Ep. 17: Concussions treated quickly can recover quickly

Neuropsychologist Josefine Combs, PsyD, calls concussions a spectrum to take seriously

Episode Transcript

Courtney Collen (Host):

Hello and welcome. You’re listening to the Health and Wellness Podcast by Sanford Health. I’m your host Courtney Collen with Sanford Health News. This series begins new conversations and continues the important ones all designed to keep you well physically and mentally.

In this episode, we are talking all about concussions. We know fall sports are underway, more athletes are taking the field, which can often lead to more injuries. It’s really a good conversation to have year-round because the reality is anyone can suffer a concussion.

Dr. Josefine Combs is a Sanford Health neuropsychologist and expert in concussion care. She specializes in the assessment, the management and treatment of concussions and people of all ages, and athletes at any level of sports participation. Dr. Combs also treats non-athletes who suffer a head injury from work, a home or vehicle accident. And I want to welcome Dr. Combs to the podcast.

Thanks for being here.

Dr. Josefine Combs:

Thanks for having me.

Courtney Collen (Host):

So to start, sort of a two part question. Dr. Combs, how do you define a concussion, and then what physiologically happens in the brain during that time?

Dr. Josefine Combs:

Yeah. Concussions are considered mild traumatic brain injuries. Just because the word mild is in there does not mean they can’t be unpleasant for the individual that suffers one. Typically they’ll result in temporary symptoms and cognition as well as physiological symptoms and even emotional symptoms. So very common symptoms are headaches, feelings of dizziness or unbalance. And often also accompanied by cognitive symptoms that would feel like brain fog or having trouble with memory or concentration. And then the emotional symptoms often encompass kind of like an increased emotionality, feeling a little uneasy, or having emotions switch more rapidly or feeling more intensely overall.

Courtney Collen (Host):

Is there a certain part of the head that feels the impact, that determines what kind of concussion? Is it anywhere on the head?

Dr. Josefine Combs:

Location does not matter as much as one would think because our brain operates as a whole. So it does not matter if I’m getting hit on the left side because it does not mean that that’s where my headache will be.

Actually, concussions do not require a direct blow to the head. If enough force is generated, it could be anywhere to the body. Like for example, in a car accident, if I’m jolted around enough, I don’t actually have to hit my head to experience or to suffer a concussion. And the injury itself is rooted in our anatomy, and that’s also why anybody could get one and it’s not just confined to sports.

Basically what happens is our brain sits in our skull and there’s a little bit of fluid around it, which is a good thing. We all have that. We need that. But when we take a big hit even to the body somewhere, if the force is big enough, the brain can move inside the skull. And when that happens inside the brain, our tiny, tiny cells called neurons, we have lots of those, and that’s a really good thing.

But with that shaking motion, those neurons, those cells can get stretched out and when they become stretched, they can become essentially leaky. And the inside of the cell can get out, and the outside of the cell can get in. And there’s things in places where they normally aren’t and that’s where a lot of those symptoms are coming from. For example, the headaches and stuff like that. And then our brain has to kind of do some extra work to put everything back in place.

The good news is that the stretching is not permanent. It’s a temporary process. Those cells do come back into their original shape and then our brain kind of has to do some extra tidy up or cleanup work, if you will. And that’s why concussion can take some time to heal. Depending on how much stuff is out of place, that will determine how quickly someone can bounce back. The average concussion can range anywhere from two weeks to six months, really. For youth athletes, it’s typically around three weeks.

Courtney Collen (Host):

You talked a little bit earlier about symptoms. Can you expand upon the symptoms that a patient might feel or experience when suffering a concussion?

Dr. Josefine Combs:

Absolutely. So we have essentially three big categories. We have cognitive symptoms, we have physiological symptoms, and we have emotional symptoms.

So physiological symptoms are typically the best known. That’s kind of the signs that people think about when they hear concussion. That’s that headache, feelings of dizziness or being unbalanced. Like sometimes it’s accompanied with nausea or even vomiting. Those are the classic physical symptoms there. Or also people that struggle with vision after concussion, like their eyes aren’t working together as well, which then makes the headaches even worse.

The cognitive symptoms are typically clustered around memory difficulties, trouble with concentration, feeling kind of like the brain is slower than it normally would be, like a brain fog type of sensation.

And then emotional symptoms can range. So it kind of depends on the individual a little bit, but a lot of people feel uneasy or a little bit anxious just because the injury can make us feel less like ourself and that can be a very weird sensation. Some people also feel their emotions more intensely or are just more emotional in general. Like, you’re watching TV, everything’s fine. Now a sappy commercial comes on and all of a sudden I feel like crying when I was fine a second ago. Those are very, very normal sensations that just aren’t that well known.

Courtney Collen (Host):

Let’s talk through the different grades or severities of a concussion.

Dr. Josefine Combs:

Yeah. So in the past, there were several different grading scales, but we have actually moved away from that just because the scientific community could not really agree on a very good scale to use universally. So that has actually gone away. There’s still the Glasgow Coma Scale that gets used in the emergency room, but that’s not just for concussion.

So typically when we now talk about severity or grading scales, a lot of people still classify as mild, moderate, severe, but we have moved away from a number system just because it does not match very well and concussions are a very individual injury, so it’s not a one fits all type of situation. I and my staff in clinic, we always joke if you’ve seen one concussion, you’ve seen one concussion because they can be vastly different. There’s a big spectrum. So, in terms of grades, we kind of think of them as mild, moderate, severe.

We do classify them in a profile model. The most common profiles are vestibular, ocular headache/migraine, anxiety/mood. And then there’s also modifiers, for example, neck and sleep that will significantly impact how the injury presents itself and how the individual feels.

Courtney Collen (Host):

So what are some of the warning signs now that someone may have suffered a concussion? Be it that mild, moderate, severe, maybe break down what those warning signs look like or how you determine which one it is?

Dr. Josefine Combs:

Absolutely. One of the interesting things about concussions is that symptoms don’t have to be present immediately. So the process I described earlier where the brain gets shaken and things kind of get knocked around or out of order, whatever we wanna call it, that is not a floodgate type of process. It is more of like a trickling motion, and therefore it can actually happen that concussion symptoms don’t show themselves until like 24 or 48 hours later.

So we often see that, for example, Friday night football, a kid takes a really big hit and then thinks they’re OK over the weekend. They’re kind of lounging around, not doing a whole lot, feeling pretty good. But then by Monday, when we have to go back to school and use the cognitive skills, really make our brain work, all of a sudden they feel really, really terrible and don’t look so good. So, there is a big spectrum.

Good things to look out for any type of symptom that does not feel normal. So if an athlete or any individual takes a hit, whatever kind, and they don’t feel right, if they have a headache, if they feel off balance – often people also describe light sensitivity, sensitivity to sound. A lot of people get very nauseated. Some people will vomit. That can also be a sign. So anything if we don’t feel right after, and then the physiological symptoms that we had talked about.

Red flags to look out for that would warrant immediate medical attention, like emergency room type of stuff, would be things like altered levels of consciousness. So if they are unconscious for a prolonged period of time, like longer than, you know, I mean people can black out for a couple of seconds, that is not too concerning in the moment. Obviously we still want them to get evaluated, but prolonged loss of consciousness definitely is a reason to seek care, uncontrollable vomiting, any gross neurological changes, and then also rapid deterioration. So if they seem OK at first, but then just get worse and worse and worse and worse, that’s also a sign that we definitely want to seek immediate care.

Courtney Collen (Host):

So really important just to know your body and understand what feels right so when something doesn’t feel right, we can identify that?

Dr. Josefine Combs:

Yeah.

Courtney Collen (Host):

And especially for athletes, young athletes.

Dr. Josefine Combs:

Absolutely. And the culture within the sport is also incredibly important. Like, we have long moved away from that sentiment of like, Oh, you get your bell rung, so just go walk it off. Right? Shake it off. Yeah, it will be fine.

We definitely want to take it seriously, especially because like we talked about, symptoms don’t always present full force right away. Right. So in order to protect the athlete from further damage and even worse injury, we always want to remove them from play immediately. So one of our little memory tricks that we use is the, the saying, “when in doubt, sit out.” So sure we teach that to our athletes. It’s better to get evaluated and checked out by the athletic trainer that is covering the game or maybe the team physician, whoever’s available, a trained medical professional just to make sure it’s better to miss a little bit of the game and be safe than to just try to power through and then pay for it. Very costly.

Research has shown that continued play after an injury can actually prolong recovery. So there’s a study that has shown that athletes that were removed after injury immediately bounce back pretty quickly, kind of that two- to three-week frame that we talked about earlier. And individuals that continue to play five to 10 more minutes actually tagged on several weeks to their recovery. And then individuals that played 10 to 15 minutes more, or more, for whatever reason – I didn’t want to lose my spot – whatever, you know, they tried to justify internally. A lot of them took months and months to recover it.

Courtney Collen (Host):

Wow.

Dr. Josefine Combs:

So it does make a really big difference. And once we kind of provide that education people kind of reconsider, especially coaching staff has been great and got on board because, you know, it matters if I get my athlete back in a week or two or if they’re out for the rest of the season. So education is incredibly important and we place a great value at that in, at Sanford and try to do outreach and have those things available. We also offer baseline testing for youth athletes to help them be better prepared for the seasons in case they do suffer a concussion. Hopefully they do not, but if that helps in the specialty treatment that we can provide here at Sanford.

Courtney Collen (Host):

Let’s say an athlete or any individual suffers a concussion, what do you recommend happens next? Do they seek care? What does that look like? Where do they go?

Dr. Josefine Combs:

Great question. Where here at Sanford are very blessed that we can offer very specialty care with a multidisciplinary approach. A lot of people seek care through their primary care first or go to acute care or the ED, which is appropriate if they, if it makes them feel safer. I do like to point out that it is very OK if the treating provider does not order imaging, a lot of people share their concern that they didn’t get a CT or an MRI. A lot of times that is not necessary and they’re not doing them a disservice by not completing that. We really only want imaging to rule out structural changes because the concussion itself is not going to show up on that. So it is very OK, if you go to the emergency room or acute care for yourself or your athlete and they do not complete imaging, that is not inappropriate and very OK.

Once they seek care, if your primary care provider or your pediatrician feels comfortable managing the concussion, they absolutely can. Typically our recommendation is that if symptoms do not improve by that second week mark, a specialty referral might be appropriate or advisable. I personally like my athletes to come see me within the first week of the injury just because that helps us kind of set the tone, make sure we can speed up their recovery by setting them up for success with the right recommendations. But it’s not that if they see their pediatrician first and don’t see us till like two or three weeks in that they’re losing a ton of time. But that’s kind of the typical timeline. People seek their you know, normal provider first and if that does not improve or get better, then they typically place a referral to specialty care.

Courtney Collen (Host):

So say someone gets a referral to you for their concussion of any severity, walk through what some of the treatment might look like and what happens next once they come to see you for an appointment.

Dr. Josefine Combs:

Yeah. So when they come to see me in clinic, they need to bring a little bit of time because as a specialty clinic, our appointments are longer than the average doctor visit. Typically the way it is set up, we will spend the first hour engaging in neuropsychological testing to get a good understanding of where their functioning is at from an emotional, cognitive and physiological standpoint. So we will do a computerized assessment that kind of screens for the major cognitive domains, reaction time, processing speed memory and visual recognition, stuff like that.

We also do a balance assessment to see how they function there. We also have questionnaires looking for any emotional distress or signs and symptoms. And then after that hour of testing, we spend typically another hour on going over results, talking about recommendations and then discussing the treatment plan together.

So depending on what the individual presents with, we tailor the treatment approach to them because as we talked about earlier, this injury does have quite a big spectrum. A very frequent treatment approach includes vestibular physical therapy. This system is a part of our brain that is basically responsible for like movement motion integration. Like it basically is the part that tells us where we are, where our body is in space. I always joke that it’s our internal GPS, if you will. Sure.

And when we take a big hit that our internal GPS basically gets notched of the rails and then kind of limps along. It doesn’t go offline where we don’t know where we are anymore and fall over often. But does not process at the level it does before. So that’s when people get dizzy or feel very uncomfortable in busy places, those physical things.

And there is physical therapy that we can provide to help retrain that system. And we have a specialty trained physical therapist that I work with very closely. I mentioned vision difficulties earlier. We also have a specialty trained therapist that is an occupational therapist that will then help the individual – whether it’s an athlete or a worker or from a car accident – help retrain the brain to kind of utilize things and put everything back where it came from and use those cells like it did before the injury.

We also collaborate with speech therapy, which can help with memory trouble. And then we also have a wonderful integrated health therapist that can help us for people that struggle with the emotional piece just to kind of provide as much support as we can. We also collaborate with neurology, pain management and rehabilitation services. And so we’re really trying to tailor as much as we can to the individual to set them up for the best success and the quickest recovery we can, because it certainly doesn’t feel good. Sure.

One thing a lot of people always struggle with is that their environment does not understand the injury. They don’t understand what they’re going through because when we suffer a concussion, we certainly look normal, but we don’t feel it and that can create quite a bit of struggle for individuals.

Courtney Collen (Host):

Yeah, I can imagine. Are there any long term effects of a concussion? We talked about earlier, you know, when in doubt sit it out, and the longer that you wait to play again, you know maybe the shorter the timeline of that concussion’s effects. But what about long-term effects?

Dr. Josefine Combs:

Yeah, so generally speaking, concussions are very treatable. So they’re not the boogeyman and if treated appropriately, they are very, I don’t want to say OK to have, but they’re not the end of the world if treated appropriately. We definitely want to take them very seriously because when they are not taken seriously and not healed appropriately, then yes, they can definitely create trouble down the road. But as long as an individual gets back to their pre-injury baseline, whether it is through treatment or the brain kind of takes care of things on its own, if it’s not that severe, it does not predispose us to more concussions.

Obviously contact sports have a much higher risk than non-contact sports, but you know, there’s assumed risk with a lot of activities. It’s definitely not something where we would want to set a record. Like we always tell our athletes, don’t try to get more concussions. But there are also many individuals that had several and they’re very OK. So as long as it is treated appropriately, the chances of long term difficulties or long term trouble are very, very slim.

Courtney Collen (Host):

So get care right away essentially.

Dr. Josefine Combs:

Yeah. Better safe than sorry.

Courtney Collen (Host):

Absolutely. You mentioned earlier part of the treatment process, “IHT” or integrated health therapists. Is depression a concern long term or even short term? You talked about maybe emotional counseling. Talk about what you see.

Dr. Josefine Combs:

So, mental health is always very important because without mental health, physical health is very hard to enjoy and have. They go hand in hand. And the thing with concussion is, it typically does not create something that was not there before. But it certainly can exacerbate things. So especially for individuals, let’s say struggled with anxiety before the injury, they are going to feel their anxiety symptoms a lot more while they’re healing. Similar things for depression.

The thing that I would like to add that to that is that the concussion itself does not cause depression, but the aftermath certainly could. So what I mean by that is, for example, we talked about athletes a lot. So if I have an athlete that has an injury that removes them for several weeks, if not months, whether it’s, you know, they didn’t know to come out right away, or they just were unlucky and ended up with a moderate to severe concussion.

A lot of times what we see is that when they’re removed from daily life, they get taken out of school, they do not see their friends at practice anymore, they basically are just told to rest and wait, that can certainly take a really big toll on their mental health. And we do see depressive symptoms kind of creep in because especially for youth athletes, that is their social environment. School is where they see their friends. Practice is where they get to hang out outside of perhaps meetups or play dates. But generally speaking, that’s a huge part of their social world. Not to mention, a lot of times kids play their sport because they love it, they enjoy it very much. So not only can they not do the thing they love, but now they also don’t get to see their friends, they’re bored, they don’t feel good. So that often takes a really big toll on mental health and especially for individuals that were anxious or struggled with depression prior, that can certainly make things a lot worse.

That is another reason why treatment-wise, we’ve seen a huge shift in the field. Initially, people always thought about, you know, just rest, go lay in a dark room, don’t do anything, it will get better. Well, we’ve learned through a lot of research that rest is not always best. It’s actually a good idea to try to do as much normal stuff as we can. So one of my first priorities if I work with a student athlete is to get them back into school, even if they don’t do all their assignments or, you know, stay the whole day. Anything beats nothing. We want to provide them with as much of their normal as we can.

That being said, obviously we need to protect them and prevent the injury from being worsened. So we’re going to remove them from any kind of contact play. But physical activity, especially cardiovascular in nature, is not a bad idea. So after day one or two, we strongly encourage our patients to actually go for a walk, move around, try to do some normal stuff. A lot of kids are also very ecstatic when they learn that they don’t have to avoid screens completely. So we just kind of teach them how to use it appropriately to manage their symptom better. Yeah. But this whole idea of, you know, isolate, laying in a dark room is actually very detrimental for the injury and we don’t want that.

Courtney Collen (Host):

This has been fascinating, Dr. Combs. Let me wrap it up with this question here. Will you talk about some of the resources and opportunities for patients that set your team of specialists apart when it comes to diagnosing, managing, treating a concussion and providing that efficient and targeted care? Essentially, what sets Sanford apart when it comes to concussion treatment and care?

Dr. Josefine Combs:

We here at Sanford are very fortunate to have a specialty set up. So we have an actual designated concussion clinic that sees concussion patients of all ages of all types of backgrounds. And like you mentioned earlier, it does not matter if it’s a sport injury or a car accident or a work incident or even, you know, a project at home gone wrong. So we are able to accommodate almost anything. And the fortunate setup here at Sanford is that we can provide that multidisciplinary approach with specialty trained providers.

A lot of times concussions during your medical education did get covered, but often rather briefly, and it can be a very complex injury. So having specialty care where you know you can go if things don’t get better after that initial timeframe, and then being able to receive tailored and targeted care that is really matched with what you are experiencing and what you’re struggling with, not only helps the individuals feel better more quickly, but also helps them to kind of go through this with a little bit more ease. And I definitely consider myself very fortunate that we have such an amazing team here that is very passionate about not only the care of our patients, but also trying to advance the field and continue to work with research and always wanting to learn more about this injury so we can continue to provide the best care for our patients.

Courtney Collen (Host):

Concussions can be a really scary situation. I mean, the head is not something that I want to mess with. So I can understand how important it is to understand the signs, the symptoms, the warning signs, the red flags, and then get into a specialist.

Dr. Josefine Combs:

What I always like to highlight is that it is a very treatable injury. We definitely want to take it seriously because as we’ve seen in recent news, it can go badly. It is a very real thing, like I mentioned earlier. Just because people can’t see it doesn’t mean it’s not happening. It can be a very weird experience because it kind of, sort of tucks the rug out from under you.

If I have an ortho injury, let’s say, you know, my ankle, I’m less mobile, I can’t do that part of my day, but I can still watch a movie and enjoy it. I can have a conversation, I can study, I can learn. Versus with a concussion, it can creep into essentially every aspect of my life. Whether it’s my thoughts, my emotions, my sleep, my daily activities, my social and my recreational things. So it is a very, very different beast.

Clinic wise, with most insurances, we do not require a referral. There are some few exceptions but generally speaking, they don’t need a referral. We can always see self-referred patients as well. It is very OK to come to us directly. You don’t have to stop with your primary care or pediatrician first. Even in cases where we might not be the most appropriate, we always work very hard to get the patient connected to where they need to go.

Courtney Collen (Host):

Dr. Combs, a neuropsychologist and specialist in concussion care here at Sanford Health. Thank you so much for this insight and all that you do here at Sanford.

Dr. Josefine Combs:

Thank you.

Courtney Collen (Host):

And this was another episode of the Health and Wellness Podcast by Sanford Health. I’m Courtney Collen. Thanks for being here.

Learn more

Posted In Brain & Spine, Children's, Emergency Medicine, Neurology, Orthopedics, Sanford Sports, Sioux Falls, Sports Medicine