With Dr. Will Duggan
What is Concussion?
A concussion is the most common form of brain injury and should be taken seriously. It can be caused either by direct contact to the head, or an impact to another part of the body resulting in rapid movement of the brain inside the skull.
The sudden force causes some brain cells to stop working properly. This results in symptoms that can last for a variable amount of time. Sometimes symptoms are only brief and resolve quickly, but then return a few hours or even days later. This is where the challenge lies to recognise the injury as soon as it happens and be removed from further physical activity immediately. Studies show that continued physical exertion after a concussion prolongs recovery by weeks or even months. These long-term symptoms can include headaches, dizziness, anxiety, sleep disturbance, impaired memory and concentration problems.
Less than 10% of concussions involve a loss of consciousness (being 'knocked out'). This leaves 90% of concussions to be detected by an onlooker or reported by the individual. This can sometimes be challenging if initial symptoms are subtle or short-lived.
Here is a list of the most common concussion symptoms: being slow to get up from the ground, unsteady on your feet, feeling dazed, ‘seeing stars’, having a blank expression, difficulty remembering, sensitivity to light or sound, headache, nausea, dizziness, blurred vision, feeling slowed down, difficulty concentrating, drowsiness, irritability, sadness, anxiousness, brief loss of consciousness and sleep disturbances. No two concussions are the same - some concussions may have just one or two symptoms while others may have several more.
What symptoms you feel depends on what part of the brain has been injured. Injury occurs at a microscopic level, so it is unlike a broken arm, or other injuries that you can feel with your hands or see on an X-ray. It is a temporary disruption of how the brain works at a cellular level. It is not a bruise to the brain, which is why brain CT scans and MRI scans are normal with concussion.
In sport, there will often be a reluctance on the part of an athlete to stop play after a knock to the head, particularly when the symptoms are subtle, and the rest of the body feels normal. In addition, a head injury impairs a player’s decision making ability in this regard. The decision must therefore be taken out of the athlete’s hands. It is the responsibility of the coach, parent, referee, physiotherapist or team doctor to detect the signs of a head injury following a hard knock, rest these players immediately and ensure they see a doctor knowledgeable in concussion management.
The brain is also more susceptible to further injury while recovering from a concussion. A second head injury soon after an initial one can result in permanent brain damage or even ‘second impact syndrome’, a severe brain swelling which is usually fatal. This is why all athletes should be immediately removed from play if a concussion is suspected, and cleared medically before returning to sport, only after being fully assessed and rehabilitated. Returning to sport before full recovery leads to a higher risk of repeated or prolonged concussions which can occur at lower impacts than the original one. Such repeated concussions can shorten an athlete’s playing career, and may lead to longer-term neurological problems.
I always feel relaxed as soon as I arrive at Sandycove Physio. Have had several treatments for sciatica and a bad broken wrist involving surgery. Deep needling was really effective and professionally administered. I found that Sandycove Physio genuinely provided the best therapies and advice for a fast recovery. Each session has been valuable.
There has been growing concern in Ireland regarding the management and potential effects of concussion in recent years. Aware of the need for an expert service in this area, Sandycove Physiotherapy have teamed up with Dr Will Duggan, partner in the Pittsburgh University (UPMC) concussion management programme, to deliver this service on site at our Sandycove Clinic.
Patients now have access to the most up to date knowledge on concussion treatment. From diagnosis to personalised rehabilitation plans and clearance for safe return to play / work / school, patients are also supported by weekly case discussions with leading United States concussion doctors.
The UPMC Ireland concussion network has 6 clinics across the country delivering the same programme of expert concussion treatment to each region. Delivered by Neurologists, GPs and Sports Physicians, Dr Will Duggan is providing this service in the Dublin and Ireland East region.
The assessment and treatment pathway involves:
Symptom evaluation and concussion history
Comprehensive neurological examination
Oculomotor and Vestibular testing
Assessment of potential associated neck injuries
Computer-based cognitive test (ImPACT)
MRI scan (if indicated)
Specialised vestibular physiotherapy / cognitive behavioural therapy/medication (if indicated)
Treatment of any associated neck injury
Individualised advice and management plan (resting/exerting strategies) based on symptoms, test findings and personal circumstances (work, school, etc.)
Exit tests (physical and cognitive) and clearance for return to play/work/school
Whether it is soon after the injury and you are keen to safely get back to sport or normal daily activities, or if your symptoms just haven't been getting better with rest alone, we have the expertise to help you.
Each appointment is for up to 1 hour, allowing time to answer as many questions as you have, and walk you through your own personalised rehabilitation programme. We acknowledge that everyone's circumstances are different, whether it be with school, work, family, sport or other demands. Symptom type and severity also varies with different concussions. Each patient receives specific advice on daily activity modification as well as solutions to questions such as returning to work/school, daytime naps, screen-time, medication, and so on. Knowing you are following the right advice will reduce the uncertainty and anxiety often associated with this injury.
Over the last 20 years, UPMC researchers have identified five different profiles or sub-types of concussion. There are specific treatments for each of these profiles. Identification and early targeted treatment using this knowledge has reduced the number of patients developing 'post-concussion syndrome' (persistent concussion symptoms lasting months or even years). Those who have symptoms lasting for more than a month with rest alone also benefit greatly from our assessment and treatments.
Some sub-types of concussion require specialised physiotherapy for coordination of head and eye movements and balance. You will have access to expert vestibular physiotherapists in our clinic to actively treat these specific issues. We will monitor and guide you through your recovery, advising you when and how to gradually increase activity levels.
The ImPACT test is a computer-based test of your mental and cognitive skills which helps to identify your concussion type at your initial assessment. It also helps determine when your cognitive function has returned to normal and it is safe for you to return to normal levels of activity or sport. Normalisation of ImPACT scores often actually occurs some time after your symptoms have resolved. If you take the decision on your own to return to sport thinking your brain has fully recovered, you are putting yourself at risk of prolonged or recurrent concussions. This is why you should be cleared by a medical professional to return to sport only when it is safe to do so. ImPACT is the test used by professional rugby teams in Ireland to ensure a player has recovered fully and is safe to return to play.
We now know that waiting and hoping for symptoms to resolve is not enough for many concussion patients. Seeking expert help early on can avoid prolonging symptoms, absence from school or work and reduce anxiety for patients and their families.
Head and neck injuries should be taken seriously. If there are indications that you may need an urgent x-ray or scan, you should go to your nearest emergency department as safely as possible, if necessary by ambulance. Indications for this include suspected skull fracture, seizure, bleeding, vomiting, confusion, reduced level of consciousness, worsening headache, weakness/numbness/ tingling in arms or legs, restricted movement of neck, fall from height >1 metre, landing on top of head, road traffic accident, age >65 or <16, pregnancy, if you take medication to thin the blood or have a known bleeding disorder.
The concussion service is for people aged 12 years and older.
Fees can be claimed back from the injury insurance scheme of your school or GAA club. This is a new and first of its kind network in Ireland. We are working with insurance companies, universities and other bodies to widen coverage. So check with your provider to get the most up to date details on what your policy entitles you to.
Alternatively, if you can’t get reimbursed from your health insurance provider then tax relief can be claimed through the Revenue Commissioners. Information on how to do this is available on the Revenue Online website.
What is the ImPACT test?
Immediate Post-concussion Assessment and Cognitive Testing.
It is the most scientifically validated and widely used computerised concussion assessment system worldwide.
1. “Baseline Testing”: This test is administered before any injury has happened, for example at the beginning of a sports season or school year. It records a normal score of your cognitive function when you are not injured, so that doctors can compare this to your score after a suspected concussion.
2. “Post-Injury Testing”: This test is administered when you are suspected to have had a concussion. Results from this test help determine what type of concussion you have. It can be repeated at intervals until back to normal to help decide when you can safely return to normal activity.
If you don’t have a baseline test, the post-injury test is still useful. A range of scores you would be expected to achieve can be used to compare to. These are based on your medical history and what kind of grades you would have got in school.
Once you complete the baseline test, your results will be stored confidentially. If you have a head injury or think you have a concussion, make an appointment with us. We will evaluate your injury, repeat the ImPACT test and compare the results with your baseline test. This will help us manage your recovery and effectively guide your return to normal activity.
Remember that we use this test to help treat you, so try your best and don’t be discouraged by incorrect answers. It is important that your brain is relaxed and focused for your assessment. Ensure no physical exercise for 3 hours prior to your appointment. Get a good night sleep the night before.
If you are part of a school or organisation and are interested in learning more about baseline testing, please contact us for more details.