Concussions can happen in sport, but how do you know if you have one and what happens when you do? This week, Sonya sat down with Adam Luu, an orthopedic, concussion and vestibular physiotherapist to talk about what you need to know about concussions.
Adam has a Masters of Science degree in Physical Therapy from McMaster University, followed by a fellowship with the Canadian Academy of Manipulative Physical Therapy. He is a certified concussion therapist – certified in several concussion management protocols like ITPT and Shift. His training in ITPT means he can administer and interpret the ImPACT test, which is a neurocognitive assessment tool that is the standardized assessment tool of North America’s top professional sports leagues. The Shift concussion management system is the Canadian-founded concussion management strategy.
Adam also has a certification in vestibular therapy, instrument-assisted soft tissue release, nervous system assessment and treatment and bracing/proprioceptive taping.
He is also Sonya’s physiotherapist!
“I think the number one thing is don’t be scared of your symptoms. So your symptoms are really, those 22 symptoms that keep referencing, those really are just a way of your brain trying to signal to you that something’s wrong. And it’s just a communication system more or less, right. So I always tell people, when you feel those symptoms, don’t get discouraged by them, just know that that’s your brain communicating to you. So if I’m watching TV and my headache goes from like a two out of 10 to a five out of 10, after five minutes, it’s like, okay, well that there’s something with the TV and my concussion that’s not jiving, right. But if I keep avoiding the TV for days and days and weeks and weeks and weeks, my concussion injury will never adapt to that stimulus.”– Adam Luu
- What is a concussion?
- How do you know if you have one of the 22 symptoms?
- SCAT tool
- Severity of concussions
- The systems that play a role in concussions
- Why are concussions dangerous?
- What is post concussion syndrome?
- Concussion rehab protocol
- What to do about kids and concussions
- Risk aversion with sports
- Concussions in older populations
- Dietary considerations with concussions
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- Learn more about Adam Luu and email him here
- Learn more about his clinic Union Health and Performance
- Related podcast: Myths about Concussions with Dr. Steven Broglio, PhD
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Sonya Looney: Adam, my physio. How’s it going?
Adam Lui: Yeah, good. Good, good. How are you?
Sonya: Good. Now’s the time to tell you that I haven’t been doing some of my exercises, but it’s time to get back on the horse.
Adam: Yeah, they ebb and flow. I tell people all the time, I’m sure I’ve said it’s up to you. There’s a time in place. And as long as you have the tools for it, and you know when to use them, then that’s all that matters.
Sonya: So your background, I mean, you’re a physio you’re also a hardcore rock climber. Tell us a little bit about you and your background.
Adam: Do you want to know more about my physio background or you want to know about my sports background?
Sonya: I want to hear about both and I’m sure one and they both inform each other during some periods of time.
Adam: Yeah, they do go into each other. I’m physio I’ve been a physiotherapist for 12 years now, which sounds crazy to me to say. But I did undergrad in kinesiology. In high school, the only things I was really good at were sports, ie gym class, and science. So the thing that kind of made sense if I was going to go to university was Kinesiology. So the science of sports, the science of movement. So I went into that based off the recommendation of my older sister. And then when I went to undergrad, I was lucky to get into a co-op program, where you do kind of a semester of school and then a semester of work, and you hope it’d be related to your field or your degree of study, when which I was lucky to have. But I had a couple cold place placements in a physio clinic. And yeah, I really liked that setting. And funnily enough physio is my second career. So my first career was working in ergonomics. So I was working in Michigan at the time, in 2007/2008. And it was more going into industrial settings and trying to fit manufacturing jobs to people. But that job, it was cool, but that Job was just so much less human interaction, and a lot more report writing and I just realized it wasn’t a good fit for me. So yeah, I applied for physio school was lucky enough to get in and yeah, finished school in 2010, and have been working ever since.
Sonya: Yeah, something I think is really special about you as a physio is that you have a really good way with people. I know, when I come see you, I feel very seen and very heard. And also, you’re very positive and encouraging. And you can tell that you’re really passionate about your work.
Adam: Oh, that’s super nice feedback. That’s nice to hear.
Sonya: So that that degree program sounds really interesting how you got to have work experience intertwined with your coursework.
Adam: It was awesome. I mean, at the time, so I did my undergrad and 2003-2007 I think. And at the time, Waterloo, which I did it in southern Ontario, it was like one of the only university programs in kinesiology that had a co-op component to it. And so I mean, it caught my attention for sure. Because, I mean, you get work experience, number one, you also get paid. I mean, university is so expensive. So for a lot of us, it was just a really good opportunity to make some money and also get some exposure. So it was a no brainer for me to apply to that school. I think nowadays, there’s a lot more undergrad programs that have co-op components but I mean, back then, yeah, that was I think the only one and it was awesome.
Sonya: And when did you get into climbing?
Adam: Yeah, I got into climbing, I hate saying this, let me say, things that you’re like oh, man, I’m so old, right? Like I’m declining. I think my high school graduation, I think we have our 20th anniversary like reunion next year. I’m like 20. That was 20 years ago. That’s so crazy. But I got into climbing I think 17 years ago, I was in undergrad. And yeah, we had an old squash court in our university gymnasium that got converted into a small bouldering cave. And then we’re walking by it one time and seeing one of my friends in there. And I was like, what is this? You need special shoes for this? Like, what’s going on? And so I really got into it at that level and, and just got sucked into it. It’s just so athletic. But it’s also so, I don’t know, do you climb at all, Sonya?
Sonya: A little. I’ve done a little bit but I’m definitely not a climber. I’ve been maybe like 10 to 20 times.
Adam: Oh yeah, nice. Yeah, but even with that amount, it’s such a puzzle, right? There’s such a cognitive piece. I know it’s to me it’s similar with mountain biking, just mountain biking happens on such a faster level. Because with mountain biking, I have to pick the right line and I know sometimes if like if like I got the trail great, but like my line choices aren’t perfect. It’s stays in my mind. And climbing is the same. It’s all about just getting like the nuances down and yeah, there’s something so cool about that on a mental level and then physicality wise, it’s just yeah, it’s pretty awesome. So I got him climbing 17 years ago, never thought, I moved to Squamish seven years ago to climb, like to be a climber. Because in southern Ontario, there’s not too much and I just never thought climbing or a sport would take me across the country. But it did. And here I am. So, yeah. And what a place to be.
Sonya: What a place to be. That’s right.
Adam: Yeah, my apartment right now. I mean, yeah, it’s saying right now I can see out well, and this is such a dream spot, right?
Sonya: Yeah. So, talking about climbing, talking about mountain biking, it doesn’t always go the way that you planned. If you do choose the wrong line, or you take a fall, and sometimes you hit your head. And whenever I first came into your office, I saw some posters on the wall and some other things. And you said, Yeah, I work with athletes with concussions. And a lot of people listening have probably either had one themselves or know somebody that’s had a concussion. And I just still think that this isn’t talked about enough, there’s still isn’t enough information out there about concussions. So that’s what I want to spend this podcast focusing on since you specifically work with athletes. But can you first just by start by telling us what is a concussion?
Adam: Yeah, I mean, a concussion it’s an injury to the head. But what people sometimes get confused is that you often think it has to have like a direct blow to the head, but you don’t. Your head sits inside of your skull, there’s like a thin amount of space that’s filled with fluid. And if you jar your body hard enough, it sounds dramatic, but your brain can hit the inside of your skull and that can result in an injury. The official definition is super long and wordy, but it can either be a direct blow to the head or indirect blow to the body that causes an acceleration or deceleration force that gets transmitted to the brain. So it’s literally anything that can cause your head to get knocked. I was gonna say, what’s crazy is that like, there wasn’t an official, complete consensus definition of a sport concussion until 2001. I always remind people. That’s how new the field is. So I can probably do that as in one, there’s no agreed upon definition of what a concussion was, which in my mind is crazy, you know?
Sonya: Yeah. It’s also weird that you can get a concussion without taking a blow to the head.
Adam: Yeah, yeah. A lot of people don’t think that sometimes I get people that come into my office for an assessment, and they’re not even sure if they have a concussion. They’re like, I didn’t hit my head. You know, my dog ran into the side of my body when I was tying my shoe and then now I just feel super dizzy, and I don’t know what’s going on. And it’s like, yeah, you don’t need that, whatsoever. I know why you’re laughing. That was a total, total random example. But that’s the one that always sticks on my mind. But yeah, so sometimes without that, that glow to the head, which is like, it’s still such a key facet that people think. But you don’t you don’t need you don’t need that close to the head at all.
Sonya: So how does somebody know if they might be contending with a concussion?
Adam: Oh, that’s a great question. I always tell people, I would say you have to err on the side of caution. It’s really tough, especially when you’re on the trail. I’ve had three concussions in my lifetime. Two of them have come from mountain biking here in the corridor. And it’s tough when you’re in the trails, and how do you get out? I mean, a lot of times, if you can you, you ride out, right, which is not the greatest scenario to be in. But a lot of times, you’ve got to just look for any symptoms that feel kind of off. So I always remind people that when it comes to a concussion, there’s 22 symptoms right now. Like when they do the sport concussion assessments, there’s 22 symptoms that I’ll ask you about. And these are only these are the 22 recognized symptoms of a concussion. The crappy thing is that like, none of them are specific to a concussion whatsoever. With different parts of the body, you know, meniscus injury to the knee, maybe it’ll get locking, something like that cues you in right away, but none of the concussion symptoms are specific whatsoever. But either you’re 22, you’ve got headaches, dizziness, nausea, fogginess, anxiety, light sensitivity, noise sensitivity, the list is pretty long and extensive. And I always tell people, if you get into an accident where there is either hit to the head or blow to the body that caused like a whiplash mechanism to your neck, if you feel off, do you just immediately label it as a concussion until you get cleared? That it’s not. Better to be safe.
Sonya: It’s tough, if you fall down, running, skiing, whatever, like you’re taking a blow to your body, even if you don’t hit your head, and you might have any of those symptoms, because whenever you get an injury, you’re going to feel fatigued, you’re going to feel a bit off. So being able to say, is this a concussion or not, and to treat it seriously, I think a lot of people don’t treat it seriously because A, they don’t want to accept that maybe that did happen, or B, they don’t want someone to tell them that they need to stop doing their activity. Or C, when you have a concussion, emotionally, it’s hard to make good decisions. So you might have a hard time even making the right decision as to whether you should get checked out or not.
Adam: Totally. Right. And it’s tough. Just situationally, it’s really tough, like a lot of concussions happen when you’re competing. And as an athlete, and I used to be a competitive athlete myself, when you’re competing, you’re kind of embarrassed. Or hey, let’s say you crash off your bike, you just kind of want to get up, dust it off, and just keep going. Or sometimes the adrenaline is really high, and you just don’t recognize what’s happening at all. You might think you’re totally okay, but externally, people will see things kind of differently. So I always tell people, if you’re competing, I mean, luckily, nowadays, we have good health team members that will look out for you, and will make the best judgment call for you. But if you’re recreating on your own, or if you’re riding with friends, or are playing sports with friends, and it’s a friend of yours that has a potential concussion, I think the best thing we can do with the education we’ve got nowadays is just advocate for each other and just really err on the side of safety.
Sonya: Is there a place that we can access those 22 symptoms so that if someone is curious, they can look at it?
Adam: Yeah, 100%. And there’s something called the SCAT tool. So it’s SCAT tool, the sport concussion assessment tool, it’s had a whole bunch of different variations. I think it’s on its fifth edition now. And there’s a whole bunch of different subsections to it. But there’s a symptom inventory checklist. It’s the most widely accepted symptom inventory checklist that exists out there. The international concussion community advocates for this use. And so that’s the same checklist that I use. So I always tell people is just if you look it up, they’ll have all 22 symbols there. And literally, if you can say yes to like three of them, you know, in my mind, you should probably just get ruled out before you compete any further.
Sonya: I think it’s kind of hard to because some of those questions, they it’s like asking how you feel, and it’s really hard to say, this is how I feel sometimes. So, how do you navigate that?
Adam: Oh, man, it’s such a good question. I mean, I could do the checklist right now and answer yes to probably three of them. Yeah, I’m a little tired. And like, maybe I’m a little bit emotional, a little bit foggy. I just had a COVID booster shot, so it’s like, how many of those symptoms are from the shot? But I always say it’s all in context. So it’s like, if if you did have some kind of traumatic injury or exposure or scenario happened to you, and it’s like, I do feel tired, I do feel headachy, I do feel dizzy. It’s like, just in the context of it all, it’s still probably worthwhile to, to get that figured out.
Sonya: And then who should somebody go see, because a lot of people will say, I’ll go see my MD or you’re a physio, who do you go see when you have an expected concussion?
Adam: Man, that’s a good question, too. And good one. A lot of people in Canada, we’ve got free access to hospitals and our doctors, right. And a lot of doctors in the corridor are super educated about concussions, but I think that’s just because of the environment and the sports that happen here, but I don’t think that can be generalized across Canada. So I always tell people if you can, you try to get in and see somebody that has some kind of continuing education that’s concussions specific. Yeah, doctors, they’re great. They’re more than the general side of things. But if you can get in with somebody that’s got concussion related knowledge or continuing education, that’s always the best thing to do. The thing I’ll say is in Canada, this is what drives me kind of crazy, is that anybody in Canada can say they can provide concussion therapy. You don’t have to get any extra education to state that at all. Yeah, it bothers the heck out of me. So sometimes we do go see a physiotherapist and they may be the best physio and have really good intentions. But if they don’t have any continuing education that’s concussions specific, you should probably seek somebody else out if you can. Nowadays with Internet, and most physios will have a bio online, whatever clinic they work at, I tell people read that bio and make sure you’re finding somebody that that says they do concussion treatment, but also is listing at least some kind of education, continuing education, that backs up that claim.
Sonya: That’s a good tip for somebody who’s looking for a practitioner. And also just a reminder that you can go see, it doesn’t have to be an MD, like you can go find somebody that can really help you. So when someone does come see you, what is the process? Is there a questionnaire, there’s things that you do, what is somebody going to expect whenever they go in?
Adam: Yeah, so usually, when they see me, it’s pretty in depth. And so usually I’ll split my assessment up into pieces. So getting through a full concussion assessment is super, if when you do have a concussion, it can be really overwhelming. So sometimes a lot of my assessment pieces can take multiple sessions to go through. But I think number one is just for me getting an understanding of your history and going through a lot of reassurance. Sometimes there’s so much, I don’t know what the right word is, or how to describe it. Sometimes when people get a concussion, they’re really fearful, you know, you’re really fearful of like, what does that mean? What does that mean for your sport? What does that mean for your health? Maybe it’s your fifth or sixth, or maybe you’ve had a couple in a row, like, you don’t really know how that’s all going to play out. And it can be really, really, really anxiety inducing. So I think for me, it’s usually that first in that first session is just trying to answer all the questions you’ve got, before we even go through the assessment just to kind of calm things down a little bit.
Sonya: Yeah, sounds like the emotional component is a really big component for a lot of people and part of your role is to help people through that first part.
Adam: Yeah, I’ve had some chronic injuries and oftentimes, when my chronic injuries get flared up, and as usually from a bad bouldering fall, or from a bad mountain bike crash, the number one thing in my mind is like, oh, no, do I have to go through this process all over again? And it’s the worst feeling, you know, so I usually try to help people out on that front first. And yeah, and staying positive is a massive component to that.
Sonya: Yeah. And I think when you’ve had a concussion, it actually is even harder to be positive. Because I don’t know what it is about it, but just emotionallyit’s so hard. Like, you’re just not yourself.
Adam: Yeah, yeah. Yeah, that’s right. It is. I think that’s the same with any recurring injury, right? I mean, you’ve had recurring injuries before. And when you get over it the first time, it’s awesome. But when you have to get over it the second time, the third time, I don’t know, it’s daunting. It’s overwhelming and it takes so much to get through injuries sometimes, especially traumatic ones. To to have to unexpectedly make that part of your process over the next couple of weeks or months, it’s not fun.
Sonya: So are there different grades of concussion?
Adam: Yeah, there are. So I mean, on the most basic sense, just like any injury, we grade concussions mild, moderate, or severe. Concussions are the only injury still where you can’t evaluate the severity of a concussion until after you’ve recovered from it. It sounds so weird. It’s so weird, because that’s at someone’s number one question is, how bad is this? And how long is this going to take? And it’s the only injury where my honest answer is, we can’t give you an answer at all. If you have an ACL grade one sprain versus a grade two versus a complete ACL tear, we have really common expectations. Grade ones, like maybe six to eight weeks, grade twos, maybe three to six months, complete tear, that’s one year minimum. With a concussion, we’ve got no algorithm yet to predict how long they take to recover or how bad they are. So it sounds weird. In my experience, anecdotally, I’ve worked with people that had crashed off their bike hard enough where they fractured a vertebrae in their neck, lost consciousness, retrograde amnesia, they can’t remember a thing. Maybe they woke up and vomited. But concussion wise, four weeks out, they pass every test I can give them and on a concussion standpoint, they’ve fully recovered in my mind and you can mark that as a mild even though day one it didn’t seem like it at all. And then you can see people that have maybe low-grade dizziness, maybe very low-grade headache. And you can see those symptoms persist for one to two years. So from day one, you might be like, oh, it’s only a headache. That’s a three out of 10. And it’s only dizziness as far as and this should be a couple of weeks. And I’m good to go. But sometimes it doesn’t. So there’s no way of predicting at all and they’ve tried to do that, they’ve tried. They’ve done studies before, where it’s like, let’s rank your intensity on these 22 symptoms, and then follow you over time and see which symptoms predict longer recovery times and there’s not too much of a pattern. There’s some symptoms that do predict a protracted recovery, is what we say, you can expect you’re going to take a little bit longer, but there’s really no way of predicting how long or guessing the severity of it until it’s over.
Sonya: Yeah, that uncertainty piece must be just so hard, even as a practitioner because you want to tell somebody, you want to give them the assurance, this is what your expectation should be, but you have no idea.
Adam: You have no idea. I know. You have no idea. So that is a hard pill to swallow for a lot of people. But I always tell people, even though we have no idea, you just got to look for progress, you have to look for that progress. And as long as there’s progress, then you’ve got to be happy enough with that. And that takes a little bit of learning to accept as well.
Sonya: So what are some things that you do to help people who have a concussion work through them?
Adam: So nowadays, I mean, the research is constantly evolving, and so much physio research is on the concussion front nowadays, too. But on a physio therapy or physical therapy standpoint, there’s a lot of different systems that can get impacted after a concussion injury that we can assess properly and treat. So I always tell people, it’s like on a really, really basic sense, my analogy is always if you are a decathlete, and you’re going to some coach that has the ability of assessing your ability in all 10 sports, whatever sports you suck at it, if it’s the sprint, it’s the long jump, whatever, those are the ones that you’re gonna work on to try and make things better, right. So after a concussion injury, we know that there’s very specific domains that we can assess. So after a concussion injury, usually there’s an injury to your neck, usually there’s an injury to your visual system. So the muscle groups that control and coordinate your eye movements. Usually there’s an injury to your vestibular system, so the system that controls your balance. Usually, there’s an injury to your cervical proprioception, which is kind of this odd thing that helps you with spatial awareness. And so there, we as physios, we can assess those things and if we feel that there’s deficiencies in them, then we train them the same way that we we would train anything else. So if you’re weak in your bicep, and we give you bicep strength exercises, and then we measure the progress. So with concussion, if you were impaired in any of those systems, we try to come up with exercises to force an adaptation, and we just see how it goes.
Sonya: For me, I’ve had a couple I haven’t had one since 2016, but there is a whiplash element in every concussion that I’ve had and doing some dry needling and some work on the cervical spine made a huge difference. And same with my husband actually who’s had concussions.
Adam: Yes, the neck plays a huge role. Your neck is massive, and a lot of the inputs to your brain, or they come from your neck, or I shouldn’t say come from your neck, but they have contributing aspects, I guess, from your neck. Way back in the day, like in the early 90s, they were able to establish that if you’ve got stiffness coming from your neck, there’s 14 different symptoms that are recognized, coming from neck stiffness, and it’s funny because neck pain that’s an easy one, right? But a stiff neck can cause headaches, dizziness, can make you nauseous, can make you foggy, can give you light sensitivity. And these are all funny enough like concussion symptoms, right? So I always tell people, there’s so much overlap. And so figuring out what’s going on with your neck and making sure we’re working on your neck because it’s a huge component to concussion recovery for sure.
Sonya: Something that I wish I had known that I did not take into account back then is how dangerous a concussion is and how bad it could be if you continue your sport despite having one. I didn’t take it seriously the times I’ve had it. I was back out there when I absolutely should not have been back out there, thinking I’m fine. And as an athlete, you always have this mentality of well, I’ll just grit my way through. But a concussion is not the time to do that. And I’ve made lots of stupid decisions in my athletic career, gritting my way through injuries. Can you tell us why it’s so dangerous to continue with a concussion?
Adam: Yeah, I mean, it’s a really critical time period for your brain. So when you have a concussion injury, without a concussion injury, we have a buffer, so we’ve got a buffer where you can sustain force, and your body can sustain that force in a really healthy way and have no side effects to it. But after a concussion injury, that buffer is gone. So I always tell people, it’s kind of like riding the Whistler bike park with no helmet and no gear whatsoever – maybe you can, maybe you’ll be okay, but a crash with no gear on, you’re going to feel that so much more than if you had the proper gear in place. So physiologically speaking, and it can get super detailed, but physiologically speaking, your brain just does not have the buffer it needs to be able to safely absorb and dissipate any kind of force after a concussion injury. And so that second concussion injury or that second hit on top, when your brain is still recovering, can actually be fatal. So they call it second impact syndrome. And people have died from getting a second concussion when they were actively experiencing their first. I always hate to mention that to people because it sounds super dramatic. But it is true. If you have an acute concussion injury, and you get a second hit, you can die. And those cases have happened before.
Sonya: Yeah. And I think that that’s an important thing to say to somebody, especially somebody like me, that will just keep going.
Adam: There’s a certain age as well, because for me as a kid growing up, you were kind of told, that was kind of a cultural norm, you just kind of shake it off and get back in there. Right. But that is changing, for sure. And I think that again, that’s where it comes to having the right people in place on your team if you’re an athlete, or having really good supportive and understanding or even inquisitive family members and friends that can restrain you a little bit if you want to get back out there.
Sonya: And what about subsequent concussions? Because maybe you are cleared to get back out there by your medical practitioner. What happens if you have another one after you’ve already been cleared to continue or return to sport?
Adam: Like, that’d be a gray answer. For me, if you pass every concussion test that we have at our disposal right now, and we do have a lot, which is great, I do think a decade from now, we’ll have even more because maybe the tools we have now don’t fully capture everything. But if you fully pass every test that I can throw at you, and you’re participating in your sport and to some degree without any symptoms at all, then for me, you’re fully recovered. And if you do get another concussion injury once you’re fully recovered…I’m going to answer this really poorly, I’m trying to try to choose the right way of saying it, but if I fully cleared you, and you do get a new concussion injury, it’s not as dire at all, compared to if you get a hit when you’re still recovering. It’s always hard to say how people react to it because obviously, cumulative injuries on any part of your body are tough on that part of the body. If you separate your shoulder and you fully recover from a separated shoulder, but then you separate it again, it’s probably going to be just as long, if not longer, for recovery process just because that part of your body has sustained multiple injuries to it. And the brain being a more sensitive part of your body, it wouldvbe the same answer to it, if not a little bit longer.
Sonya: So is there a time where you might… it’s hard to tell somebody what to do…but if somebody’s had a certain number of concussions, you mentioned fifth or sixth concussion, should that person maybe consider stopping that sport?
Adam: Yeah, that’s such a hard one. I don’t know. I usually have a really honest conversation with people and I always hate to be the one to make that decision for people. And luckily, in my career, I haven’t had to be the one that makes that decision for people. I mean, you would see those warning signs, I think, clear as day if you’ve had seven concussion injuries and you’ve noticed that your first one happened 10 years ago, and then your second one happened five years ago. And then you had four last year and five this year, like you can just see the trend is worsening. And if you notice, that does not take much for things to happen again, that’s kind of a question where it’s like, yeah, maybe if all of these concussions were a result of the same sport, you’re a hockey player or your MMA fighter or something, you might be looking at making the tough decision, in terms of if this is something that you want to keep on doing. But in the greater conversation, the mental health conversation, I know for me, physical activity is how I keep my mental health in check. And it’s all of my concussion injuries were from mountain biking until somebody told me I don’t think you’ll mountain bike ever again, that would be a really, really tough thing for me to evaluate.
Sonya: And I want to talk about post-concussion syndrome, because you mentioned sometimes symptoms lasting for years. And this is the reality for, I don’t know the stats, but it seems like it’s bigger than just a small population that this happens to. Can you tell us more about that?
Adam: Yeah, so the statistics that are out there…so concussion statistics are hard because there’s different ways of measuring concussions. And a lot of times in the literature, there’s small sample sizes, and there’s statistical nuances that make it hard to generalize, I guess. But you’ll often hear really common statistics, like 80% of concussions recover in four weeks or less, and the remaining 20% that don’t recover within that first four weeks can last up to a year. And then in that percentage, there’s another further 20% that last two years. So post-concussion syndrome is basically a concussion that persists longer than four weeks. So in the literature, right now, an acute concussion injury is a hit to the head where you have symptoms and diagnosed with a concussion and that’s within the first four weeks, which is a kind of a different management strategy, I guess. And then a post-concussion syndrome is when you have concussion injuries beyond four weeks, and in the medical literature, it’s thought that after four weeks, the actual physiological injury has recovered, but for one reason or another, you’re still experiencing symptoms. So think of post-concussion syndrome like a broken bone that’s healed completely and on imaging, it looks like a completely healed bone, but yet this person still has pain where the brake was, and still has loss of function where the brake was and can’t use the same way. So like, physiologically, it seems like everything should be working just fine, but it’s not. That’s, that’s kind of what post-concussion syndrome is.
Sonya: Sounds like some of the post COVID things that happened too.
Adam: Totally, right? Yeah, that’s right. It’s kind of unexplainable. They don’t know why it happens. But there’s a good percentage of people that experience it.
Sonya: And this is just a quick moment, this is my suggestion for people who have experienced this, whether it’s post-concussion or post COVID, or whatever post problem you’re dealing with, is to meet yourself with some self-compassion, because it’s really easy to get frustrated and critical and impatient and judging, and that doesn’t help the healing process at all.
Adam: No, it doesn’t at all. I know. And it’s so easy, because you get so frustrated, and especially when health professionals can’t tell you the answer because sometimes people will come to me for the answer and I can’t tell you why you’re still experiencing this. And when people have been like, but it’s been a year and a half and I’ve been doing all the right things, it’s like, why. I know, I can’t tell you why it’s not happening. But you have to try to stay motivated to keep doing the right things. And it is such a frustrating journey to be on. But you’ve got to be nice to yourself, easier said than done, for sure.
Sonya: So what does the recovery process look like? Because I haven’t read up on what it’s been like since in the last whatever, how long has been? Six years? But it used to be you have to stay in a dark room and you can’t use your phone and you can’t have any other inputs. Is that a myth now or is that still kind of the protocol?
Adam: Yeah, it was funny that was the protocol for sure. So when I came out of school in 2010 that was totally the protocol. I remember this list that I think like the Canadian Physio Association published, where it was, these are the things you should avoid after a concussion. And it was literally anything you could think of that was a stimulant, right? It was like TVs, phones, music, reading, conversations, going outside, right? It was a ridiculous list. And I was like, wow, I really can’t do anything. But the research has changed. One of the last consensus statements that came out for guiding concussion rehab in 2017, it was starting to advocate early reactivation. So it’s, honestly a 48-to-72-hour period of rest. And this is case by case too, which is why it’s really important that there’s a clinician that has some kind of concussion experience or concussion education. But generally speaking, it’s about 48 to 72 hours of rest. And this is going to sound funny, and I usually spend a lot longer trying to clearly make sure people understand this, but then it’s trying to get back to everything that you used to do as normally as you can, until your symptoms go beyond a certain threshold. So it’s like, yeah, have conversations, watch TV, be on your phone, read a little bit, play board games with your kids or with your friends. And all of that is okay, until your symptoms get worse by like two or three points. At that point in time, whatever it is you’re doing is when you have to kind of cut back. I always use the analogy of trying to get your cardio system better. So I always tell people, if you’re really wanting to get your cardio better, it’s going to feel a little bit uncomfortable, right? And you’re going to have to experience feeling slightly short of breath. And if you’re working on your cardio, and you never for a second feel shortness of breath at all, you’re probably not working hard enough to try to facilitate a change, right? So concussions the same. You’ve got to give your brain a reason to adapt. And if you are scared of your symptoms, which a lot of us are initially because we just don’t get educated enough about it. But if you’re scared of your concussion symptoms, and every single time you feel the symptoms, you stop what you’re doing, your brain is never going to adapt to whatever that stimulus is. So you have to work into it a little bit, but into a safe zone where doesn’t make things worse, but forces things to get better.
Sonya: You just said most of us aren’t educated enough about our symptoms; is there anything that I’ve missed so far to help educate people on this?
Adam: Yeah, well, I think the number one thing is don’t be scared your symptoms. So your symptoms are really, those 22 symptoms that keep referencing, those really are just a way of your brain trying to signal to you that something’s wrong. And it’s just a communication system more or less, right. So I always tell people, when you feel those symptoms, don’t get discouraged by them, just know that that’s your brain communicating to you. So if I’m watching TV and my headache goes from like a two out of 10 to a five out of 10, after five minutes, it’s like, okay, well that there’s something with the TV and my concussion that’s not jiving, right. But if I keep avoiding the TV for days and days and weeks and weeks and weeks, my concussion injury will never adapt to that stimulus. So sometimes I tell people, it’s kind of like, imagine you’ve been seeing a pitch-black room for, let’s hypothetically say four straight weeks, if you’ve been seeing a pitch back room for four straight weeks, what amount of light is going to hurt your eyes – any amount of light, even though the tiniest light from a lighter. You might be piercingly in pain, because your eyes haven’t been exposed to that at all. But if you don’t find a level of light that is okay for your eyes to get exposed to, you’ll never get used to the stimulus of light again, right? So I always tell people, listen to your symptoms, but it’s a lot of coaching in terms of trying to figure out and find proper thresholds that are okay. And people eventually I think get really good at it, which is good. But step number one is not being scared of your symptoms at all, which I find that after any concussion injury, really, we’re usually pretty anxious and pretty scared of everything that we’re feeling.
Sonya: It sounds like using curiosity instead of judgment in this scenario, and in many scenarios in life, is important. And also just being brave enough to experiment a little bit because it sounds like it’s not just sit in a dark room, it’s see how things go and then not get freaked out if your headache comes back in full force. Not saying this is an end all be all this is just some information to inform what I need to do next.
Adam: That’s exactly it. Curiosity is such a good word. It really is just trying to be curious about the boundaries of your injury, and then you have to push those boundaries for things to get better. And it’s a little bit people hate. People hate to hear this. And sometimes I’m like, it may be the expectation is weird, but I always tell people with post-concussion syndrome, it’s a little bit trial and error, right? You really don’t know where are the boundaries, you have to go out there and find them and explore what they are. So sometimes I use the analogy, it’s like going into the gym for the first time. If you’re going to the gym for the first time, and you want to jump on these five different machines, what weights are you going to use? Who knows? You try once you move the stack, you can’t budge it? Well, let’s drop it down. It’s too easy. Well, let’s increase it. And it’s a little bit of trial and error to find out what that buffer zone is for you. And then once you find out that, yeah, the lat pulldown was 75 pounds is a good challenge. If we can keep that exposure over a couple of weeks, you’re going to notice things are getting stronger and better. So concussion injuries are the same. It’s finding out what your exposures are, and training them the exact same way so that your brain gets used to that type of stimuli again.
Sonya: I wanted to ask about kids and concussions. And I know it might be a different type of education. Even with coaching, like health coaching, or mental skills coaching, there are special rules around coaching children, but there are lots of children that play sports, whether it’s an endurance sport, like mountain biking, or they’re playing football, or soccer or a sport where they might get a concussion. So what advice do you have for parents listening, where they’re like, oh, I think my kid might have one or my kid could get one?
Adam: It’s tough. That’s a really hard question, especially for me. I know that most of the time other physical types of injuries, kids typically heal way faster than adults do. But when it comes to concussion injuries, kids typically heal quite a bit slower. So with kids, you have to be a lot more conservative than with adults. And kids also have a very poor ability, and it’s not their fault at all, but really poor ability of communicating to you how they feel sometimes, maybe they just don’t know. Sometimes I’ll ask kids, do you feel dizzy? Or do you feel mentally foggy? And they’re like, I don’t know what that means.
Sonya: The self awareness of a kid for sure. Like the mind body connection and all that.
Adam: Oh, totally. And so when they can’t answer some of the things that we need to be able to guide you properly, it gets really, really tough. So with kids, you always have to be way, way, way more cautious and conservative, for sure. And they’re going through a lot depending on the age of going through certain stressors that we as adults don’t have to go through either, like school can be a stressor or changing schools or maturing, like puberty. All those things can cause a lot of anxiety, which can bring on a lot of symptoms on their own. So there’s a lot of confounding variables to it for sure. I do personally often struggle with kids under the age of 12 with concussions. I just find that there’s a lot of other confounding things going on that make my judgement of the injury itself difficult to navigate. But for parents or parents listening, it really is just if your kids are feeling off at all, and there’s a suspected concussion injury, we just have to play conservatively and be patient.
Sonya: I’m going to ask a dumb question, can someone get a concussion from say, heading a soccer ball or something like that?
Adam: 100%, yeah. 100%. Soccer headers are one of the leading causes of concussion injuries, actually. Which is why I believe in soccer, adolescent soccer is not a sport I follow in terms of rule changes and policy changes, but I do believe that there are leagues out there and provinces out there that have limited heading the ball for certain age groups.
Sonya: Yeah, and I’m just thinking about this risk aversion, right. If you play any type of sport, you’re at risk. I mean, I don’t know if the word any is even appropriate, but if you’re playing most sports, it seems like there’s a chance that you could get a concussion and concussions can be serious. So some people will say, well, I’m not gonna play any sport, or my kids aren’t gonna play any sport, because I just don’t want them to take any type of risk. But then there’s also the reward, like you said, the mental health and there’s tons of other benefits of playing sports. So what advice do you have for people who might be very risk averse and afraid?
Adam: I know, that’s a tough one. That’s a tough answer. It’s kind of up to your personal philosophy, to be honest. In Ontario, they limited body checking in ice hockey to over a certain age, because same thing, just to help to curb the risk of concussion injuries. And we looked at concussion rates when they introduced new body checking rules. You saw those concussion rates plummet, really, but I mean, there’s the argument that learning how to body check and learning how to absorb a hit at a younger age may make you more protective in terms of protecting yourself against concussion injury. And I actually fully believe that as well. I took martial arts when I was younger and in martial arts, one of the first things, we learned how to deal with something called a break fall. And a break fall was just kind of like using different, you kind of hit the ground really hard with your arm when you were flipped over. And you were using your body to absorb and dissipate that force so that didn’t go into more vital parts of your body. And so I think learning that at a young age helps transfer some athletic skills where I was able to protect myself a little bit better. So it’s a tough one. I understand on the policy side of things, if you eliminate some of these skills that you eliminate by checking for kids or eliminating headers, in soccer, you’re gonna lower the risk of concussion injuries. But at the same time, I do think that some of that exposure, and learning how to navigate through sports, is a healthy thing. So I don’t know, I don’t really have a good answer for that. I do really think it’s kind of up to the parent and personal philosophies to drive what you end up doing.
Sonya: Knowing what your personal philosophy is around. This is the answer, because there is no right answer. It’s going to be individual.
Adam: Yeah, that’s exactly that’s exactly no right answer at all.
Sonya: I think my last question is going to be about older populations. Because I’ve asked about kids, I’ve asked about sort of general populations, but you always hear people say when you get older, it takes longer to heal, and this and that. Have you seen any trends with older people? And I don’t even know how to define older. I don’t want to get myself in trouble by putting in an age.
Adam: Are we older?
Sonya: Yeah, I think I am. You can say you had your 20-year reunion.
Adam: Yeah. Good question. It’s funny because here in Squamish, the median age of Squamish is quite young. Right. So a lot of people I see with sport concussion injuries are all in their 30s and 40s, which I mean, for me, that’s not old whatsoever. So I haven’t seen too many people that are in their 60s 70s or older that have concussion injuries. But like with everything else, and to be honest, that’s a really good thing for me to read up on. I haven’t read any concussions specific research on recovery rates of an older population, which I think would be a really interesting read. But with all other injuries, it’s always slower. Just our metabolic rates are slower reactions that we need. And tissue building capacity is much slower as we age. And so I would expect that if that research is out there, which I’m sure it is, I would expect that in the population, your concussion recovery timeline is probably going to be pretty, pretty slow.
Sonya: I realized I forgot to bring up one last point here. This was recommended to me by a chiropractor when I went in for some concussion rehab, but they said, there’s some dietary considerations that you can take into account for brain health. Do you make any recommendations to people?
Adam: Yeah, I always tell people…so in Canada, physiotherapy wise, we can’t really recommend things that are outside of our scope of practice. So unfortunately dietary recommendations, it’s outside of our scope. But I do always tell people, you want to optimize the environment as best as you can. So when you are recovering from any kind of injury, on a purely molecular, physical, mechanical standpoint, we need building blocks to repair things. So if you’re preparing for a flood, and you don’t have sandbags or the manpower to stack them, good luck getting anything done, nothing’s going to happen. So when it comes to concussion injuries, I always tell people just optimize as best as you can when it comes to nutrition. So reduce anything that’s inflammatory. So all your delicious processed foods… Yeah, you can’t eat it, right. So anything that’s inflammatory, because inflammation, your body is already running at a critical energy level. And if you are eating something that is causing inflammation in your body, now instead of fixing your body, it’s trying to deal with eliminating the inflammation. So you’re prolonging things. So I always tell people, instead of having one fire to deal with inflammation, it’s like introducing 12 fires every single day. And your body just doesn’t stand a chance in terms of addressing all of its focus on into one spot, but reducing processed foods, making sure yes, you have enough water most people most people don’t check water at all. I work for people that like drink one glass a day. I know, I know, I hope those people I work with are listening to this. And they’re like, yeah, he’s definitely talking about me right now. But most of the biological chemical reactions you need to carry through in your body need molecules of water. So we have to make sure you have it in your system. And protein, your brain after concussion injury preferentially chooses protein as an energy source. So I always tell people, like make sure you’re getting enough and Canadian protein dietary guidelines are public knowledge and so I usually just direct people to that and make sure that you’re following the needs that they recommend. And there’s lots of other research that’s out there for other things like magnesium and your B vitamins, and creatine and all that stuff. And usually, I’m happy to direct people to those resources.
Sonya: Yeah, something else my chiropractor told me about is omega 3s.
Adam: Oh yea, Omega 3s. There’s not unfortunately a lot of research on the dietary stuff and as and how it pertains to professional recovery. But it’s funny because all the things that we know are good for our general health are also all helpful for concussion recovery, for sure. So omega 3s, good one, yeah, that definitely slipped my mind, but a huge one for concussion recovery.
Sonya: Great. Well, thank you so much for coming on the podcast and demystifying concussions, giving us a little bit more information, but also to take away some of the fear. Because if you’re playing a sport, the odds of getting a concussion, I don’t know what the odds are of that, but like I said, most people listening probably either had one or know somebody that had one. So yeah, having some education around it, just like what you said, is super important when it comes to injury, and especially an injury of the brain.
Adam: Yeah, yeah. I’m glad we could do this.
Sonya: If anyone has any questions is there a place that they could find you potentially to ask?
Adam: Yeah, absolutely. So I always encourage people to email me all the time. So it’s my email address. I’m not sure if you guys will link to it or anything like that. But yeah, you can always shoot me an email and then you can find us at our clinics, our clinic Union Health and Performance, our info is on there as well. And I’ve got my own website, which you can reach out if you have any questions, but for sure, through my Adam Luu physiotherapy website, people email me concussion questions all the time, and I appreciate them for sure because I’m usually pretty protective of concussion injuries and making sure people get the right guidance. So I love it when I get people that have questions.
Sonya: Great. Well, thanks so much for coming on the show.