Evolution of Concussion Management with Dr. Angela Carol
You’d be hard-pressed to find an organ more complex than the brain – a wrinkly lump of electrified tissue responsible for our every thought, action, and emotion. Rarely do we pay it any attention, content to let it labour away on our behalf… that is, until something goes wrong. Perhaps you slipped on an icy driveway, or maybe you took a tumble on the slopes. Regardless of how it happened, the result is likely the same: a Traumatic Brain Injury (TBI). Suddenly, your hard-working brain is struggling to keep up, and you’re left to deal with the consequences.
A TBI occurs when there is a forceful bump, blow, or jolt to the head or body, or when an object pierces the skull and enters the brain. The most common form of TBI is a mild TBI (mTBI), also known as “concussion”. The brain “floats” within the skull in a protective fluid, anchored at its base to your spinal cord. When the head moves rapidly, the brain can slam into your skull, which can cause a concussion. Some symptoms of concussion can include headache, irritability, and fatigue [1].
The McMaster Students for the Concussion Legacy Foundation spoke with Dr. Angela Carol, a physician with the Hamilton Urban Core Community Health Centre in Hamilton, Ontario. She shared with us her insights regarding the evolution of concussion management, as well as the challenges associated with treating concussions in people experiencing homelessness.
Dr. Carol advised us that the way medical professionals treat concussions has changed as they’ve learned more about them. Ten years ago, it wasn’t even mandatory for youth to wear helmets when figure skating. We also used to wake kids up who hit their head because we thought they were in danger of dying while asleep. We now know that this practice isn’t necessary; in fact, it’s probably detrimental, given that we’re disrupting the child’s sleep during a key period in recovery.
We also used to adopt a strict rest protocol to treat concussions. We would tell patients to sit in a dark room until their symptoms improved. It was believed that sheltering patients from overly stimulating environments would prevent the aggravation of their symptoms, allowing their brains to recover. Doing so would also limit their risk of incurring secondary concussions, the symptoms of which are often worse than the initial injury.
However, extensive research has shown that prolonged periods of strict rest can delay the recovery process [2]. Instead, clinicians now advise patients to adopt a stepwise approach, gradually allowing them to return to their usual activities so long as they do not aggravate their symptoms [3]. In adults, research has suggested that slow, controlled physical activity like walking or riding a stationary bike below the symptom threshold may aid recovery [4]. Today, we generally believe that after 24-48 hours, incorporating exercise can help someone recover faster [4].
Dr. Carol also informed us that concussions have long been without any objective diagnostic tests. Instead, we relied on patient symptoms alone to guide our management. In the last few years, we have implemented more objective testing, such as the Buffalo Concussion Treadmill Test (BCTT) in adults, a graded exercise protocol [5]. When the athlete completes the BCTT without exacerbating their symptoms, they can begin a return to sport. Return to sport would include introducing sport-specific activities over an extended period before the athlete can compete again. Besides the BCTT, Dr. Carol informed us that physicians have begun using neuroimaging to guide management. For example, if a child has positive neuroimaging findings, they should take at least three months off from contact sports [6].
One of the most powerful tools to combat the burden associated with TBIs is also one of the simplest – awareness and education. Knowing what TBIs are, who they affect, and how they present are simple ways to ensure that they are adequately addressed. Data demonstrates an increasing prevalence of TBIs in Canada, warranting dedicated efforts to quell what some have referred to as a “silent epidemic” [7].
McMaster Students for the Concussion Legacy Foundation (MSCLF) hopes to be a part of the solution. Leveraging our medical training and community connections, we hope to increase TBI awareness amongst the McMaster student community and the Hamilton area. If you would like to get in touch with us, please reach out via email at concussionmac@gmail.com – we would love to hear from you!
Tator, C.H., Concussions and their consequences: current diagnosis, management and prevention. CMAJ, 2013. 185(11): p. 975-9.
Silverberg, N.D. and T. Otamendi, Advice to Rest for More Than 2 Days After Mild Traumatic Brain Injury Is Associated With Delayed Return to Productivity: A Case-Control Study. Front Neurol, 2019. 10: p. 362.
Harmon, K.G., et al., American Medical Society for Sports Medicine position statement: concussion in sport. Clin J Sport Med, 2013. 23(1): p. 1-18.
Haider, M.N., et al., Exercise for Sport-Related Concussion and Persistent Postconcussive Symptoms. Sports Health, 2021. 13(2): p. 154-160.
Haider, M.N., et al., The Predictive Capacity of the Buffalo Concussion Treadmill Test After Sport-Related Concussion in Adolescents. Front Neurol, 2019. 10: p. 395.
Recommendations for Return to Contact Sport After Multiple Concussions. 2018 [cited 2023 March 9]; Available from: https://canchild.ca/system/tenon/assets/attachments/000/002/574/original/Return_to_Activity_Guideline_WEB_1_.pdf.
Buck, P.W., Mild traumatic brain injury: a silent epidemic in our practices. Health Soc Work, 2011. 36(4): p. 299-302.