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“So the concussed patients have a lot of different types of symptoms. One of them, I think, or one group of them, I think, is coming from this autonomic nervous system dysfunction and this lack of autoregulation of blood flow. One very common one is when they report they get dizzy or lightheaded upon standing. Not just from when they get up in the morning, but if they are lying on the couch and they get up during the day, they typically feel lightheaded. Sometimes they feel actually, vertiginous, they get a sensation of motion more often it’s lightheaded. And I think the lightheaded part is because they are not pumping enough blood to their concussed brain when they stand up for a few seconds and they feel that. Now they may also have a vestibular component to that, which they usually describe if you ask them.
And the kind of little trick I use, which I learned from a physical therapist is tell me what you mean by dizzy, but don’t use the word dizzy. And so that will force them to describe it. And usually, they’ll say, well, I’m swaying, or I feel like things are spinning around me and that gives you, the therapist, or the trainer or the doc an idea that this may be a vestibular issue. In a concussion, most of the vestibular issues are central or not out in the inner ear, middle ear. They’re not BPPV, they’re in the brainstem and the cerebellum most likely, and with contributions from the neck. So like many other symptom generators and concussion, there are often several sources. And as therapists, you are probably well aware that you can have cervicogenic dizziness compounding your complaints of central dizziness.
So orthostatic, we call it orthostatic intolerance, it’s not actually orthostatic hypotension, but it’s intolerance. And we see this a lot. We have a paper coming out on it in fact, where 40 to 50% of these patients. And I think it’s even more than that, frankly, but will soon after the concussion be asymptomatic upon changing a position. The other thing that that autonomic dysregulation of blood flow presents us as is, symptom exacerbation with activity. And, and again, exercise intolerance is sort of how we got started in this business. And that is just a lack of control of cerebral blood flow during exercise or physical activity that causes symptoms to develop in the concussed brain. I think another autonomic or dysregulation symptom is probably insomnia, to some degree. I talked about in the talk, how people have trouble switching from the appropriate branch of the autonomic nervous system, one to the other, sympathetic to parasympathetic and reverse. Well, when you’re trying to sleep, you have to enter a parasympathetic state and the concussed patients almost, to a person can’t sleep very well for a while. And I think that may be autonomically mediated too. So those are some of the symptoms you’ll see.”
John Leddy, MD, FACSM, FACP
Dr. John Leddy is a Professor of Clinical Orthopaedics and Rehabilitation Sciences at the University at Buffalo Jacobs School of Medicine and Biomedical Sciences. He is the Medical Director of the University at Buffalo Concussion Management Clinic, the Director of Outcomes Research for the UBMD Department of Orthopaedics and Sports Medicine at the University at Buffalo, and the former Program Director of the University at Buffalo Sports Medicine Fellowship. Along with Barry Willer, PhD, Dr. Leddy developed the Buffalo Concussion Treadmill Test, the first standardized treadmill test in the U.S. to determine a concussed patient’s exercise tolerance and to prescribe sub-threshold exercise treatment to speed recovery. In 2016, Dr. Leddy received the Best Overall Research Award from the American Medical Society for Sports Medicine.
Brian Roberts, ATC
Brian Roberts is a Certified Athletic Trainer (34 years). During his career he has worked with NASA as a consultant in the Exercise Countermeasures program, the US Olympic Committee, the Games of the 23rd Olympiad, and has a 25 year history as a consultant to the NFL and Major League Baseball. Brian is affiliated with MLB Umpires where he has provided clinical and rehabilitative consultation for the last 12 years. Brian was part of the NATA Concussion Task force that developed the ImPact Trained Athletic Trainer (ITAT) program and the corporate partnerships between ImPact and Wells Fargo Student Insurance. In addition, Brian was one of the first Certified Athletic Trainers in the country to design and develop a Comprehensive Concussion Center.
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