I’ve just spent the last two days in Auckland CBD at the bi-annual Brainstorm conference. A conference specifically focused on all things concussion. So, I thought I would give a quick rundown of my highlights.
I think the biggest thing that confirmed my thinking was the huge parallels between pain management and persistent post concussion syndrome (PPCS). Interestingly, a reductive underpinning favouring anatomical structures persists as the slide shared by Dr Steven Flanagan captures below.
Professor Nicola Kayes presented a captivating lecture on ‘Whose Behaviour Matters?’ Discussing the importance of understanding “why someone presents in the way they do at that time”, is something that all clinicians need to be cognisant off. More importantly, was the message of how clinicians need to be mindful about being reactive to an individuals behaviour, particularly when things aren’t going well, which can lead to the person living with ill health to be inadvertently labelled as unmotivated or non-compliant. Compliance and adherence, words that clinicians use in a negative sense to describe the behaviour of the individual. Instead, consider the word engagement as this consolidates the introspective qualities of the clinician with the ‘sense-making’ from the individual. Engagement is a process and a state – it is collaborative, supportive, understanding, empathetic, motivating and embraces the pedagogical relationship between clinician and client. An important reflection is that clinicians only capture a snapshot of how people live their lives, which means clinicians cannot be in a position of judgement.
I think a slide and message that really encapsulated and embraced what people (and for clinicians) with ill health face on a day to day basis was that of understanding context. It is so important to be aware of the influence of context and, how the reciprocity people have through their sensory, emotional, and cognitive experiences with context, can influence their behaviour.
It was a real pleasure to have Dr John Leddy as the conferences keynote speaker. Dr Leddy is best known for his work with Barry Willer on the development of the Buffalo Concussion Treadmill Test (BCTT). The BCTT is a physiological tolerance test to identify physiological symptom reproduction when people, who have sustained a concussion, undergo an incremental increase in exercise intensity on a treadmill. Following the test, people are advised to exercise between 80-90% of heart rate (HR) threshold identified at the end of the BCTT. Much of the recent concussion evidence refutes the old traditional advice of rest following a concussion with sub-threshold exercise now highly recommended. I myself as a teenager (back in the 90s) sustained a rather nasty concussion after falling out of a tree and smashing the back of my head on a stone. I blacked out for what seemed a couple of seconds only to come too and realize my older brother was carrying me back to my mother. I was taken to the local GP, briefly assessed, threw up in his sink and then returned home to rest until I felt better, which I have been informed by my mother was about 48 hours.
Dr Leddy began by summarizing the physiology of concussion, discussing the role of the autonomic nervous system (ANS) and the resultant effects on function. In particular, a dysregulation of cerebral blood flow (CBF) demonstrated by a decrease at rest and a significant increase with exercise or cognitive load that is understood to be outside of what would be considered normal CBF perfusion pressure. It is understood that the disturbance in the ANS following concussion effects baroreceptor activity and this causes the resultant changes in CBF as mentioned above. A brief discussion with one of my colleagues, resulted in a proposal that perhaps in the acute stages of concussion the brain is succumbed to hypercapnia due to the significant increase in CO2 accumulation as a result of the metabolic “storm” within the brain. Something that Dr Leddy also alluded too in his lecture.
Dr Leddy continued his lecture into the differences between males and females following concussion with respect to CBF and recovery. According to Dr Leddy, evidence suggests that CBF in males and females beyond the age of 8 years old trends downwards until the age of about 14 where female CBF begins to level out and increase slightly. Unfortunately lads our CBF continues to trend downwards with age. The study he quoted only recorded age up to 22 years old.
Following concussion, the differences in symptom score in exercise vs rest for adolescent males and females is quite astonishing. Research has identified that the narrative has a large role to play (unsurprisingly) when advocating for exercise vs rest in females. Those females that were told to rest had a higher overall symptom score over 14 days compared to females that exercised. In males there was little difference. I understood this to have something to do with the declining CBF in males.
Finally, Dr Leddy discussed the effectiveness of the BCTT as being a safe and reliable test for PPCS. It would seem that irrespective of the duration of symptoms and the resultant vestibular-oculomotor disturbance and/or cervicogenic nature of symptoms, it is appropriate to have individuals undergo a BCTT. This also has good predictive validity in adolescents.
The final lecture that was of particular interest was presented by Dr Robin Sekerak. Dr Sekerak discussed the nuances in pathophysiology between PPCS, WAD and migraine indicating that it was hard to determine the classification when symptoms became persistent. For instance, because of similarities in symptoms between an injury to the neck and concussion it can be hard to diagnose concussion from symptoms alone. Furthermore, the Trigeminal Nucleus Caudalis (TNC) extends down as far as cervical level 3 and is understood to be correlated with headaches and facial dysesthesias. This blurs the classification of a clinical diagnosis which is attributed to a broad range of symptoms. I understand that whilst the Rivermead questionnaire does identify symptoms it has poor predictive validity and reliability. Therefore assessment is crucial for determining a diagnosis.
Just some other brief mentions from other lectures during the 2 days
- A two year propsective study by an NZ doctor, Stephen Kara, found that less than half (45%) of patients recover within two weeks of injury following a sports related mild TBI. The current consensus statement (5) indicates that by 14 days concussion should be resolved in adults, if it is an individual’s first concussion.
- Dr Mark Fulcher pointed out that Rugby is misattributed to be a sport associated with serious head injuries. It is more likely to be cycling, skateboarding or equestrian. All of which use helmets as part of the sport.
- Dr Mark Fulcher also stated that the evidence suggests that a player sustaining a concussion is at a higher risk of sustaining any other injury in the body in the subsequent year
- Preliminary data suggests that at 14 days post-concussion if an individual reports symptoms beyond the 14 minute mark on the BCTT it’s unlikely to be attributed to a physiological issue.
- Preliminary data also suggests that at 14 day post-concussion if an individual fails the BCTT between the 4-14 minute mark on the BCTT it is likely to lead to a prolonged recovery.
Apart from gaining knowledge and consolidating my understanding of concussion, I wanted to find out more about the parallels between concussion and persistent musculoskeletal pain. Interestingly, from an ontological and epistemological standpoint, PPCS continues to be treated from a position of symptom resolution compared to persistent MSK pain, which is management. I wonder if this comes down to a classification issue. I have highlighted that it is difficult to identify nuances in PPCS / WAD / Migraine and so I wonder if when WAD and or Migraine become the predominant issues does this then become a management issue. The change in classification of the diagnosis means that concussion as an entity resolves and so do clinicians attribute the success of recovery to their intervention? Whereas when the clinical diagnosis becomes WAD or migraine is this regarded as a persistent pain issue and as such clinician attitudes change and a management approach is recommended?
To sum up it was an interesting 2 days particularly with respect to the parallels between concussion and pain management. I’d like to finish this blog with the Maori Proverb that was shared at the opening of the conference.
Mā te rongo, ka mōhio; mā te mōhio, ka mārama; Mā te mārama, ka mātau; mā te mātau, ka ora.
Through perception, comes awareness; through awareness, comes understanding; Through understanding, comes knowledge; from knowledge comes wellbeing.
Thanks for having a read
Apologies for the lack of referencing, I didn’t have time to look them all up.