Welcome to a discussion about concussion I'm Geoffrey Lauer with the Brain Injury
Alliance of Iowa and I'm pleased this morning to be with Megan Andresen and
Rene Crumley. They're both physical therapist with UnityPoint - St. Luke's
Hospital in Cedar Rapids. Megan and Renee, thank you for coming. So we're talking
about concussion today and you're both physical therapists and you work in a
rehab program here. Are are there specific kinds of therapies that are
recommended for a child, for example, after concussion? Well often physical
therapy and occupational therapy may be recommended and they would first start
with more of a detailed interview so they can review and ask questions on all
the typical concussion symptoms that may occur. As everybody knows no two
concussions are the same so there would be an individualized treatment plan kind
of developed right away, but first you got to figure out what's going on and
then physical therapy would look at probably various sources of dizziness
that could be coming from, and then figure out the treatment for those
reasons. Physical therapy may also look at
balance, they would look at how well somebody can see an object while their
heads moving, because they're definitely exercises can be done to improve that
reflex. Physical therapy would look at their neck and shoulder muscles, if
there's anything going on there. Occupational therapy would look at
and focus more on the thinking skills, so like memory, attention can they multitask,
how well they multitask, in the reaction time. And therapy in general definitely looks
at trying to provide modifications so how they
can improve their home, their work, their school environments, and then, you know, of
course, look at exercises they can do to get their symptoms to improve. Wow, really
holistic approach. For sure, so team work. It's a team, it is a team approach it
sounds like. This is often provided to kids, in this case, with concussion that
don't recover, if you will, in that first four to six weeks.
Fortunately the literature suggests about 70 percent of kids will recover but this
is for that 30 percent that have more persistent symptoms, so how do people get
access to physical therapy and occupational therapy if they have those
kinds of persistent symptoms? Typically they're gonna be following up with their
primary care provider, especially if say. they entered the emergency department
or Urgent Care, they will have a follow-up within a few days and then
they would continue following up with that primary care provider and have that
discussion, you know, do I need physical therapy or occupational therapy? Ideally
when in doubt, order it, and then we can screen, we can give them ideas, definitely
provide a lot of education to try to help reduce the symptoms that they're
having. We know in the brain injury world that early intensive and specialized
treatment makes a big difference in recovery, is that that's also the same
with mild brain injury and concussion? I would say yes and especially more and
more research is even coming out now that you know after that first 24-48
hours, more active exercise is best and physical therapy, especially in
occupational therapy, can help navigate that world of how much you can do
without making your symptoms worse. So some challenging symptoms that may
occur after concussion are problems with balance, dizziness, and difficulty
focusing visually. Why does this occur? Well I think there are lots of reasons
it could occur some it's just concussion is a energy crisis when it happens and
often we don't have the energy that we need to to take care of these things
our brain and eyes and ears work together and it's a very complex system
and you can break down in so many levels. You can have problems with your gaze,
stabilization, your ability to see clearly when you're moving, you could
also have a problem with the way your eyes and ears work together. Some of us
are born with something like a lazy eye and often after a concussion that can be
worsened even if you've accommodated for it in the past, you could have a problem
with your ability just to move your eyes and read and be dizzy with head
movements. You could have a problem with your balance because you know the inner
ear is right behind this part of your head and if you hit that part you could
get a concussion of your inner ear and so your balance could be impaired. We
know now that many people have trouble with blood pressure regulation after a
concussion so they could be lightheaded or dizzy from that and that might be a
reason. There is some evidence that anxiety and depression can play a part
if someone is prone to that sort of thing and there you can have a
post-traumatic migraine, especially in someone who's maybe had a propensity
toward migraine fire. So if you've had some other symptoms before you have a
concussion, it sounds like concussion isn't like the
best thing for them. Obviously it can make them worse. Yeah. So that's part of
that can be part of the triggering component as it can. So you also said
earlier that there's an energy crisis. Is that like the whole body or
are we talking about the brain itself? In the brain, the neural
modulation of the brain, the way the neurotransmitters work, those
kind of things it's very complicated. Can I solve that by eating more energy, just
eat more candy bars? No, so it's just wait and recover. Time and make, yeah, pathways.
Thank you. So are there specific triggers for those
kinds of things to happen? Mental fatigue is likely a big factor. Other factors
could be visual demands, or busy, loud environments, complex thinking skills, or
tasks that you're doing. Quick head movements definitely could bring it on.
Sleeping issues, a big issue as well. It's all symptom driven so, for example,
if, you know, being on your screen or your tablet or your computer your phone is
giving you a headache, or causing another symptom to get worse, then we need to
look at reducing that. You want to increase the activity as your symptoms
improve you don't want to do too little, but you don't want to do too much either, so
you got to find that sweet spot where you can still do activity, but not make
the symptoms worse. Got it. So when we talked about the energy crisis combined
with that a mental fatigue, is there are the different parts of the times of
the day that might be more challenging for a young person, morning versus
afternoon, do we see these symptoms jump out in any given time? Well a lot of
times you might feel okay in the morning and then you go and then, especially if
it's those mental tasks, and the mental fatigue is gonna bring it on. You may be
up doing okay at school for that first hour, hour and a half, and if you're not
taking the needed rest breaks to make sure you don't burn out of gas, then
you are likely gonna kind of do yourself in maybe for the rest of the day. Where
if you would have had scheduled rest breaks mid-morning, late morning, you
might make it through that whole day of school which is ideal, we want to keep
kids there all day and not just go for the first two hours. I love your analogy
about burning out of gas. It sounds to me like before a concussion
there may be a larger gas tank that you're able to refill, but after
concussion the tank might be smaller. Yes. And so the rest periods are ways, to what,
to fill the tank up? To fill the tank up and to not burn through it so soon. Got
it. So, yeah, that's a hard one. So the question is, does the tank typically get
bigger over time and you'll recover? Yes. Okay, so therapy seeing physical or
occupational therapy might help that tank get bigger quicker, is what-okay
thank you. What can be done to treat or support people who have these types of
concussion-related dizziness or visual symptoms, vestibular symptoms? Are there
any usual or typical treatments that you guys use? Typically we work with the
vestibular ocular reflex, which is how we see clearly when we're moving our head
so there's some specific exercises. It's very individualized on everybody, you
know, no two are alike, everybody's a little bit different. Their tolerance to
things is a little bit different, but we typically do vestibular
ocular exercises, balance work, graded exercise to try to get that regulation
of the blood pressure and heart rate and symptoms back together and increase
activity. Sounds pretty technical. If I were to come in for a typical PT or OT
experience, what might I expect? What would be a usual or typical
encounter with a PT or an OT? For concussion? Yes.
You know, the first visit we're gonna try to figure out and tailor
what's going on with them because somebody might not have dizziness, they
may have more difficulty with headache and that mental fatigue issue so we've
got to figure out first what are their symptoms and what is going on in their
daily life, and then from there we can figure out which exercises they may need,
or which education they may need. A lot of times the sooner they can get
education and know what they can do that's making themselves better or worse
is going to make that concussion hopefully not last as long if they're
taking care of themselves the way they could be. So connecting those dots is a
way that you can make that difference. Got it. Are there any differences you see,
for example, or any therapeutic differences you have between men and
women? Or younger versus older, younger kids versus older kids? I don't think
that is very supported in the literature. I just think it's all so
individual, you know. Kind depends on, you know, what was going on with that person
even before the concussion, can often and, what's going on in their life in general,
with the concussion sometimes can make it. Or, so, a lot of times you may see
those younger kids bounce back quicker because, quite frankly, they may not have
as much going on they may not have as much stress in their life, they may not
have you know it's just have to deal with as much life in general they may
bounce back a little quicker. But they may not, too, if they had attention deficit
disorder, or visual issues so it's really hard, like Rene said, you just got to
look at that individual. That is probably the biggest theme that I hear you saying
is that if you've seen one concussion, you've seen one concussion,
which can be obviously frustrating for a parent who wants the answers - tell me
what's gonna happen? It doesn't sound like that's as easy to have happen as
somebody might want, or to be able to be explained with a sprained ankle, for
example, where there's a trajectory for healing. So individualized, holistic
support is what I hear is available through these kinds of therapeutic
supports. Right. Anything else that you might share
with some family members or our parents of kids with concussion, that they should
keep in mind as they're trying to move through a recovery process? I can think
of, I'll give people all these supports, like
their lights are bothering them and put them on sunglasses, do all kinds of
crutches to help them get through the day and I think the literature now is
maybe supporting that maybe that's not the best plan to use that stuff all the
time because we all have to live in this crazy world where there's lights and
vision and we can't, you know, we need to need to get used to it,
just like you talked with a sprained ankle, you don't keep that brace on it
forever you won't, you know, get stronger you want to kind of gradually try to get
away maybe switch use your crutches as you need, but try not to be too over
reliant on them. So use the supports perhaps for a period of time, but be
careful not to get dependent on them and push yourself within reason back and
have licensed health care professionals on your team. if possible to help guide
you through that process. Yeah. Thank you very much for taking time. Geoff Lauer
with the Brain Injury Alliance I've been talking this morning with Meghan
Andresen and Rene Crumley, both physical therapist with UnityPoint
Health at St. Luke's in Cedar Rapids. For more information about concussion in
Iowa you can look to Iowa concussion dot o-r-g. Thank you very much.