I am not a doctor. I did not study neurology past my first-year psychology classes in university, nor do my six years of studying sociology help me to better understand the science behind concussion recovery. What I do have, is first hand experience of the lack of answers out there for treatment and recovery expectations. If there is someone in your life who has suffered a brain injury, or if you have yourself, I invite you down my rabbit hole. We’re taking recent research of Traumatic Brain Injuries (TBIs) and Post Concussion Syndrome (PCS) and breaking down the facts, to offer a better understanding of what is going on after a serious blow to the head.
Point of Impact: The Concussion
Concussions are not restricted to athletes, although the sports industry may be the most common place to hear of the injuries. Car accidents, falls, work incidents, and physical violence can all lead to a concussion. A concussion is the forced impact of your brain against your skull. Considering the plethora of mysteries we have yet to solve surrounding brain function, we sometimes forget how much the brain is affected after a concussion. All of your senses, thoughts, personality, memories, and basic functioning happen because of your brain. When such a vital organ gets injured and jostled around, there can be devastating effects.
A brain injury can also occur as a result of whiplash. Just because your head did not make direct contact with another object, does not mean you are in the clear. Whiplash causes hyperextension and hyperflexion in your neck within milliseconds. This rapid bending to your neck’s extremes not only causes neck injuries, but as the head is thrown backwards, your brain collides with the front of your skull, resulting in injury to the frontal and temporal lobes. When your head is thrown forwards, the opposite occurs, and your brain collides with the rear of your skull which can injure the occipital lobe and cerebellum. It is important to note here that every incidence of whiplash does not bring a concussion, and this should in no way be used as a tool for diagnosis. Now for those of us who no longer remember high school biology, the frontal lobe controls writing, speaking, personality, behaviour, concentration, problem solving, and motor control (so only minor importance, right?). Your temporal lobe is responsible for comprehension of languages, memory, sequencing, and hearing. Meanwhile, your occipital lobe interprets your vision for movement, light, and colours, and your cerebellum controls balance and coordination.
When seeking diagnosis of a concussion, not every doctor will have the same protocol, so I will be discussing only what has been most common in my geographical area. If there has been a loss of consciousness, it is advised to seek immediate medical attention. However, the official ‘concussion’ diagnosis may not be given unless symptoms persist beyond 48 hours. Again, this is not medical advice nor is it official protocol, so if you experience something different, don’t be alarmed. The severity of a concussion has changed in name several times over the years, and so you may find two different doctors use different scales. A scale commonly referred to in the past was mild, moderate, and severe concussions. This was also translated into ‘grades’:
Grade 1: no loss of consciousness, and either no memory loss or memory loss that subsides after 30 minutes
Grade 2: loss of consciousness for under five minutes; memory loss anywhere between 30 minutes and 24 hours
Grade 3: loss of consciousness for more than five minutes and/or memory loss lasting longer than 24 hours
This grading system has changed since its conception in 1998, and some medical professionals choose to disregard the scale entirely, and instead choose to simply diagnose brain injuries as either a concussion or a TBI. Now, is there a real difference between the two? No. A mild Traumatic Brain Injury (mTBI) is just a fancy way of saying concussion. Since there is no official grading scale for brain injuries, and what new research determines is in constant flux, there is not going to be a consistent measurement or diagnosis.
Surprising to some, 90% of diagnosed concussions do not involve a loss of consciousness. This means that just because you didn’t pass out doesn’t mean you should not take your hit to the head seriously.
Some TLC: The Recovery
If you thought defining a concussion was difficult, now is a great time to grab a snack and get comfy. With all the uncertainty that still surrounds the brain and its three-pound grey and white mysteries, it isn’t surprising that treating brain injuries is like playing leapfrog with a unicorn.
There are some myths surrounding the do’s and don’ts of concussion recovery. The key to remember is to treat your brain injury like a really bad muscle injury. If you can’t put weight on your ankle at all, you aren’t going to play in your soccer game tonight. If you do, you’ll find out rather quickly just how bad of a decision that was, and your injury will feel worse. The same thing happens with your brain; the problem is that we use our brain for e-v-e-r-y-t-h-i-n-g. Dimming any screens, wearing sunglasses indoors, earplugs, and taking a lot of naps are all common in the days after your concussion. It used to be taught that sleeping immediately after a concussion was the worst possible course of action, however recent studies have shown that the more you let your brain rest, the better! Yes, that does mean daytime naps - yes, it is glorious.
In the past, it was also thought that exercise was detrimental to concussion recovery. Recent studies have actually found that exercise does not lengthen recovery time in athletes with concussions, and researchers from Ohio University Heritage College of Osteopathic Medicine found that those who exercised during their recovery had a shorter time span between seeking medical attention and recovery (you can read more about their research here). This, and other similar research, was used in the new guidelines from Concussion in Sport Group, saying that “patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-exacerbation thresholds.” Start slow, and don’t continue to exercise once your symptoms begin to increase. If you are cutting grass or shovelling snow and you have an onset or worsening of symptoms, do not continue to exert yourself. Rest, to allow your symptoms to subside.
Vestibular physiotherapy is a great plan of treatment for post-concussion rehabilitation. It deals with eye movements, eye tracking, balance, and motion sensitivity. Your vestibular system senses linear and angular speed, head movements, as well as sensing your head’s actual position in relation to the space around it. The most common symptoms for post-concussion clients seeking vestibular physiotherapy include dizziness, nausea, problems with balance, headaches, blurred vision, and sensitivity to visual motion (eg. motion sickness). Vestibular treatments can include head eye coordination exercises, eye tracking exercises, ocular-motor exercises (which help your ability to look quickly from different targets and your ability to turn your eyes inwards to look at an object), and balance exercises. Below I have added some pictures of a few of the more common exercises for vestibular physiotherapy.
Here we have two objects or targets where you first practice moving your eyes from target to target without moving your head. The second part to the exercise is to look at the first target, close your eyes and turn your head, then open your eyes to look at the second target. As is true with all of your concussion rehabilitation exercises, once your symptoms increase, stop. Time how long it takes your symptoms to return to ‘normal’ or your ‘base’. Ideally, in time, it will take less and less time for your symptoms to go away.
This is the infamous Brock String. Holding one end of the string against your nose, and the other either tied to a stable object or attached to a wall, the beads are spread along the string at various intervals. The goal is to be able to shift your focus to each bead without feeling like you are going to vomit or have your head implode. Feeling like you just stepped off of a roller coaster or wanting to hit your physiotherapist may also be experienced with this exercise.
In this exercise, you hold the paper a fair distance from your face and start looking at the letter A. You want your eyes to track A,1,B,2,C,3, and so on. I find it helpful to say it out loud as I go, that way I know I am doing it in the right order (we hope).
The Happily Ever After: Maybe
For roughly 80% of people, your concussion will be fine after 7-10 days. The remaining 20% often recover within 3 months or less. What happens after that three months is often determined by how many concussions you have suffered previously. In short, if you’re going to hit your head, don’t. If a life-changing experience is what you’re looking for, go do some serious volunteering. We are talking about leapfrog over a freaking unicorn people.
When you have at least 3 symptoms persisting past the 3 month threshold or your Doctor’s expected time of recovery for you, we welcome you into the PCS family (again, this is more of an observed guideline not a rule, and can change depending on the doctor). Post Concussion Syndrome (PCS) is like permanently housing the Dursleys. The symptoms go far beyond physical difficulties like vomiting, balance, dizziness, light/noise sensitivity, and headaches. There are cognitive symptoms such as difficulty concentrating, memory, or feeling slowed down. My personal favourite cognitive symptom is ‘feeling in a fog’ which is something that makes zero sense until you experience it for yourself. A friend once shared a video that explained it as ‘staying awake for three straight days then trying to calculate advanced quadratic equations’ - I had always just described it as feeling drunk when you’re completely sober. Beyond physical and cognitive, there are sleep problems and emotional symptoms. Feeling more emotional or irritable are symptoms of PCS, as are anxiety and depression. If you suffered from mental illness prior to your concussion(s), do not be alarmed if your mental health declines. Speak with your support systems and doctors, and make sure you stay on top of it. Just know that you are absolutely not alone, your PCS family has been (or is still) there, and you WILL be ok.
If you need someone to talk to or having trouble coping with your mental illness call 1-844-437-3247 (Waterloo-Wellington Region) or visit http://www.yourlifecounts.org/need-help/crisis-lines for the list of international support lines.
I was diagnosed with PCS in 2013, and have used way more sticky notes since then than I had ever thought possible. However, just because I have been dealing with this for the past five years does not mean I have not shown significant progress. Below I have added a snapshot of where I was at in 2015 after I was hit in the head again, versus where I am today.
This progress was not miraculous, nor did it come easy. Physiotherapy takes a lot of hard work, and you have to commit to your exercises. Since 2013, here are the tricks and treatments I found worked best for me (again, not a doctor, this is not medical advice):
The emotional side effects of PCS are by far the most difficult to deal with. Accepting that the person you used to be is no longer the person you are, is incredibly difficult. (You can read more on that here). Once you have overcome this incredibly difficult challenge, you then have to re-introduce yourself to your friends and family. No part of PCS is easy or simple, nor should we expect it to be. Our brains are still an area where we have only scratched the surface of understanding. Recovery from a head injury is complex, and no singular solution is going to work the same for each person. It is incredibly frustrating to not have a solution to a problem, especially when it concerns your health. Unfortunately, this is a reality we face with PCS. The best thing you can do is be aware of your limitations, track how your symptoms are doing day-to-day, and work with your trusted health professionals. If you plateau, or stop showing signs of improvement, don’t give up! The brain can do a lot of incredible things, and it may take its sweet time to recover.
My main advice: take preventative measures, be cautious. Do not hit your head again. (Coming from the girl with double digit concussions...)
Still not sure what your findings mean, or what to expect with your injury? Call us at 519-895-2020, or use our online booking tool on www.strivept.ca to book an appointment with one of our knowledgeable physiotherapists, and they will be sure to help you understand your injury.
Best of luck on your road to recovery,
Administration and Social Media Coordinator at Strive Physiotherapy & Performance
If you follow along in this blog, you’ll already know that we used to work alongside surgeons. (If not, check out our blog!). One of these surgeons completed A LOT of joint replacement surgeries - almost entirely on the knee and hip. Therefore, we’ve treated our fair share of post-operative clients - especially post-hip replacement! As an FYI, a total hip arthroplasty (THA) is science speak for a total hip replacement (THR), so they are used interchangeably!
The purpose of this blog post is to try and clarify the ins and outs of having a hip replacement surgery. Knowledge is power! Be prepared, and things will go smoothly!
Aside: We will use the same headings in this post as we did in the other ‘Must Know Knowledge’ posts. We’ll try to stick with the same format so that it’s easier to navigate. Some things might look similar, as some advice is “surgery” related, and less specific to the type of surgery.
How do I know if I even need a total hip arthroplasty (replacement)?
Typically, to qualify for a hip replacement, many, or all, of the following statements are true:
Do I have to do pre-operative physiotherapy?
In short, yes, you should. It helps in the following ways:
What else should I do before I get a total hip arthroplasty (replacement)?
How is a total hip arthroplasty (replacement) performed?
Every surgeon has their individual preferences, and this section could get extremely lengthy if I’m not careful. That being said, I will provide a general surgical outline, and then describe briefly the most common methods of hip replacement surgery.
This is what your day will look like:
This animation on YouTube is an average example of what generally happens, but don’t watch it if you’re super squeamish. It’s an animation, but the drawings would be considered graphic to some people:
Note on the video: not every surgeon uses the posterior approach seen in this video.
More on the methods used:
Does method matter?
Before we get into the next part of this blog post, it is important to note that everything in this blog post is for information purposes only. This blog post is not intended to be strict medical advice. As previously mentioned, everyone is an individual, and therefore, individual variances do occur. It is important to consult your physiotherapist, surgeon, or doctor for the most applicable advice for you.
Hip Precautions - The post-operative RULES
Each surgeon will have a preference on these precautions, and for how long you should follow them (also, the method at which your surgeon uses may alter the need for these precautions!). That being said, following these precautions is EXTREMELY COMMON, and they usually apply for THREE MONTHS post-operatively.
After surgery, you should:
There are some great tips on how these precautions apply to dressing, sitting, bathing, etc., on the U.S. National Library of Medicine website here:
What does the typical rehabilitation process look like?
First, it’s important to reiterate that everyone is an individual, with individual circumstances, and therefore, the rehab process will be very individualized. That being said, in almost every case, it is safe to walk on your leg immediately after surgery, and you will typically spend 1-2 days in hospital post-operatively. In the hospital, you will learn how to walk with a walker, climb stairs safely, and be monitored for any post-surgical complications.
Once at home, you will often be allotted home physiotherapy appointments with a physiotherapist (for free), through the Community Care Access Centre (CCAC). That being said, the amount of appointments provided by the CCAC has been significantly reduced in the past couple years (down to 1-4 total appointments), which is not enough.
Due to the limitation in the number of CCAC-funded appointments, you will continue with further physiotherapy via one of two options: publically-funded (OHIP) physiotherapy, or privately funded (out of pocket/private benefits) physiotherapy. OHIP physiotherapy often has a limit to it as well, and many people require more than the “program of care” allows for. Therefore, it is important to consider the potential financial costs of ongoing physiotherapy when undergoing a total hip arthroplasty.
This next sentence is important: Complete rehabilitation after a total hip replacement will usually take 6-12 months. It’s likely that someone will tell you 3 months. 3 months of rehabilitation can get you back to work (depending on your job), or allow everyday life tasks to be more easily and comfortably completed. To get back to 100%, it will probably take longer. You may not be required to frequently attend physiotherapy appointments, but you should expect to be working on exercises, and self-management, for up to 1 year postoperatively.
Overall, post-operative care looks something like this:
How long does it take to heal after a total hip arthroplasty (replacement)?
In uncomplicated cases,
As with any surgery, here are some additional things to consider:
What exercises are safe to do right away after a total hip arthroplasty (replacement)?
In the hospital, or from the surgeon, you will likely be provided with a list of exercises to get started on. These usually include light range of motion, and muscle activation exercises. These are a great place to start. Remember that these will have to respect the RULES outlined above (the hip precautions)
Overall, you will progress in this order with rehab (roughly):
Lastly, it’s highly likely that you and your physiotherapist will work on other areas of your body (such as the back and knee/ankle) together. This should help to reduce any postoperative complications in your other joints, all while decreasing your pain, and improving your overall function!
How much function and how little pain can I expect at the end of my rehabilitation?
Alas, the loaded question. (We know we’ve started this section with that same sentence for each of the ‘Must Know Knowledge’ surgical blog posts… Sorry, but it’s always a loaded question).
Again, everyone is an individual, everyone heals differently, and therefore final pain and function are highly individualized. Further, if there are complications with surgery, it may alter the progress/end result of your recovery.
Here are some things we consider:
All that being said, the vast majority of individuals that we’ve treated post-total hip arthroplasty did very well overall, and outcomes are typically very favorable. Many have no pain at all, and they return to an active lifestyle. The caveat to this is that our experience is based on people who actively attended rehab! (We are physiotherapists after all!). Remember, the rehabilitation stage after surgery is VERY important to reach a full recovery!
What are the potential complications associated with a total hip arthroplasty (surgery)?
All steps will be taken to limit complications postoperatively, however, it’s important to understand the possibilities. Complications include:
There’s a lot of information in this blog post. But there’s also a lot to know. Be informed, ask questions (even the hard ones), and look out for yourself.
Let us know if you thought this blog post was helpful, and we will try to post new ones outlining the helpful points for other types of surgeries!
Are you planning to undergo (or have already undergone) a total hip replacement? At Strive Physiotherapy and Performance, we are committed to providing an in-depth assessment to ensure we can work together to find the best plan of action for each individual client. Call us at 519-895-2020, or use our online booking tool on www.strivept.ca to book an appointment with one of our knowledgeable physiotherapists, and they will be sure to help you understand your injury.
Physiotherapist at Strive Physiotherapy & Performance
You start having pain on the side of your hip, seemingly for no reason at all! Your symptoms may include pain over the greater trochanter, which is a bony protrusion on the outside of your hip. It can feel more painful when lying on that side, climbing stairs, rising from a seated to a standing position, or prolonged walking or running.
Let’s pause for a moment. What exactly does your “hip” even look like?
First, you have your femur (upper leg bone), which attaches to the pelvis through a ball and socket type of joint. This allows your leg to move in many different directions! The greater trochanter is the bony bulge at the top of the femur, on the outside. In other words, the bone you feel sticking out when you touch your hip joint. You can also see the location of a few bursa in the image below. Bursa are fluid filled sacs which help reduce friction in the body - this makes movement easier!
You also have many different muscles in this area which allow you to control the motion of these bones. Many of these muscles either attach to, or run over the greater trochanter. Two important muscles here are the gluteus medius and the gluteus maximus. The gluteus minimus attaches to the greater trochanter and is active when bringing your leg out to the side. It also works to control your pelvis when standing, walking, climbing stairs, or pretty much any other movement on your feet! Your gluteus maximus, however, passes over the greater trochanter but inserts nearby at the “IT” band (a tough band of tissue which runs down the side of your leg into your knee)
What is causing this hip pain? It could be Greater Trochanteric Pain Syndrome, which can result from irritation of a few different tissues. It can include injuries to the tendon of your buttock muscles which is sometimes called a “glute tendinopathy”. It can also include irritation of one of the bursa that are in this area, which is sometimes called “trochanteric bursitis”. In this case, if a bursa in the side of your hip gets irritated, it can cause pain with movement INSTEAD of making movement easier.
Because there are so many muscles, tendons, and bursa that either attach to, or run over the greater trochanter, when one gets irritated it can result in irritation of the others. The initial cause of this irritation can be from a hit to that area (ie. falling on your hip), long distance running, or weakness in your hip muscles.
Did you know?
This type of hip pain is most common in females, and recent studies have begun exploring associations between knee osteoarthritis that alters lower-limb biomechanics and Greater Trochanteric Pain Syndrome.
What can I do to help it feel better?
What exercises can I start with to help my hip pain get better?
These suggestions are just the first step to feeling better and decreasing symptoms. To return to your full activity level, you will need a progressive exercise program to help strengthen the muscles in your hip without making your symptoms worse. You may have to take a break from some activities that are making your pain worse, and slowly return back to them over time. A physiotherapist can help guide you through this recovery process.
Do you have some hip symptoms that haven’t gone away? Call us at 519-895-2020, or use our online booking tool on www.strivept.ca to book an appointment with one of our knowledgeable physiotherapists where they will perform an assessment and create a treatment plan for you.
Amanda McFadden, PT, BSc, MPT
Physiotherapist at Strive Physiotherapy & Performance
Strive Physiotherapy & Performance
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