines. Sometimes it’s intentional, sometimes it’s not.

Along with the media hype, we also see an increase in personal testimonials, also with their pros and cons. Folks love a good story – especially a comeback story! – and it’s also very helpful for individuals who are struggling to realize that they’re not alone, and that there’s hope.

What’s most frustrating to me about these testimonials, though, is when they seem to inadvertently convey mistruths about injury and recovery. A recent release by the CDC – typically a source of balanced, trusted information – seemed to do this and left me feeling particularly compelled to respond because their concussion-related information is characteristically well-researched and accurate.

The most troubling thing to me about this article was how it described this athlete’s months-long recovery; the absence of any critical or editorial comments about that aspect of this athlete’s injury seemed to convey that this is typical, when it absolutely should not be. While we know that everyone recovers at their own rate, and that risk-factors such as one’s history of previous concussions, psychiatric issues, and medical factors can prolong recovery, it’s widely accepted that 80-85% of young adults will recover fully in 2-3 weeks, with 90% achieving complete recovery within a month, if properly managed.

Note the emphasis on proper management – this, too, will vary from person to person – there is no one-size-fits-all handout or formula that truly works – but will generally include such factors as:

Adequate sleep (8½ – 9½ hours for most adolescents, which most don’t get), hydration (64 oz water/day, min) and nutrition
Appropriate lifestyle adjustments – remaining engaged in school and social activities, but with sufficient adjustments and supports to remain sub-symptom threshold, with gradual withdrawal over recovery
Headache management – by a good neurologist with particular expertise in concussion-related headaches; I refer if headaches are persisting past a week despite appropriate behavior changes, with consideration of cervicogenic causes, too
Vestibular screening / therapy – if dizziness is persisting past 2 weeks, I will refer to trained PT’s with expertise in vestibular evaluation, orthopedics and strength/sports conditioning
Consultation with cognitive-behavioral psychologist if stress and wound-too-tightness are interfering with treatment compliance

So, when I hear stories of recovery extending over many months, I not only wonder where things went wrong, I am also concerned that this will only serve to perpetuate the “suck-it-up-and-don’t-tell” culture out of fear that one’s likely to miss the season if symptoms are reported.

I much prefer the CDC’s mantra – “Better to miss one game than the whole season” – but we need to make sure the stories that are circulated behind it are consistent, and that they represent the current best standards of care. Or, if not, that there are at least some qualifiers for the lay public and related healthcare providers who would not know differently and otherwise presume that this is just the new normal.