Q&A on Concussion with Professor John Olver: Part 2
30 Apr 2019
Discussing concussion, expert Professor John Olver highlights the need for increasing awareness of the topic.
Do all hospitals have a concussion clinic?
No. We’re one of the few places that actually treats it, but many just refer a case to a neurologist who may or may not give the right instructions about what to do about a concussion.
For those that we see, we have a specialist physiotherapist who helps with the dizziness through habituation exercises and in 90% of cases it turns off the dizziness. If they have a headache, then I will treat it with medications I use but I also have a physiotherapist who has expertise in neck problems, because a lot of people with concussion have stiff necks. Their heads have been jerked around and they’ve got soft tissue problems in the neck. So you can treat the spasm and mobilise the neck. The psychologist looks at mood and sleep. A therapist and even an occupational therapist will talk to a patient about pacing strategies, which is the graded return to work. Psychologists can help people with anxiety. It’s treating the symptoms and trying to turn them off before the natural recovery process has run its course, and trying to get them back to their normal lives as quickly as possible.
What’s happening in the world of concussion?
There are a couple of studies going on, one at The Alfred Hospital on acute concussion and in which they look at the first 15 days. A second part of this study looks at the first 48 hours of a concussion, which is very complex in terms of what’s actually happening. It looks at whether you can predict what’s going to happen and how or whether it’s possible to intervene. Are there ways of telling how significant the concussion is in those early days? Scanning is not much use at the moment. There might be types of scanning that prove useful in the future, and types of biomarking or a blood test to see if anything is elevated by a certain amount that would indicate a worse concussion than if it’s not elevated… all of these things are in development but none of it is here yet.
What did you take away from the recent concussion conference you attended in the US?
Two points of interest that came out of the concussion conference I attended in Texas was the gender and age differences in how you might treat a concussion. Children should be more conservatively treated when returning to activities like sport. There is possibly a blood test, or biomarker, that is not in use yet but it looks promising and that might be able to tell us very early on the day of concussion the severity of the damage to the brain. That could be very useful in terms of how you treat acutely. The other interesting point that came out of it was that if you start getting concussed quite early, and I’m talking about 12 and 13-year-olds, some of the studies done in the States (with American football which is a lot more impact-driven) then it seems that those people don’t do so well later on. In fact, it has led to a reduction in the number of 12-year-olds playing American football. It can possibly affect them academically but more in terms of getting other injuries and having more persistent symptoms of concussion if they get more head knocks. The extreme end of this chronic traumatic encephalothapy is after 30 years when behavioural changes take place and thinking goes off, and there are physical problems. Other studies show that people can be a bit slower than they were before, and that can be measured. The earlier you start having concussion the more likely those long-term affects are going to occur. All of these studies need more development.
What does post-concussion feel like?
If a person has symptoms after a few days, and certainly after two weeks, then they should be treated. Teachers and parents should be making sure those symptoms are treated in children. The two worst ones are headache and dizziness. A student won’t be able to concentrate as well. Fatigue is also one, which means that they won’t actually be able to make it through a day very well. Then there are the problems with concentration and memory, which are sometimes very evident in a classroom where you tell a student something and they don’t seem to take it in. There are behavioural symptoms and emotional symptoms with becoming teary and crying, being anxious, seeming different in the classroom. That’s why I’m saying that you don’t want a teacher to go through that symptom checklist but you want them to have seen the symptoms checklist. It’s so that when they know a child has had an accident and a head knock on the oval or playground, maybe even the week before, they can recognise the kinds of things a child might be experiencing.
Are helmets useful?
Kids think they’re invincible, and they can become targets for rougher play. Now that may not happen so much in the school yard, but I can tell you from personal experience of treating footballers that it does happen at AFL level. Players have said that they’ve become a target because they were wearing a helmet. It’s sounds a bit vicious but that’s the game. Win at all costs. In the US they are exploring innovation in the design of the helmet. It seems an angular blow to the head is worse than a straight on blow. They are looking at helmet design now that may reduce angular impact in American football. These are issues being presented now at conferences. There have only been five concussion conferences in the US hosted by the American Association of Neurologists, and I’ve been to the last two. The first I went to was small and the last there were several hundred there and of those attending half were on-field trainers. So these were people who were not doctors but they were the person going to on-field first to see the injured person initially, and to make some assessment and then call the team doctor from the sidelines. They would then most likely take the injured person to the dressing rooms and start some of the SCAT 5 testing.
An incident at AFL level saw a player lose teeth from a head punch. Was that concussion also?
He had a broken jaw and yes, lost his teeth. Sometimes the jaw can act as a bit of a bumper bar, and restrict the impact to the brain. But that sort of thing has to be outlawed. He must have been concussed but we didn’t hear much about that, we only heard about his teeth and that he was drinking through a straw. That’s just thuggery and you wouldn’t allow that to happen on the streets.
Is rest important for concussion?
Many people think rest is so important after a concussion. Well, it is and it isn’t…There’s going to be a conference in Auckland where neurologist is going to tell people that he makes patients rest for a day because he thinks that’s the done thing, but if he had his way people would go straight back to some sort of activity, though not the type of activity that caused the concussion obviously.
So the old adage is when you have symptoms you rest until the symptoms go away. That is 100% wrong. If you do that the symptoms will persist. You’ve got to start getting back into some sort of graded activity. So I tell patients rest for a day when your headache’s thumping, but then start doing something. Go for a short walk, even if it’s only ten minutes. Read a book for a few minutes, but don’t take to your bed because if you do your symptoms are actually going to get worse.
Are there gender or age differences in concussion impact and recovery times?
Women can get a worse concussion than a man from the same impact. The studies and literature on this aren’t complete. You’ve got to be a bit more conservative with getting children back to contact sports than you do with adults because they are more vulnerable in their neck sizes.
What are some common concussion signs to look out for in elderly people?
If someone has a head strike and there’s no loss of consciousness and no loss of eye sight that is apparent for an elderly person, then the signs would be if a person becomes a bit more confused, doesn’t respond or doesn’t seem to know things and is even garbled in speech. A protocol would mean getting a scan and a medical review. In the elderly, sometimes people who were continent can become incontinent, sometimes people who are walking well start to shuffle soon after a concussion because they don’t have as much control of their arms and legs. Sometimes they can be good with cutlery and then they will suddenly spill things. It’s behaviours or activities that are different, with the only difference being a head strike, and I’m talking about acutely and not symptoms coming over time.
Have you ever had a concussion?
No, but I recall I played hockey at high school, I got hit in the head with a stick and got a big egg of a lump. I wasn’t concussed but because of the lump the teachers were asking if I was okay and everyone else was asking me too. If I hadn’t had that no one would have known and there’d be no mechanism for the sports teacher to tell my class teacher that I’d had a bang on the head with a hockey stick.
About Professor John Olver AM MBBS MD (Melb) FAFRM (RACP)
John Olver is an internationally-renowned expert in Acquired Brain Injury rehabilitation, and was recognised in Australia Day Honours in 2014 for his many decades of service improving rehabilitation for people suffering from Traumatic Brain Injury. He supervises a team at Epworth’s Rehabilitation and Concussion facilities who treat patients and are involved in pioneering research. He advised on the clinical panel of Victoria’s Transport Accident Commission (TAC) for many years, and mentored and trained rehabilitation doctors across Australia over two decades. He is the Victor Smorgon Chair of Rehabilitation Medicine, Victoria’s only chair in rehabilitation medicine – a position that comprises dual relationships with the Epworth Rehabilitation division and Monash University’s Faculty of Medicine, Nursing and Health Sciences. In 2012, Professor Olver chaired the seventh World Congress for NeuroRehabilitation (WCNR) in Melbourne. He was selected to bring the Conference to Australia for the first time, following his presentations and involvement at others in Malaysia and Austria previously. More than 1800 rehabilitation personnel from 53 countries including the USA, Canada, Scandinavia, Europe, Malaysia and Australia, arrived at the Melbourne Conference to hear leading international experts and to discuss the latest clinical advances, patient treatment, and research in neuro-rehabilitation.