Episode 1 - Diagnosing a Concussion: The Physician's Perspective

 
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Episode 1 - Synopsis 

Moderator: Steph Dallaire (Family Doc)

Panelists: Alex Weiler (ER Doc), Kristian Goulet (ER Ped), Shannon Kenrick-Rochon (NP), Sean Robb (Neuropsych)

Episode Description: Dr. Steph Dallaire leads a discussion with other doctors, a nurse practitioner and a neuropsychologist from across Ontario to speak about the complexity and challenges of diagnosing concussion/TBI. 

how to listen

Main Points, Timestamps, Themes & Resources

Challenges in Diagnosing Concussion – 5:30

  • Competing interests in the emergency room – sometimes can be hard to give a thorough diagnosis when doctors get pulled from one place to another.

  • In the emergency room they first check for life threats such as bleeds or damage to the neck with the limited amount of time they have.

  • The symptomology of concussion can have a number of different factors to consider so they often need to figure out whether symptoms are related to concussion or other factors.

  • There is a possibility of developing new concussive symptoms after the emergency visit or throughout the next few days of recovery.

  • Oftentimes there’s memory problems surrounding the injury which is why it’s always helpful to have someone who witnessed the injury when visiting health care practitioners. 

  • Anxiety around the injury can also impede memories.

  • Lack of education and awareness can make it difficult to recognize concussion outside of sport.

Initial Management – 12:02

  • Begins with education and reassurance in the emergency room.

  • Recommended 24 to 48 hours of rest.

  • After 48 hours start pacing back into activities that do not involve the risk of reinjuring like sports or activity in confined spaces.

  • It’s important to limit physical and cognitive activities for the first 24 to 48 hours which means reducing screen time, reducing driving, and reducing physical exertion.

  • Research says that it’s important to paint a positive picture of recovery. 

  • Often after the first 48 hours it is highly recommended to get some sort of routine and socialization back into the person’s life.

  • With persistent cases it’s important to identify symptoms that are non-concussive or that there isn’t an underlying factor that could be preventing healing such as metabolic or mental health issues.

  • It’s important to understand who your patient is. Some people hold back from doing activities and others are too aggressive in their recovery process.

  • In some cases, thinking of the injured brain like building a new user’s manual can be helpful for people learning to cope with persistent symptoms and adapting to their new way of life.

Children and other Vulnerable Populations - 19:06

  • With pediatrics it’s important to consider other factors that could be preventing healing.

  • Important to not make children or adolescence “feel sick” and to focus on a holistic approach to their health. 

  • Consider the environment they live in, their mental health and other stressors that could be in their life.

  • Just as adults need structure when recovering, kids also need some normalcy in their recovery.

  • Children or adolescence in school is very important and sometimes is best for them to be in school even if they aren’t learning anything. 

  • School provides socialization and structure into their life during recovery.

  • Children or adolescence tend to compare their recovery to athletes they look up to, but it’s important to note that their recovery is different. They’re not making millions of dollars, nor do they have access to all the resources these high-end athletes have and it’s okay not to fit into that timeline. That is why an individualized approach to recovery is typically recommended.

  • Reassurance for both the child, adolescent and parent is very important as hyper awareness of head injury can be an issue. 

    • Example: A mother who has a history with concussion may be hypervigilant when, or if her child gets hit in the head – whether or not any concussion symptoms are present.

  • “Sleeper Effect” is when there is delayed onset of symptoms particularly with executive function and frontal lobe activity - this makes it difficult to diagnose children in the early stages. 

  •  Adolescence can be difficult to understand when considering whether or not symptoms are a result of everyday stressors or due to concussion.

  • There are several differences in attention between anxiety, ADHD and concussion. The “Interaction Effect” between the three can play a role in the recovery process.

    • Anxiety: attention is looking for threats

    • ADHD: attention is easily distracted

    • Concussion: stuck or unable to shift attention

  • The developing prefrontal cortex is affected by anxiety, ADHD, and concussion in children and adolescents – this makes it hard to diagnose and manage in real time.

  • Minimizing symptoms can make it difficult for a physician to help children or adolescence going through the injury. This is often present with children or adolescence playing sport.

  • Erring on the side of caution is typically the best protocol.

  • Emergency department will not always make a diagnosis if they cannot say definitively someone has a concussion or not. Afterwards they will give clear instructions for a follow up or next steps.

  • Focusing on symptoms individually and referring to specialized care providers when necessary is a pathway for concussion recovery.

What Happens When There is No Primary Care Available – 32:30

  • Offering resources and spending a bit more time explaining the potential ramifications of the injury with the patient is a key component for an ER doctor when this is no primary care option outside of the emergency department. 

  • Pointing to more resources they have access to, ensuring further education on the injury. 

  • Reassuring they can come back to the emergency department if they are not progressing.

  • Offering the OBIA pamphlets and Parachute Protocols can guide them in the right direction.

  • For children or adolescence under the age of 21, they can be referred to the online Holland Bloorview specialized concussion clinic.

  • Try to follow up with the same walk-in clinic - although this can be a challenge in rural settings.

  • People can use physiotherapy and/or chiropractor follow-ups on a weekly basis if they’re already seeing them.

  • There is a need for primary care providers to stay up to date on concussion management as there are not enough specialists to see all concussion cases.

  • Supporting primary care providers is paramount to ensuring people get proper concussion management when there is not specialized clinics.

Sleep Management – 40:00

  • Sleep in an incredibly important aspect of concussion/TBI recovery. 

  • Anxiety can be looked at the opposite of sleep.

  • What a person thinks about when going to sleep matters as much as their sleep winddown routine. 

  • It can be very hard for a brain to transition to sleep when there is activity or stimulation close to the time of sleep.

  • Mindfulness or meditation approaches to sleep can be a helpful tool.

  • Research suggests that 85% of Post-Concussion Symptoms (PCS) can be attributed to poor sleep, therefore sleep is a major component of recovery.

  • The quantity and quality matters, making sure patients are getting proper REM sleep and being mindful of sleep apnea.

  • Sleep is where reprocessing of stimulus happens in the brain.

Resources – 45:30

 
Ryan SuttonConcussions, Mental Health, Health care, Family, Traumatic Brain InjuryComment