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Matthew: Hello and welcome to the Brainhub Podcast I am Matthew Holmes and with me today is Dr. Carlo Rinaudo, a chiropractor and the owner of the Brain Hub Clinic in Sydney. Hi Carlo.
Carlo: Hi Matt, great to be here today, how are you?
Matthew: I am great thanks, yourself.
Carlo: Awesome, thank you.
Matthew: Today we are going to be talking again about concussion in particular about using preseason screenings in combating concussions. Now, we did go into concussion quite a bit in our first episode where we reviewed Will Smith’s new movie called Concussion. So if you haven’t heard that episode be sure to check it out at brainhub.com.au/blog.
Preseason screening for concussion has become a bigger thing in recent years, given the time of year in the Southern Hemisphere when people are starting to move into sports where they are more likely to sustain some sort of head impact or concussion. We are going to touch on why that is the case but first Carlo perhaps you could give us an overview of what a concussion is.
Carlo: Certainly, a concussion I guess is the most conform of a traumatic brain injury and it is often correctly labelled as a mild traumatic brain injury. The term mild means that it is obviously, it is a closed head injury so there is no open wound but more importantly it’s an injury that results from some sort of mechanical impact where the soft brain which is often described as the consistency of jelly often hits the inside of the skull causing it to shear or compress as it moves around within the skull cavity. With concussions we typically see more of a change in the way the brain functions and how processes and thoughts and movements and so on rather than any change in the structure of the brain. People see this with MRIs and CT scans, typically after concussion you don’t see any structural change on a scan but you certainly do see changes in the way the brain functions.
Matthew: Right. So why do you think that this has become such a big deal in recent years, I mean obviously this has been happening for as long as people have been having head impacts, why are we certainly so much more aware of it?
Carlo: I think for two reasons, there are short term and there are long term effects to the concussion both of which have been played out in the players as well as obviously in the media. With some of the short term effects that many parents of children, players and even coaches are seeing and these include things like poor memory, brain fog, poor attention and concentration, headaches, dizziness, poor balance, difficult reading, nausea, poor sleep, I mean, these are all the things that parents note. So it is not being dismissed now as being ah well, you just sleep it off and you will be fine, I think parents are becoming more aware of it and these are some of the short term effects. The long term effects of concussion are also being played out at the moment in the media from the Concussion movie as we spoke previously as well as some of the high profile litigation cases against American Football and even Aussie Rules. People are suffering from chronic traumatic encephalopathy where essentially the brain after multiple head injuries turns to marsh and there has been many links to early deaths and suicides and also to things Alzheimer’s and dementia have been to linked to as well. So I guess to answer your question Matt, it’s becoming a big deal because of what parents and coaches are seeing on a day to day basis but also some of the long term effects that medical practitioners and some of the deaths and long term conditions are seen.
Matthew: Cool. Or not cool in this case. So that sort of gives us a really good idea about why these are important. Can you tell us then what are preseason screenings?
Carlo: Preseason screens are a series of tests that are typically performed on an athlete to gauge their baseline performance and what it’s like before the season starts or before they start preseason training. It gives us an idea of where they are at typically ideally when they are healthy without sustaining any injuries and then we can use that as a measure of just how much impairment they may have and also what their capacity for them to return to play is like.
Matthew: Right. So why wouldn’t you just use say a normal database, you touched there on the idea of individual capacity but and for those listeners who aren’t familiar with the idea of a normal database, that is where quite often manufacturers of a certain bit of equipment will collate a lot of data from large number of tests they do and work out what is “normal” for that particular piece of equipment. As clinicians we often check people against those databases to work out if they are at normal. Why can’t we just do that when we are looking at these preseason screenings?
Carlo: Great question the best way to answer that would be there is a lot of subtlety and individuality in each person. That one person compared to a large database and used later for a comparison is not sensitive, they are not specific to that person. So we always recommend that the best control is themselves. So we want to see, when I say relative change in that person, so comparing to how they are “as normal” during season and after an injury is really important and as I said earlier, it allows us to see how suitable someone is to return back to play because they might start at an extraordinary high level, they have an injury and if figures like cognitive scores or the behavioural scores or the balance scores drop relatively to where they started but they still might fit in the normal range and that may go undetected but yet parents might say look my son is just not focused at school, I am getting some bad reports from teachers. So what a preseason test enables us to do is to see where they are at and then compare them to a later point and we have always got that as a reference.
Matthew: Right. I suppose that really highlights an aspect that is so true when you are looking at these functional brain conditions isn’t it that in that we are really talking about subtleties with these as opposed to gross deficits which will probably be showing up as structural deficits on an MRI or something like that whereas we are talking about subtlety here aren’t we?
Carlo: Exactly and be aware of those subtleties and looking for them and as you said making a comparison is the key and I guess this where at times if someone were to present to a medical specialist or a doctor doing a quick screen or a comparative test to a normative database they might be given the all clear but we know through our experience and what research is going to show and this a lot of subtle things you need to be aware of and there is no better way to highlight that in comparing to how they work prior to this injury and this is why we certainly encourage a lot of people to get preseason tests because it is search a valuable data that even for subsequent needs you can plot on the graph and we can plug with our results in a declined or improved scene in people’s performance from preseason to throughout the season but also season one, two, three, four and five and some will say it is incredibly important.
Matthew: Right, do you want to talk us through then how you would actually conduct this baseline screening in your clinic and what tests do you do? Are they sort of intrusive or painful etc?
Carlo: These two types of tests that we do one of which is a real quick screen which we can do in a club or even on the sideline if we need to but the more comprehensive one is the one that we perform in our office. It is about an hour and a half long test, we go through a computerised and standardised cognitive tests which helps look at various forms of memory, the ability to switch tasks to perform various tasks at once, looks at attention and various performances like that. So that is a great way to measure up someone’s memory and cognitive function. Two, we also look at people’s balance and we have a computerised posturography device which very accurately measures the ability to stay still or combat different surfaces eyes open, eyes closed and we are looking at how they react to various conditions and it is a great way to see how balanced and coordinated their body is. An area that we use and again research is showing more validity is looking at eye movements, there are very subtle discrepancies or problems with eye movements after a concussion or a brain injury and this might be the ability for them to follow a smooth target for their eyes to jump from side to side accurately and with speed or even just to be able to fix at a certain point and not have their eyes flicker off that point. We use various high end diagnostic equipment, video electronystagmography, video head impulse test devices which have cameras attached to these goggles and accurately measure eye movements and there are some low tech devices like the King-Devick test and other forms of eye tracking. So we use those as well as the physical practices as a chiropractic we also look at spinal and limb movement and function and how one controls their body and that gives us a really good idea of their spine and joints control.
Matthew: Right, so based on what you are saying a lot of the testing then is testing the frontal lobes with the cognitive testing that you were talking about and then also the balance aspects. Are there particular components of concussion that make those areas of the brain more susceptible to injury or is it just that they are good ones to test.
Carlo: Well I think because of the typically the mechanics of the injury where people typically get hit front on and this is also seen with whiplash injury for people suffering from motor vehicle accidents where the front of the head gets hit by something whether it will be helmet or another person and this side of injury of the brain, remember that jelly like structure normally impacts the inside of the front of the skull as well as the back of the skull and often there are shearing or rotational forces involved in which the brain stem and the cerebellum are areas that are likely to be involved and bruised, for lack of a better word, in concussions and it is these areas where a lot of our balance, a lot of our memory and our lot of our higher function like attention concentration and eye movement originate from. So it just so happens that the areas that get affected and the areas of the brain that coordinate these functions and that testing is really targeting these areas of the brain.
Matthew: Well obviously that testing is quite involved and obviously very necessary. If a coach or team manager who is listening to this how would they go about getting their team tested? Is it something that you always have to do in the clinic or like you said can you travel to a club room and still get an effective baseline test for somebody?
Carlo: With our experience with local clubs we provide two levels of testing one of which is a screen only can take fifteen twenty minutes where we place individuals through a quick balance test, we look at their eye movements and we can do a very quick cognitive memory recall test. And from this we get a sense of where they are at. So we can note that down again that is a good preseason test that we can do. If any of these come out lagging further attention like they are falling when they are attempting to stand on one leg or there are movements are showing a lot of breakdown and they are unable to focus on a certain point or they are having troubles recalling certain events that you would expect them to remember then it is our recommendation at that stage to the parent or club to say I think little Joey needs some more detailed assessment. We will then arrange that assessment to happen in our clinic.
Matthew: I think that perhaps brings up another important point as well in that you can with this preseason testing actually pick up problems that people weren’t aware of in the first place and given that people are more susceptible to sustaining another concussion if they have these balance or awareness issues, you are having a preventative from that point of view as well?
Carlo: Exactly you mentioned a subsequent injury, second impact syndrome is a real problem where the brain after having received an injury it is prone to receive a second injury with less of an impact and the consequences both in symptoms and management become more challenging and we strongly encourage that clubs managers take a proactive and I guess a responsible step in ensuring that their team members particularly kids are properly checked and screened which helps identify risk factors in players, obviously it also helps identify the safe time and stage for a player who has been injured to return back to the sport. For parents I would say if your club is not doing this ask, best practice and evidence now in sports management is recommending this from our top level down, so be sure to get on the case and if not then approach us and we will be happy to contact clubs, we do talks and presentations to clubs on this exact topic.
Matthew: So I think that has covered the topic of preseason screening very well and given our listeners a good overview of the reasons why they should be doing it and what is involved, if they want more information they can just contact you via our websites which is brainhub.com.au, just go to the contact page and fill out the enquiry form there or the phone numbers on the website as well,
Carlo: Our number is 1300 770 197
Matthew: Great, excellent, well that wraps us our episode today, the transcript will be available at brainhub.com.au/concussions-screening or if you just want to go to brainhub.com.au/blog you will see the most recent episodes there. So until next time take care and we will see you then.
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