You’re at the top of your game, both mentally and physically, tackling life head-on. Then, bam! You suffer a concussion, and suddenly, everything feels off.

Headaches, dizziness, memory loss – the usual suspects.

But what about those silent saboteurs lurking at the bottom of the SCAT score sheet?

Anxiety, irritability, sadness – the uninvited guests crashing the post-concussion party.

 

The link between concussions and mental health struggles isn’t a mere coincidence; it’s a well-established fact. Studies reveal that over 65% of concussion survivors battle with depression and anxiety post-injury. And if you’re among the unlucky 20-30% stuck with lingering symptoms for more than two weeks, those odds skyrocket to a staggering 76%.

Now, let’s put things into perspective. The World Health Organization defines mental health as ‘a state of mental well-being, that enables individuals to cope with difficulties in life, understanding their abilities, and working towards the betterment of themselves as well as for the community.’  But what happens when a concussion disrupts this delicate balance?

In adolescents, a history of concussion in the past year increases the risk of suicidal thoughts and actions. Considering that suicide ranks as the second leading cause of death among U.S. teens, and an estimated mind-boggling 33 million children worldwide suffer concussions yearly, the gravity of mental health post-concussion becomes painfully clear.

Mental health matters. And post-concussion, it really matters.

 

So, what’s going on inside our heads after a knock to the noggin? Let’s explore four potential culprits:

First up, the physical aftermath of a concussion have been proposed to affect the neural mechanisms of mood regulation circuits. When your brain’s emotional control centre takes a hit, it’s no wonder your mental health takes a nosedive.

Secondly, concussions aren’t just about physical pain; they’re a psychological rollercoaster. Factors like social isolation, fear of re-injury, and decreased participation, compounded by concerns over selection or contracts, as well as the dread of letting teammates down, can create a downward spiral into mental health challenges. This combination can morph into a vortex of despair, leading to significant mental health consequences.

Thirdly, your family and personal mental health history might increase your susceptibility to poor mental health post-concussion. It’s like having a genetic predisposition to a double whammy of emotional turmoil.

And let’s not forget the sleep-depression connection. With persistent concussions throwing your sleep regulation out of whack, it’s no surprise that executive function, working memory and processing speed take a hit, dragging your mental health down with them.

 

Now, here’s the kicker: despite the glaring mental health implications, a whopping 50% of concussions reportedly go undiagnosed. With no definitive test in sight, concussion remains a clinical diagnosis. So, when a patient waltzes into your office with nothing but mental health symptoms, are you equipped to connect the dots?

Tools like GAD-7, PHQ-9, and the Pittsburgh Sleep Quality Index might just hold the key to unlocking the silent suffering of concussion survivors.

Because mental health matters, today and every day.

Muscle capacity, Yo-Yo, Counter movement jump. Tick

Heart, lungs, liver and kidneys. Tick

Gait analysis, technical analysis, biomechanics. Tick

Now the brain.

 

Such a drag, and something that bores the players. A common response from colleagues who work in sport when discussing concussion baseline testing.

But before resigning our interest let’s consider the why, the what and the how.

 

Why

In simple terms screening is a reference point, an opportunity to gain some insight.

Is it the best a person can be? No.

Is it how the person is functioning on that particular day – no more no less.

Sporting endeavour can require exceptional musculoskeletal capability, cardiovascular attributes that blow the mind (let alone the lungs), and technical nuances that provide a foundation for consistent performance –understanding some of the data that that underpins these super human feats can be valuable.

Additionally, sport can require cognition, balance, emotional control, eyes that work accurately and at speed.

It makes sense that gleaning a rounded view on these factors may have its uses too.

Whether used as a reference point for comparison in a time of challenge (concussion being one of the more obvious possibilities); or to provide an understanding of functional capabilities (something that can be used to identify areas to be worked on), or simply used as a comparison between peers (one that may provide a layer of insight when it comes to talent identification) the insights gained are there to help.

 

What

Tests come and tests go, sometimes led by research, sometimes by fashion.

As the brain does so many things, a better baseline test is one that is multimodal.

And the insights are not simply a list of numbers and objective markers. Understanding the subjective and the history is important too. If you know that someone suffers from migraines, or is challenged by poor sleep quality, that can only help if evaluating symptoms post a possible concussive episode.

How is the persons mental health? Do they have any learning challenges? Is ADHD an issue? Further things that help complete a holistic picture.

 

How

Well, that will be down to you – there are a range of tests that can be used.

Considering the amount of time that is spent looking at muscle balances, joint range, speed, power and technique, it is ironic that looking at the very organ that controls these things is considered such a chore.

Do you understand BEST practice when it comes to concussion management?

We think we do.

That’s why we’ve come up with our BEST practice model of concussion care.

Baseline screening

We have removed time and cost limitations by designing fast and cost-effective multimodal screens that focus on key measures monitored and compared at an individual level to inform best care following a concussion.

Education

We have developed a world class programme of three critical courses for anyone involved in concussion management. From parents and teachers through to medical practitioners wanting evidence-based updates. Knowing the most up to date developments saves lives.

Support

We facilitate support by providing opportunities for global networking within our custom designed online community of experts. Knowledge around concussion continues to evolve rapidly from the fields of neurology, vestibular, musculoskeletal and sports rehabilitation. Collaboration and sharing are key to innovation and best practice moving forward.

Technology

We are at leading the way in the selective use of the very best technological advances. From specific software, apps, virtual reality, eye-tracking, balance, movement, heart rate and cognitive testing devices, we know what people need and when.

For the eagle eyed amongst you, you’ll have spotted why we call it BEST practice. If you didn’t, have another read. It’ll be good fodder for your brain.

BEST practice. It’s not something enough people know about when it comes to concussion management.

Odd really, given that ignorance isn’t bliss, it costs lives.

We were delighted that Millie Bishop was joined by Nicola Hunt alongside Head of Medical and Research at Neuroflex, Dr David Stevens as the latest guests in our 2024 concussion webinar series.

Watch back as we discussed:

* The development and research behind Vestibular-Ocular motor technology

* How the technology works

* How NeuroFlex can be used in practise to improve clinical care and patient outcomes.

We explored all of this, and much more besides, in what was an interesting and lively update on the current research in concussion care, followed by a live Q&A.

Neuroflex: Utilising Technology to Support Vestibular-Oculor Assessments

You might not like cricket, but as the song goes, at Your Brain Health we love it!

A game that requires considerable physical characteristics, is also one where the players need to consider balance, visual and cognitive capabilities.

With this in mind, we are delighted to announce a project with Middlesex Cricket that will look to enhance both player welfare and performance development across the Men’s and Women’s game.

The collaboration will incorporate two key components; education and technology.

 

The education will focus on a proactive approach to the management of concussion. Whilst not as big a challenge as seen in a number of sports, the development of scoop shots and the acrobatic feats that are seen in the field mean that there is a possibility. The days of rest and return are now past us, and the word rehabilitate now sits firmly at the centre of the pathway.

 

Pete Waxman, Head of Medical Services said of the partnership:

“Knowledge around concussion management has advanced significantly over the past few years and it is imperative that we are at the forefront of understanding and implementing a proactive approach’.

 

As part of the partnership, the club will also be introducing NeuroFlex; a technology that uses eye and head tracking VR technology to both evaluate and train the performance of the Vestibular Ocular Motor System – crucial for balance, visual acuity and co-ordination. The approach will be part of the club’s multimodal screening programme and, in addition to the enhanced concussion pathway, will be used to develop performance markers across both Middlesex and Sunrisers squads.

 

James Fleming, Head of Athletic Performance feels the technology could support performance gains:

“We have seen new research coming out of the US showing the visual differences in certain baseball players. Our role is to develop the physical skills of our players, and if visual training can be then it is something I am keen on to give us a competitive edge.”

 

David Bartlett of Your Brain Health commented:

“We are committed to developing a global network of clinicians who are dedicated to improving brain health. It is exciting to have formed a partnership with the Sports Science and Medical teams at Lord’s, the Home of Cricket, to be part of that community.”

Ten years is a long time.

When it comes to both the landscape relating to the management of concussion and the advancing role of the Athletic Trainer within sporting organisations in the United States a lot has happened.

As such, it was great to read the latest position statement from the National Athletic Trainers’ Association (NATA) on the management of concussion.

One that provides an excellent update that bridges the condition and the profession.

One that considers the last decade of clinical evidence.

One that, if we reflect that the last position statement from the NATA was offered in 2014, is something that is overdue.

It is an essential read for all Athletic Trainers who want to consider an alignment between recent advances and current practice.

We have summarised the key points below.

Biopsychosocial Model:

The paper emphasizes a holistic approach to concussion management.

Beyond physical aspects, consider psychosocial factors (e.g., mental health, social support).

Personalized care is crucial.

 

Education and Prevention:

From athletes, to coaches, to parents improving education in this area is essential.

The paper underscores the authority of licensed medical professionals in decision-making.

Preventive measures, such as proper technique and equipment, play a vital role.

 

Assessment Advances:

The assessment process has evolved, including an update on the optimal value of baseline screening measures.

A comprehensive evaluation includes symptom assessment, cognitive testing, balance assessment, vestibular-ocular and mental health screening.

Athletic trainers should be proficient in these areas.

 

Prognostic Recovery Indicators:

Factors affecting recovery post-concussion are explored.

Initial symptom severity, early care seeking, and other individual characteristics influence outcomes.

Monitoring these indicators can inform key management decisions.

 

Mental Health Considerations:

Pre- and post-injury mental health are critical.

Screening for mental health conditions is recommended.

Establish referral networks for athletes with mental health needs.

 

Return to Academics:

Returning to school after a concussion requires careful planning.

Individualized support, academic adjustments, and communication with educators are essential.

Monitor academic progress during recovery.

 

Physical Activity and Rehabilitation:

Early controlled aerobic exercise benefits recovery.

Targeted rehabilitation interventions address persistent symptoms, including vestibular and cervicovestibular rehab protocols.

Gradual return to physical activity is part of the process.

 

Return to Sport:

Updated return-to-sport guidelines emphasize a stepwise approach.

Clinically directed aerobic exercise is part of treatment.

Individualized decisions consider the athlete’s well-being.

The above points can be quite daunting for some, when considering the complex and challenging nature of concussion and potential serious health implications.

The authors encourage Athletic Trainers to:

‘engage with domain-specific stakeholders who have expertise beyond the scope of AT clinical practice when feasible. Despite the updates provided herein, concussion science and care will continue to evolve, including in the areas of diagnostic and treatment capabilities. To best facilitate a successful outcome for their patients, ATs are encouraged to stay abreast of scientific advances and thoughtfully modify clinical policies within their scope of practice to provide evidence-based care whenever possible.’

And Your Brain Health is here to help Athletic Trainers!

We provide education with our specific level courses in addition to clinical support and networking through our Community Platform.

If you are an Athletic Trainer who works in this area please do reach out.

View Video

Jon Patricios on our latest webinar

“Concussion has evolved into a complex evaluation that mirrors what we do with other sport injuries”

The words of Professor Jon Patricios on the recent Your Brain Health webinar discussing the advancements in concussion care.

But how much of this ‘complex evaluation’ has really dripped down into our day-to-day clinical practise?

As a profession, Physiotherapists pride ourselves on our clinical reasoning skills. Utilising evidenced based practise is fundamental, regardless of setting, to delivering best outcomes for patients.

But when it comes to concussion, are we really abreast with current research?

I certainly wasn’t.

And it seems like I am not the only one. In a recent survey that was completed by 92 people from around the world, it was clear that the lowest levels of confidence were ‘Re-evaluation’ just keeping ‘Rehabilitation’ off the bottom of the list with scores of 52% and 51% respectively,

 

So let’s take a hamstring. There would be subjective questioning, objective testing, and a range of imaging options. Clinical outcome markers would be considered and used as a basis for test and re-test throughout the rehab journey.

For those in the high-performance environment, utilising technologies like force plates and isokinetic testing would form part of our battery of tests. Ensuring a player has covered the appropriate number of metres at varying percentage bands of their max velocity would be a non-negotiable for return to performance.

At a less resourced setting, we wouldn’t feel comfortable unless there was minimal asymmetry on single leg bridging or manual muscle testing. We would conduct a gait analysis, whilst assessing the function of the full posterior chain has become second nature.

 

So how do we mirror that in concussion?

How many MSK clinicians would feel confident to conduct a modified VOMS?

When it comes to assessing the Autonomic system, are we doing a Pittsburgh Sleep Quality Index or Buffalo treadmill test to ensure a return to performance?

We know the effects concussion has on mental health. Are GAD-7 and PHQ-9 undertaken routinely post-injury to support player welfare?

Concussion has evolved into a complex evaluation, but in reality how competent are we in assessing the multiple domains that lead to better clinical reasoning?

 

A physiotherapy colleague recently said to me: “it feels like the world has to catch up with how to assess and manage a concussion. I am a convert”.

And it feels like the job now is to support and educate clinicians to feel more confident and competent in proactively managing a concussion.

We were delighted that James McLoughlin was joined by Co-Chair of the Concussion in Sport Group, Professor Jon Patricios as the latest guest in our 2024 concussion webinar series.

Watch this on demand video as we discussed:

* Why there has been advancement in Vestibular Oculor Motor Assessments in concussion care

* Why the CISG decided to vote on the VOMS being included in SCAT-6

* The importance of gaining objective baseline screening data on the Vestibular-Oculor motor system.

* What the future of concussion care might look like.

We explored all of this, and much more besides, in what was an interesting and lively update on the current research in concussion care, followed by a live Q&A.

Advancements in Vestibular-Ocular Assessments in Concussion Management

Picture the scene. 

It’s the last hole. 

You must make the final putt. 

Your partner has missed theirs. 

You’ve been missing putts to the right all day. 

In fact, you’ve been missing putts to the right your whole life. 

You take the shot. 

Guess what? It misses right. 

You think you suck at golf. 

The good news is that you’re not alone. 

I suck at golf too. The only difference is that I might know the reason we both suck. 

I have been fortunate enough to work in high-performance golf for over 15 years with my roles as a physiotherapist within the high-performance teams for Golf Australia and the Japan Golf Association.

Even a slight improvement in your average round score in high-performance golf can mean the difference between a garage full of Ferraris and a failed career. Technology is crucial in analysing every aspect of a golfer’s game, from swing metrics to ground force reactions. As technology advances, so does our ability to improve golfers’ games. 

Recently, at a high-performance golf camp, we used advanced technology to assess players’ visual performance. By employing platforms like NeuroFlex®, which utilises virtual reality to track head and eye movements, we can delve deeper into understanding how visual performance impacts a player’s game.

NeuroFlex® allow us to measure and analyse head and eye movements with greater precision. We can uncover potential factors influencing a player’s performance by correlating this data with statistical shot and putting data. At Your Brain Health, we hope platforms like NeuroFlex® become a standard part of golfers’ pre-game routines to optimise visual performance. In our work, we have been using NeuroFlex® in vestibular ocular-motor screens to obtain objective data. This data helps guide clinical decisions such as targeted concussion rehabilitation and more sensitive tracking of concussions for improved return-to-learn and play decisions. The more we learn about brain health, the more we know we can help people lead happier, healthier lives. 

With fewer golf shots thrown in for good measure.

So, the next time you miss that putt to the right, remember it may have nothing to do with your stroke. 

Maybe you don’t suck at golf after all. 

A ball thuds against Joe Clarke’s helmet at 89mph.

‘Where are we? I ask. ‘Cardiff’ he replies
‘Who are we playing? Oval Invincibles.
‘Who was bowling at you?’ Muhammed Hasnain
‘Who did we play last week? Southern Brave.
‘How did we get on?’ We lost.
‘How are you feeling?’ Bit of a sore head where it clipped me, but I’ll be ok.

He’s desperate to continue. He’s in the middle of English cricket’s flagship franchise tournament and doesn’t want to miss a ball. He’s one of our best players, so no one in the leadership team will want him to miss a minute.

But Joe doesn’t know what I know. The dangers of a head injury are catastrophic, and they are dangers I’ve witnessed first-hand. I’ve also been in far too many inconclusive debates about whether soreness at the point of impact is a strong enough reason to confirm a concussion diagnosis.

So, it’s decision time.

Concussion or decision to play?

These difficult diagnosis decisions will continue to depend on the experience and knowledge of clinicians to make an on-the-spot call in the sporting setting.

Do they know enough to make those potentially life-saving decisions?

Do they know that the real danger lies in a secondary event on top of an unresolved concussion?

Are they meeting the International Concussion Consensus standards?

I’d put all the money I lost at Cheltenham on some of those answers coming back as a no.

And in the improbable event, they’re a yes. Are the likes of FIFA helping by opposing the use of temporary concussion substitutes in football to allow medics time to assess?

In a lightning-fast landscape, the need for CPD amongst medics on concussion care is as critical as it is urgent to ensure all potential domains of diagnosis are managed optimally.

We know that concussion diagnosis is challenging, with so many factors at play.

We know an incorrect diagnosis can be catastrophic in the short and long term.

So, why are we not prioritising giving clinicians the knowledge they need?

I’m proud of our work to educate and inform, and I’m hopeful that progress can be made.

The recent Concussion and Brain Health Position Statement in Australia advocating that every sports club must have a designated trained concussion officer feels like a progressive and pragmatic step in the right direction.

But, as professionals who understand the hidden dangers, we must work harder to make the world of brain health safer.

People’s lives depend on it.