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[Physio Explained] Understanding concussion: symptoms, assessment, and recovery with Laura Fazzari

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In this episode with Laura Fazzari, we explore the topic of concussion. We discuss:

  • The broad scope of symptoms within concussion
  • Full VOMS assessment (both with and without equipment) 
  • Evidence based treatment and preventative measures for concussion
  • Return to play from concussion

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Laura Fazzari is an APA Titled Sports and Exercise Physiotherapist with more than 15 years of experience in private practice, hospital settings, and elite sport. She has extensive expertise in managing a broad spectrum of injuries and rehabilitation needs, with particular interests in sports injury management, concussion care, and post-operative rehabilitation. Over the past decade, Laura has worked closely with elite athletes, including positions with AFL teams like the St Kilda Football Club and high-level cricket programs. 

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SPEAKER_02:

You don't need much equipment to be able to just do a basic VOMS. The equipment helps out, but realistically, other than a convergence ruler, even at the concussion clinic, we just use a post-it note, some pens. If you don't have a convergence ruler, you can just use a tape measure.

SPEAKER_01:

Today we are diving into the complex world of concussion management, from the varying ways it can present to how we assess it, treat it and guide recovery. This conversation is packed with practical evidence-based insights you can use straight away. Laura Fazzari is a titled APA sports and exercise physiotherapist with over 15 years of experience across private practice, hospital settings including the Epworth Concussion Clinic in the Alfred and Elite Sports. Her expertise spans a wide range of injuries and rehab needs with a special interest and this is Physio Explained. Well, welcome to the podcast today, Laura. Thanks for having me. Thank you for joining us. We shall dive into the first question, which is essentially around the incidence of concussion. Do all patients present the same and are there some odd presentations?

SPEAKER_02:

So in general, 90% of people with acute concussion will recover completely within about the first two to three weeks. And then it's usually the other 10% that I generally see that Some sort of have symptoms that say persist for maybe just another few weeks and they just need a little bit of a helping hand through the next couple of weeks and getting them back into whether it's contact-based training or even just things like work and school. And then there are others that develop quite persistent symptoms, some of which don't fully recover and there can be a variety of reasons for that. But in general, it is a very heterogeneous population, which does make it hard to research as well. And so a lot of them need... a central issue, there are a lot of systems that can be impacted. And so a lot of them need a variety of different sorts of treatment to facilitate full recovery or as best of a recovery as some people can get. Some people get things like double vision when they're only using one eye, which is not the norm, but something that still then needs to be further investigated. Tinnitus is quite common, but some people describe other sort of sensations in their ears as well. And different sorts of particularly visual and motion based symptoms, especially like some people test beautifully in a clinical setting, but then panic a bit in the car when they're stationary, they feel like the car's still moving. and will hit the brakes frequently and in a clinic setting and even trying to get them into a state of sporting setting, they test completely normally. So it's just trying to piece together what other things could be making them present that way.

SPEAKER_01:

It sounds like nothing much would surprise you with some of those presentations these days. Just on that, I'm curious, because obviously the subjective for something like that requires those follow-up questions. Questions do you dive further into on those? Subjectively,

SPEAKER_02:

B, Being such a broad category of symptoms, I try and separate it out into different categories. So trying to ask about more visual-based symptoms, things like whether they're getting blurred vision, how are they coping with reading and screen use in particular, that can give you a lot of information as to whether the visual system's involved. Often it is because 70% of the brain is involved to some extent in the processing of visual information. So often it's a good place to start, but some people don't have many or any visual-based symptoms either. And then asking about motion sensitivity, how they go traveling, whether it's in a car, are they better as the driver or a passenger? Have they had motion sensitivity before? Do they typically get car sick? Because that gives you some sort of sense of the vestibular system potentially being a little bit sensitized already, and they're probably a bit more likely to then experience further symptoms or an exacerbation of symptoms with their concussion as well. And then autonomic symptoms, can they exercise if they're back to being able to do like hitting to full sessions and running and they're completely asymptomatic with most of that? They're sort of things that then you would park further to the side when you're deciding how to process your objective assessment. And cognitive symptoms, so how are they going, say, whether it's at work or just with, you know, if they're at school or uni. So often people do have particularly people with persistent symptoms, sometimes they've got a pretty full sort of schedule pre-concussion, which can be an exacerbating factor of the symptoms as well as something that can also delay it. Like some people that do have, say, more capacity to potentially, say, take leave after, it can be a good thing and a bad thing. So sometimes if people take too much leave and they hibernate away for too long, it can delay recovery of symptoms. But sometimes it does give people just a few days to sort of refresh a little bit, have that relative rest and then grade themselves back into their normal routine. So some people will describe crying for no reason and realizing that they're not the sort of person that maybe cries at, say, movies or someone telling a sad story, but that they've developed a sense of that or being more irate or aggressive than they normally would be in response to sort of little

SPEAKER_01:

triggers.

SPEAKER_02:

That's

SPEAKER_01:

a really nice summary of your subjective. And then I suppose moving into your objective assessment. Can you give listeners a bit of a basic understanding of your vestibular oculomotor screening assessment, perhaps where it's relevant for those in clinics with equipment that's relevant and those with no equipment would be grand?

SPEAKER_02:

So you don't need much equipment to be able to just do a basic VOMS. The equipment helps out, but realistically, other than a convergence ruler, even at the concussion clinic, we just use a post-it note, some pens. If you don't have a convergence ruler, you can just use a tape measure. So you just have to be sure that you're sitting about 90s or the targets are 90 centimetres away from the patient and that you're more just for standardisation across your assessments. And in total for your smooth pursuits and your saccades assessment, your targets are placed about 90 centimetres apart. Generally with smooth pursuits, I just use a pen and ask them to track the pen side to side and up and down. So generally you're doing that twice in each direction and you just have to make sure that with your pace, you're not actually speeding it up too quickly so that their eye movement becomes circadian anyway, because that's a different part of the assessment. And then circadian eye movements, I pop two pens up and get them to flick from one to the other as quickly as they can, doing it both in a horizontal direction 10 times. You wait and see how their symptoms are and then go vertically as well. So with the screening, you're screening for things like a headache, dizziness, brain fog and nausea off Often, depending on how far down the track you're seeing them, nausea is probably one of the less common symptoms that get triggered in that assessment. It still does sometimes, but the headache and the dizziness and the brain fog are far more common. And then convergence. So if you don't have a convergence ruler, you just put a two centimetre by two centimetre X on a card and then get them to bring it in towards them until it'll blur first, then it should double. and then you're recording the point where it doubles, try and take three measures of that, as well as checking in on how their symptoms are going. If you're doing it as a quick, you know, same tennis where you get three minutes with someone, if you're doing it as a quick screen, you're just really checking that they're under about 10 centimetres and they're asymptomatic. If you're doing it more as an actual test of how their concussion symptoms are going, then you can just stretch a tape measure out from their forehead and measure it that way. So you don't need much equipment. Accommodation I don't always measure. So with the chronic ones, particularly the chronic ones that are having issues reading or processing visual information, like if they're only tolerating a couple of minutes on the screen and have a role that really involves that, then I'll make sure I measure it because it can mean that they're, particularly in the sort of older population, it can mean that they're heading towards needing glasses, which they potentially were anyway. It's just that then the the symptoms that little bit further by reducing their brain's capacity to actually clear up visual information and so rather than needing glasses maybe in say a year or two they're needing them now and that can really help their symptoms sometimes and then looking at gaze stabilization so horizontal and vertical VLR just holding that card in front of them about 90 centimeters away getting them to rotate their head it's quick rotation so you're looking at 100 180 beats per minute in each direction. So first horizontally get the guide of their symptoms and then vertically. And the vertical VOR can often feel quite just uncomfortable for patients, particularly those with neck pain, because it's definitely less coordinated than the horizontal VOR. It's a lot easier to get people to shake their head than it is to nod that quickly. And then doing VOR suppression. So I usually just do one thumb in front of the other, get them to pop it out in front of them, and at a rate of about 50 beats per minute, you're getting them to rotate side to side with their whole torso, getting them to actually keep focus on that thumb. And that can give you a lot of information sort of then going also into motion sensitivity as well, because sometimes the rest of the exam will be fine, and that's the only thing that is symptomatic. So as well as working on that, you can then delve a bit more into more motion-based assessments. Often, not with everyone, but often there is a direction that people are worse in. So between smooth pursuits, saccades and VOR, sometimes they're all in a horizontal plane that they're having issues with, or sometimes it's vertical. Sometimes the ones that are trying to, for instance, say run, if it's in a vertical plane, it can take them that little bit longer to run just because of the bouncing aspect of things and the vertical displacement that their head undergoes with running. So sometimes you've got to factor to that in when you're programming their cardio as well.

SPEAKER_01:

Fantastic. Gosh, that's a nice comprehensive list. So we've got accommodation, convergence, saccades, smooth pursuit, gaze stabilization, VOR suppression, and your 180 beats per minute. We have staying alive for CPR. Have you found any songs that match 180 beats per minute?

SPEAKER_02:

I need to actually look into that. I tend to try and use a metronome if they're really not getting it. But often, sometimes I'll just document that they can't actually achieve the 180. And whilst it's not standardized, you're going to lose the patient if you make them really symptomatic by throwing them into, or even just panic them by making, even if they're not super symptomatic, you'll panic them by trying to push them into a really quick movement. So see where they're at, but particularly if they're really chronic or if they're describing like, you know, net-based symptoms, which normally they don't because you're only going sort of 30 degrees in each direction. But yeah, just be careful how much you push it in that first assessment.

SPEAKER_00:

And so I suppose that leads into the

SPEAKER_01:

next question, which is around a brief overview of sort of the current evidence-based treatment for concussion?

SPEAKER_02:

Yep. So again, because of the fact that the population is so different and have such a vastly different presentation in the way of both symptoms, duration, severity, and just triggers of their symptoms, the research tends to sort of often show that more research is needed. One of the big things that has come out of the last concussion forum was that mouthguards, there's actually been a 28% reduction in some of the studies that have been tested in ice hockey players where mouthguards have been able to actually reduce the severity and the frequency of concussions. Really, concussion-based, contact-based sports, everyone should be wearing a mouthguard just for the teeth protection aspect of things. But hopefully that also then helps with the concussion risk at the same time. In the way of headgear, it is still sort of, and this is more the soft-based headgear, not the sports like the NFL where they've got hard helmets. There is still more research needed but at the moment there's nothing to suggest like we get asked about it all the time. There's nothing to suggest that any sort of headgear will help reduce any sort of severity or the frequency of people that do get concussed or the frequency of concussions that that person will naturally have. They're trying to use helmets that dissipate the force across the actual helmet but that hasn't really been been shown to have the same sort of effect as what they were hoping either.

SPEAKER_01:

I suppose we wait and see what the evidence reveals, don't we? In terms of treatment and rehab and return to play from concussion, what does the return to play look like? I'd imagine it's largely sports specific and varying. Do you mind delving into that a little bit?

SPEAKER_02:

Just more so that you can go through it systematically. They need to be asymptomatic with all their impairments first before you actually delve into returning to full contact. Now, that's not to say that they can't do any activity, but you need to then sort of make a little list of things that they need to accomplish. So it's good that you have a really good handle on what their sport actually involves so that you can expose them to any of the sort of potential elements, whether it's change of direction, whether it's ground balls, whether it's anything overhead, and then looking at more some of the psychological things like their physical of getting hit in the head again because, you know, there's a difference between going back into, say, return to play versus return to performance. If they're feeling quite fearful and have changed the way they play, not only is it not safe for them or other people, it will impact how they actually perform. So initially you're looking at their autonomic symptoms, so things like, you know, they don't have to be asymptomatic to be able to do some light exercise. So once they've started walking, hopefully that's within the first few days So usually you give them a day or two off and then provided they're comfortable enough, they should be able to go for some easy walks. Sometimes they haven't and they haven't done much activity for, let's say, months. And so it's going to take a good few months, even just from a musculoskeletal point of view, to get them back into their normal sport. So progressing through, say, some cycling. Cycling can be a good thing to do for the ones that are quite vertically symptomatic as well. So starting off with some cycling first, then going going into more some running and then adding in change of direction. Doing it within initially, they may need to do it in situations where there aren't a lot of people around. So running around their footy oval or their basketball court where everyone else is training at the same time might not be a great way to initiate them in. You might need to do it outside of hours and then bring them in once things calm down a little bit. Then looking at some of the visual aspects of things. So doing sometimes it's It's as simple as doing some of the things that you've assessed on the VOMS, just in more of a treatment-based setting. So let them trigger the symptoms a little bit. You sort of tickle the symptoms, but don't poke the bear too much. And then back off, let them recover the symptoms, particularly if it's a headache that it's producing, because that can often be quite irritable. Usually I would get them to do about three sets of that till they're building up to a good 20 or 30 second burst of being able to tolerate it. You know, some mild dizziness, particularly with some of the head turning ones is, completely normal for sort of a second afterwards, but it should back off really, really quickly. The vestibular aspect of things. So sometimes I'll get them really early on just sort of scanning the room with their head. They might be doing it at a lower speed at first and then trying to pick up the speed so that they're getting used to the head turning aspect of things. Sitting down or standing and reaching down really quickly to try and get that vertical element as well. Bouncing on a mini tramp. And then you can do it sort of where they're bouncing and say pivoting at the same time then looking also at the musculoskeletal aspect of things so whether it's their neck or their TMJ just making sure that physically or any concurrent injuries that they may have had with the concussion as well if it was sort of at enough force then just making sure that physically they can get back into that because as well as the dizziness being able to be brought on more from the vestibular based symptoms you can also get cervicogenic dizziness and cervicogenic headaches and so people just need to remember to delve into that as well. So I don't do this for everybody, but if they've had symptoms for quite a few months, it's good just to tick off a black fork test, which is just looking at motion. You do a bike test initially just to really get into some high interval training and some really high heart rate levels so that then you can make sure that they're tolerating all of that. Then going through some motion. So they're going over hurdles, they're doing burpees, they're doing pivots at 100 180 degrees and just making sure that they tolerate all of that without symptoms before you're getting them into some contact-based training with their club. And what that looks like might is different obviously for, say, if you're prepping someone to go back into training with their local club where they may not have the staff to be able to perform some of the drills that you want them to compared to if they're going back into an elite level sport where it's a bit easier to control some of the variables at times. They may not have a system where they have of like a non-contact hat or bib. And so you might be having to set up some of those challenges for them by yourself. Noodles work really well as contact aids, just having an extra person to sort of bump them, doing some grambles while someone's trying to actually tackle them. Things that are quite anxiety provoking and everyone, you know, and it's the same for any chronic rehab, the first time they get hit in the head again, you're trying to prep them for the fact that they will be worried about it and that Hopefully you try and get them to, generally my advice would be not to think about it. So if they think about whether they're symptomatic or not, they probably will develop symptoms. So I tell them to get up as if they're fine and keep going. If they get symptomatic, then they obviously have to come off. Or if they initially feel dazed or confused, they obviously have to come off. But it's asking, you know, seeing someone scratching and then from a mozzie guard and then realising you're itchy as well. If you actually consider whether you've got symptoms or not, you will probably develop a headache and then potentially sit yourself out for no reason. So yeah, especially with the ones that anxiety or stress about the symptoms can provoke it, I generally get them to try not to think about it too much initially. And then, you know, getting them back into, especially if it's more chronic based, two weeks of full contact training. Not everyone needs that, but if they've been out for a few months, I will always get them to do a couple of weeks of it to make sure that they've been well and truly exposed to it and then returning to play.

SPEAKER_01:

That's a fantastic summary. Thank you so much. No worries. Happy to help.