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News from where we live. ABC News SA brings you the day's top stories, exclusive investigations and original reporting on issues that matter to you. Presented by Jessica Harmsen, plus Richard Davies, Candice Prosser, Bethanie Alderson, Isabel Dayman and the team.
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The confusion about concussions
Sana Qadar: Hey, just a heads up, this episode is one from our archives. Lewis Freeth: The way to think about your brain is that it's it's very it's very vulnerable. And if you had to pick an organ, some guys would say it's the second most important. (Sana and Lewis laugh) If you had to, if you had to pick an organ, which is most important to you. I think I mean, it's who you are. Sana Qadar: Yeah. Lewis Freeth: And so if that's damaged. Then your whole experience of, of life is, is altered. Lewis Freeth: So I was in third year Newcastle Uni halfway through medical school. Sana Qadar: This is Lewis. Lewis Freeth: And I'd just done four weeks placement in a place called Saint Lucia in South Africa. Sana Qadar: And this is Kate. Kate: And it was a beautiful sunny Friday afternoon. I just finished work for the week. Sana Qadar: And on these particular days, several years apart and on separate continents, they were both in great moods. They were happy and excited for what lay ahead. Lewis Freeth: It was the first day of kind of backpacking around South Africa and Zambia after I'd finished my placement. Kate: And it was 35 degrees, I had a long weekend coming up. It was just like I was just so ready to go home and start my long weekend. Lewis Freeth: And I got the hire car, the cheapest one I could. As a uni student. I drove five hours to really cool place to go hiking. Kate: I was riding my bike. I was probably going about 15km/h trying to cross an intersection that was part of suburbia. Lewis Freeth: I was driving to the hostel, a beautiful hostel in the middle of kind of the main valley, and as I was coming up to the turnoff, there was a car behind me, probably the only one I'd seen for about an hour, going really fast behind me. Kate: There was no cars around, and I hit the kerb and a lot of things happened at once. My front wheel somehow has become dislodged, so I faceplant straight into the footpath. I am on my back screaming like I've never screamed before. Lewis Freeth: There was a car behind me going really fast, so I put on my right blinker. I didn't want him to come up the back end of my car and that's the last thing I remember. Sana Qadar: This is All in the Mind. I'm Sana Qadar. Lewis was knocked unconscious in the crash. Kate was awake, but she was pretty banged up. She'd broken some bones and had a black eye. Both had concussions. Lewis Freeth: The next thing I remember is waking up in a middle of a paddock with about 20 people around the car. Sana Qadar: Now, usually when we hear about concussions, it's in the context of professional sport. Much less attention and research is paid to concussions that happen in everyday life. That means for the average person, it can be surprisingly hard to get clear information on what to do next. Kate: I had my head scanned and I was discharged that night and given a pamphlet about concussion. We'll see you in six weeks, essentially. I felt not equipped at all. Lewis Freeth: I saw one neurosurgical registrar and I said, what? What should I do? He said, oh, I think, don't use your brain. And then another one I saw said, use your brain as much as you can. Try to get it going. And like in my head I was like, what? Which which one am I bloody doing? Sana Qadar: Add to that the unpredictable nature of concussions. Naznin Virji-Babul: You take two people and hit them over the head with the exact same amount of force and in the same place, and they would probably experience that blow very differently. Lewis Freeth: And there's not an exact correlation between how hard you hit your head and the impact that it has on your brain. Kate: Concussion is so underplayed and poorly understood that I felt like I wasn't prepared, and I felt like everyone around me wasn't prepared because it's not taken as seriously as it should be. Sana Qadar: So today we wade through the confusion around concussions, why they often fall through the cracks of medical care, and what the research says you should now do if you hit your head. Sana Qadar: It looks like I'm getting the thumbs up from my... Sana Qadar: Have you ever thought about what happens in the brain during a concussion like the mechanics of it? Naznin can you hear me? It's pretty graphic, actually. Here to describe it is Naznin Virji-Babul. Naznin Virji-Babul: I'm a physical therapist, a neuroscientist, and associate professor in the Department of Physical Therapy at the University of British Columbia in Vancouver. So when there's a blow to the head or any part of the upper body, the brain actually slams into the inside of the skull on the front part of the skull, and then the brain kind of vibrates backwards. So both the front part of the brain and the back part of the brain are actually slamming against the skull. On top of that, there's actually a rotational component. So you get some shearing, micro shearing that's within the wiring of the brain. That's essentially what happens when somebody is hit on the head or body. But you know, it's not really necessary to have a physical blow. What we're now starting to understand from studying the soldiers on the field is that blast injuries result in the same type of brain injury. The blast actually causes the brain to vibrate inside the skull. Sana Qadar: Wow. Naznin Virji-Babul: And it is a similar type of damage. Sana Qadar: So even if the body hasn't been I mean, in those situations with the body have been moved and blasted backwards as well. Naznin Virji-Babul: Sometimes the body has moved, but other times, you know, they're quite far away from the blast and it's just the impact of the vibration on the brain inside the skull that causes that. Sana Qadar: That's incredible. So you could be standing still and your brain still gets a concussion. Naznin Virji-Babul: That's right, that's right. Sana Qadar: And when you say shearing, is that like tearing of the wiring in the brain? Naznin Virji-Babul: Yes. Micro tearing is what we call it. So your brain is made up of grey matter and white matter. The white matter are actually it's what we call the wiring that actually connects the neurones to each other. And that wiring starts to get sheared. Shreya Mcleod: It creates a huge neurometabolic cascade, which means that there's quite a lot of changes within the ions in the brain itself. And this creates an energy crisis, so to speak. So there's a huge amount of energy required to deal with this injury. And that creates changes to brain function. Sana Qadar: That's why you end up with symptoms like headaches, dizziness, trouble concentrating and processing new information, trouble seeing, nausea. Shreya Mcleod: But it's only usually for a short period of time. Sana Qadar: This is Shreya McLeod. She's a physiotherapist and lecturer at the Australian Catholic University, and she's currently doing her PhD in sport related concussion. And like she says, luckily, most people who get a concussion will recover on their own within about four ish weeks. But, and there's always a but, there is a sizeable portion, around 15 to 30% of people who take much longer months or sometimes even years, and they can be left with ongoing brain fog, trouble sleeping, mood changes like anxiety, even personality changes. Naznin Virji-Babul: And this one woman who came to our lab who had fallen off a ladder, she said she used to be a very kind of Type-A personality, you know, very intense, very organised. And after the concussion, she was just so laid back. She feels like she's a completely different person. Sana Qadar: Is that the kind of change that would be permanent, or would that sort of go away after a while? Naznin Virji-Babul: With her, it went away, but it took almost six months before it went away. Sana Qadar: Wow. How much force is required to result in a concussion? Like what tips a head knock over into concussion territory? Do we know? Naznin Virji-Babul: You know, there's been a lot of studies on this, and there doesn't seem to be a direct correlation with the amount of force, or even where the person has been hit on the head or the body. There's it's so complex how the brain responds to that. I think part of it is, you know, first of all, whether someone's had a brain injury before, we know that there are certain kinds of genes that seem to be more linked to how quickly you recover from something. There are so many, many factors. So you take two people and hit them over the head with the exact same amount of force and in the same place, and they would probably experience that blow very differently. Sana Qadar: Or you take the same person and give them two separate knocks. And experience can also be very different. That was the case for Lewis Freeth. So initially he was lucky no one died in that car crash he was in and his brain injury was mild. Despite what was a pretty dramatic crash. Lewis Freeth: One lady saw it at the hostel from a distance, and what probably happened was that I turned right. To go into the hostel. And don't ask me why this rule exists, but there was some unwritten rule in that specific rural area of South Africa that if you put on your right blinker, then it means I'm slowing down, Overtake me. So I went to turn right and he thought overtake. So he hit me right on the driver's side. Sana Qadar: Oh wow. Lewis Freeth: And so I would have I would have lost consciousness. And my foot probably went on the accelerator. And then, and then I went into a ditch on the side of the road, and the car flew over the paddock fence and I went another probably 50m into the paddock, but when I got out of the car, didn't have a scratch on me. Felt okay, obviously a little groggy, but. And then got into the ambulance. Went to the hospital like pretty remote hospital and I was fine. And I've thought about it since it happened and I wasn't really using my brain in a very taxing way backpacking around. So I probably didn't test to see how it was feeling. Sana Qadar: Right. And the weeks and months following no sort of effects afterwards? Lewis Freeth: I think if I had have been working or studying then I would have noticed them. But I was able to do everything I wanted to do. I was also 22 or 23, so I probably yeah, I sort of had a bit more of a carefree mindset. Sana Qadar: But nine months later, back home in Newcastle, Lewis' carefree luck would run out. Lewis Freeth: So growing up I played a lot of rugby and I was playing for the University of Newcastle all through the first few years of uni up there, and this one is actually on video. I can show you after the recording. And it's probably one of the more spectacular head knocks you'll see. Sana Qadar: Can you actually show me while we're recording? Lewis Freeth: Yeah, I can show you right now. Yeah, yeah yeah. Sana Qadar: Yeah. If you're happy to share. If that's not too hard to watch. Lewis Freeth: No, no it's I've watched it a lot of times. Sana Qadar: Gosh. Okay. Lewis Freeth: One of my friends made a meme about it actually. Sana Qadar: Okay. You're well and truly processed. Then before Lewis gets to the video, he shows me a photo of what he looked like after the hit. Lewis Freeth: So this is the aftermath. Sana Qadar: Oh my gosh. Wow, that's a very black eye. Okay, yes. In the photo, he's sitting up on what looks like the hospital bed. His right eyelid is shut, and it looks like someone's painted a big splotch of purpley black eyeshadow all across it. Lewis Freeth: This is the video here. Lewis Freeth: Okay, so I'm at the back. I don't know if you're a rugby. Sana Qadar: No, I know nothing about rugby at all. Lewis Freeth: I'm playing a position called fullback. Okay I'm in the red and white. The Maitland players in black okay. He kind of steps inside and my own player who was coming from behind to tackle him didn't adjust and just more or less headbutted me. Okay. Sana Qadar: So this first time that Lewis plays the video, it's only four seconds long and I see a bunch of people go down, but I miss the actual hit. Lewis Freeth: Did you see that? Sana Qadar: No, hang on, that was hard to catch. Lewis Freeth: Yeah, yeah, sorry. I'll point it out. Sana Qadar: Where are you? Lewis Freeth: So that's me at the back there. Sana Qadar: Okay. Yeah. This time I've got my eye on him, and I see when the two heads make contact and Lewis's head and neck jerked backwards at an angle really violently, and he falls to the ground. Oh, my God. Lewis Freeth: So you can see. So I was probably. Sana Qadar: That's a direct hit right to the head. You're straight down. Lewis Freeth: Yeah. So I was probably 100 kilos there and just via impact to my head, my feet left the ground you see. And what's really interesting. Sana Qadar: He was fine like because his head smashing into yours? Lewis Freeth: So he, he got a concussion. But if you look closely at the video, I was a bit more upright. Okay. And he was kind of bending down ready for the tackle. And so in terms of the actual impact on the brain, there wasn't really much. Sana Qadar: Right, okay. Lewis Freeth: Whereas I copped a bit more on that one. Sana Qadar: Do you remember that moment? Do you remember him coming at you. Did you have any? Lewis Freeth: Yeah. So what's really interesting. And one of the things that kind of intrigued me with TBI was I actually didn't lose consciousness with that one. Sana Qadar: TBI stands for traumatic brain injury, which is what a concussion is. Lewis Freeth: And I remember everything. And in terms of the effects in the weeks to a month or two after that, that was much worse. But yet I didn't lose consciousness. So it showed me the maybe complexity of of the issue and how just putting it down to a simple, you know, did you lose consciousness or not, paints nowhere near the whole picture. Sana Qadar: After his hit, Lewis was immediately taken off the field. Lewis Freeth: Part of me was thinking about going back on the field, which a few great physios we had there convinced me not to. Sana Qadar: Next, he was taken to hospital, where doctors found he'd fractured his skull and was at risk of infection. He was given antibiotics and the next day he was discharged. And so once you were discharged from hospital, what information were you given about the concussion and, like what to look out for and what to do to heal? Lewis Freeth: It was a while ago now, but there definitely wasn't anything substantial told to me in terms of follow up with anyone dealing with concussions or what to do for your brain health. There was, I would say, probably nothing if there was something, I don't remember it. Sana Qadar: This was several years ago, it was back in 2017, so you'd hope things have changed a bit since then. But when Kate got her concussion this year after falling off her bike, she also felt she didn't get enough information on what to do apart from a pamphlet. Kate: The pamphlet was kind of like a cheat sheet, and it was told to reduce screens for the next 48 hours to have someone with me. Sana Qadar: So you left hospital. You had this pamphlet. How did you feel about how equipped you were to monitor and deal with your concussion? Kate: Not equipped at all. I felt so out of my depth. There's this piece of paper telling me what to do. I'm the one who's concussed. I can't process information at the time. Sana Qadar: Over the following weeks, Kate found herself feeling more anxious and unable to concentrate. Kate: All of a sudden it was just falling apart. I felt like I couldn't go to work remembering to do simple things like check emails and actually reply to them, which is something I experienced with my ADHD anyway. But that problem would persist more than normal. So all the things that I normally struggle with my ADHD, they suddenly became ten times worse. Sana Qadar: A side note, having ADHD puts you at greater risk of getting a concussion and can make recovery harder. Shreya Mcleod: Because the brain is already working harder to respond to the environment. So having an additional load which is created by a concussion just increases the cognitive load. Sana Qadar: Physiotherapist Shreya McLeod says gender also plays a role. Shreya Mcleod: Females are more susceptible to head injuries than males. They tend to take longer to recover as well than males. Sana Qadar: That partly has to do with the fact that women have smaller necks. Shreya Mcleod: So when women take a hit, we can potentially get a stronger or higher whiplash, which then creates a change in the response to how we deal with concussion. Sana Qadar: But Kate had been told none of this. Kate: And then I think what happened is, as my shoulder became broken, that was the more visible injury. So I would have friends, family, acquaintances come up to me and say, hey Kate, how's your shoulder going? Instead of how's your brain going? So I think this is the insidious nature of concussion and mental health in general, is that it's not visible. Sana Qadar: There are a number of factors that collide in a way that mean concussions don't often get the attention they need. Visibility is one, but there are few others. First, if you're not a professional athlete, you're already at a disadvantage. Shreya Mcleod: People who are playing high level sports have several health practitioners available to them. Athletes are dealt with in a sequential manner in the sense that they are managed with what's called a head injury assessment process. It is very different in the community because there are no trained spotters, so to speak, and people playing sport in the community or people in the community don't have access to a concussion management team. Sana Qadar: This is the camp Lewis fell into even though he was playing rugby when he got his second concussion. It was at a university level. So while he initially had a team physiotherapist that got him off the field, in the weeks and months following, he was left to navigate his symptoms alone. And even though he was a medical student at the time, even he was confused, especially after one neurosurgeon said to him: Lewis Freeth: don't use your brain. Sana Qadar: And the other said, Lewis Freeth: Use your brain as much as you can. Try to get it going. In my head I was like, what? Which one am I bloody doing? Sana Qadar: So unless you're in high level sports, there's no one to help you manage and navigate what to do afterwards. But why is that? Well, point two: concussions aren't the domain of any one medical speciality. Lewis knows this especially well because after medical school, he started training in neurosurgery before switching to psychiatry. Lewis Freeth: TBI doesn't fit neatly into a specialisation, so it's basically a structural problem with largely psychiatric symptoms. So working in neurosurgery, the question is operate yes or no? No. Okay. Move on. Working in psychiatry. The structure of the brain I've never seen considered. And I think that's why TBI has slipped through the cracks. And I think that that's a product of just the over over specialisation. When we're thinking especially about the brain within medicine, when you're dealing with the brain, you've got neurosurgery, neurology and psychiatry. And I think to make our jobs as doctors easier, we like to pretend they're three largely separate fields. And I think the lines between them are so much more blurred. Sana Qadar: A third factor that means concussions are often overlooked is simply that they're hard to diagnose. Naznin Virji-Babul: We don't actually have a good objective way to diagnose concussion. Lewis Freeth: No blood tests. There's no scans. It's like the neuropsychological tests take a long time. They're pretty onerous. Naznin Virji-Babul: It's usually done through a physician doing various assessments just to look at very generally balance memory symptoms. But it is it's not a very reliable way of diagnosing. But right now that's all we have. Sana Qadar: And the final factor I'll mention here is the research on concussions has evolved rapidly. So not all clinicians are always up to date. Here's neuroscientist Dr. Naznin Virji-Babul, again. Naznin Virji-Babul: For the longest time when somebody had a concussion, the advice from the medical community was that you basically rest and rest in a dark room and don't go anywhere and don't do any, you know, screen time, don't talk to people and just rest. I've had people come into my lab who have been resting in a dark room for several weeks and are just getting worse, and we now know from a lot of studies that prolonged rest is actually the worst thing. It actually delays your recovery, but it's also associated with greater mental health issues because you have someone who's usually, especially if it's the athletes, they're usually very social, and now suddenly they're deprived of any stimulation. I think anyone would probably start to feel some anxiety, some depression. So I think now, you know, all of us who work on concussion are trying really hard to get the the word out to medical community, the health professionals, but also to people that the most that were recommending is that you rest maybe for 24 to 48 hours, but after that you really have to start getting up, exercising, whether it's through a stationary bike or going for a walk. Shreya Mcleod: We certainly want graded exposure. Sana Qadar: Physiotherapist Shreya McLeod agrees, slowly going back to your normal daily activities after a period of 24 to 48 hours is the way to go. Shreya Mcleod: So every 24 hours we build on the amount of exposure to your normal activities. So every 24 hours you progress through a different stage. If you find that your symptoms are exacerbated, we want you to drop back to the previous stage. Sana Qadar: And is that because you need to challenge the brain as it's getting better so you're actually recovering fully? Is that why rest fully isn't recommended anymore? Shreya Mcleod: Correct. We want to provide the brain with the ability to gauge whether it's ready to move on to those activities. If you rest completely for longer than 48 hours, it actually is detrimental towards your outcomes. Naznin Virji-Babul: We used to think that concussion was just a simple ding to the head. You know, something not to be taken very seriously and that you would recover right away. And a lot of times we would hear this from I would hear this from the participants who were coming into my lab that, you know, they got hit in the head, they felt dizzy, they wanted to step off the field and people would just say, you know, be a man, just get in there and playing. That was, you know, literally only ten years ago where that attitude was that it's not anything serious. And you should just keep playing. Now we know. And you know, ten years is a fairly short time span in the field of research. But within the ten years, what we now really have a good understanding of is that concussion really is a traumatic brain injury. There's no question about that. And there are widespread changes because of the kind of damage that occurs in the brain. And one thing that I was quite surprised about when I started my research was the changes in emotion regulation. A lot of would come to the lab and say, you know, my kid had this blow to the head and now it's, this is not my child. You know, they're always upset, always crying. Little things like, they've completely changed their personality in terms of how we see them responding to just normal things that are happening in their environment. Sana Qadar: Emotional dysregulation was the hardest symptom Lewis Freeth struggled with after his second concussion. He also had trouble concentrating and processing new information, but the emotional stuff really threw him. Lewis Freeth: There's one instance I remember really clearly where I stubbed my toe on the, I don't know, a coffee table or a chair or something, and instead of, oh, Lewis, you've stubbed your toe. That sucks. Like, ordinarily you'd be able to put that into some sort of context. This is going to be painful for a few minutes. It's not the end of the world. Like you can kind of talk to yourself like that, but I remember there was no processing there. So it was just like instead of Lewis feels pain, it was just like pain, only pain. Sana Qadar: When we spoke on the phone, you described it in a really incredible way. You said how you stubbed your toe and your emotional response was like, as if the world was ending. Lewis Freeth: And that's what it was. I don't know how else to explain it, but that's that's what it felt like. Sana Qadar: Do we know why? Why that happens? Naznin Virji-Babul: Well, you know, one area of the brain that seems to be very vulnerable to these kinds of blows to the head is an area called the prefrontal cortex. And that area controls a lot of our emotions. It controls how we make sense of the stimuli that we're getting and how we respond to that, and how we express and understand and perceive our emotions. So it's not surprising that we see that, especially with people who've had multiple concussions. Sana Qadar: Thankfully, both Louis and Kate eventually recovered from their concussions after about 3 to 4 months. But it wasn't easy. Kate: I definitely had to advocate for myself with my concussion. It's something that I had to seek out myself, and I would have kept wondering, there's got to be something else going on here. It's not just my ADHD, it's not just my ADHD medications. Sana Qadar: Kate ended up taking a few months off work to recover, but Lewis was mostly able to stay in medical school. The biggest change is he no longer plays rugby. Speaker6: Do you miss it? Lewis Freeth: Yes, yes. Lewis Freeth: It's the camaraderie and the physical challenge and the mental challenge of rugby. I wouldn't change the fact that I played rugby at all, and I got a lot more out of it than than damage. Sana Qadar: Now he's researching new and better ways of diagnosing concussions. Lewis Freeth: We still don't know enough. Like it's not something that, you know, anyone can say based on data and science, X amount of concussions, this happens. And most TBI patients do recover. But I think the issue is they go through something which is very unfamiliar and can be very confusing, and none of it's visible. It's the same with psychiatric illnesses, but depression much more talked about anxiety probably more common as well. So people have more familiar with it and it can present very similarly to something like that. And so a lot of people can be put on psychiatric medications with side effects when that's not the issue. And later in life with multiple concussions, that's where a lot of issues can happen. Like there's links to Alzheimer's disease and dementia of different kinds, just generally your brain not functioning as well. Sana Qadar: I think people also think of like CTE. Lewis Freeth: Yeah. Lewis Freeth: Yeah, exactly. And that's that's really only a new phenomena as well. But we don't know what's going on to 100% accuracy. Sana Qadar: And so based on what we know now, I want to leave people with a practical takeaway. What's your key message for what someone should do if they hit their head? Lewis Freeth: I think if if it's a severe hit or if you experience any major changes physically vomiting, double vision or nausea, not just vomiting, major headache, anything like that, probably go to ED. You're always better off being safe than sorry. If there are any emotional cognitive changes, go see your GP. I think probably go see your GP either way. And I think just understand that there's not an exact correlation between how hard you hit your head and the impact that it has on your brain. And like I was saying before, it is who you are. It's the most important organ, in my biased opinion, and you really should be putting very, very high priority on getting it checked out. Sana Qadar: That is Dr. Lewis Freeth. He's now training as a psychiatrist in Sydney. You also heard from Kate from WA, as well as Dr. Naznin Virji-Babul, who is a physical therapist, neuroscientist and associate professor at the University of British Columbia, and Shreya McLeod, physiotherapist and lecturer at Australian Catholic University. Shreya is also doing her PhD in sport related concussion at the University of Newcastle. Now, one thing we didn't get into in this episode was how concussions are a bit different in children. They can take a lot longer to recover. Naznin Virji-Babul: So you have this very active, dynamic stage of development that's going on in the brain, and then all of a sudden you have an injury, you know, your brain now has to not only reroute and recover, but it also has to continue with the development. And I think that's why it takes longer. Sana Qadar: So just something to keep in mind if you have little ones at home and that's it for All in the Mind this week, thanks to producer Rose Kerr and sound engineer Russell Stapleton. I'm Sana Qadar, thanks for listening. I'll catch you next time.
