Part one of a series on the people who have suffered concussions as well as those who treat them. For other stories, click here.
The question is the same every time.
Every patient asks it, and Michael Brennan thought about what his answer would be two months ago as he made the drive from Nelson to the Okanagan.
The parents had reached out to him after they'd run out of options. Their daughter had banged her head playing a sport in February, 2015, but was still suffering from a concussion that was keeping her out of school.
Their question, then, was the same Brennan hears every time he meets someone with a head trauma: How long is this going to go on?
"Truthful answer is we don't know," says Brennan. "Everybody's brain is different, type of concussion you can have can be different. It varies so much, but [I'm] trying to be honest and trying to get across the severity of the situation without frightening. I don't want to put people in a state of fear, you want to give people hope if you can. That's the biggest thing is just hope that we'll be able to do something to help them."
Brennan is a chiropractic doctor who, along with his wife Kristen, runs Active Balance on Baker St. He's also one of only a few people experienced in the assessment and treatment of concussions in Nelson.
What that means is the Brennans are constantly trying to convince not only their patients, but local sports organizations that concussions need to be taken seriously. Thus far, they haven't had made much progress.
"The awareness is there, but people don't get how important it is," says Kristen Brennan. "That's one of our struggles is trying to get that message out, how important a baseline test is, how important it is to seek proper care after concussions."
Eighty to 90 per cent of people who are concussed recover, with early detection and proper rehab, within seven to 10 days. It's the other 10 to 20 per cent who haunt the Brennans.
"I've got people who come in two years post-concussion and emotionally they're a wreck," says Michael Brennan. "They don't have their life. Their life is not what they know. And we don't know if they're ever going to get back. At that point in time, is it permanent?"
At this, he shrugs.
The Brennans started their practice in 2011 and initially treated concussions like most general practitioners do by recommending rest. That wasn't effective, new research actually suggests patients need to return to regular sleep patterns after three to four days, but most doctors aren't trained to assess concussions nor do they know how to read baseline test results.
"You're going to go to your doctor, they're going to assess you for a traumatic brain injury, they're going to make sure you don't have a bleed, they don't want you dying overnight," says Michael Brennan.
"But in terms of concussion protocol, I think they are just saying rest. This is the experience that we've had. Medical doctors are saying you need to rest until your symptoms go away, if it persists go back, which is the classic treatment."
Dr. Sharisse Kyle is the rare local doctor who is up-to-date on new concussion treatments. Kyle, a member of the Kootenay Boundary Division of Family Practice, has been working on concussions for 18 years. She operates a referral-based practice and sees patients who have lingering post-concussion symptoms.
Kyle says she thinks while concussion awareness has grown, the injury still isn't taken as seriously as it needs to be by the public.
"They think, 'oh, I've just had a small hit to the head, I'll be fine. I'm not feeling that bad so tomorrow I'm going to do the same thing that I usually do,' whether it's going to soccer practice or going skiing or going to hockey or whatever the case may be," says Kyle. "And if they don't really recognize that as a significant event and take the proper rest period after that initial injury, then those are the people who may be more likely to be re-injured and may take longer to recover from their concussive symptoms."
The Brennans started adopting new treatments in March 2014 when one of their staff members suffered a concussion in a car crash. This is what patients can expect when they visit Active Balance for a baseline test and concussion assessment:
First, Michael Brennan performs an ocular exam. Eighty per cent of brain energy is dedicated to the eyes and vestibular system (the part of the brain that assists balance). If a concussion occurs, the brain's energy is reallocated to cope with the injury and eyesight and balance suffer accordingly. Eyesight naturally degenerates over time, so an ocular exam alone can't account for a concussion. But something as simple as following a moving target can be difficult for someone who's concussed. "When you have a concussion, some of this people can't do," says Brennan. "It's too hard. It's pretty incredible."
Next he performs a physical exam in which he checks the neck and shoulders for hypertonicity, or increased muscle tension. Vestibular nerves exist in the neck area, which means if, for example, someone has suffered whiplash, then the brain has a harder time interpreting balance. The test can be uncomfortable. Brennan equates it to checking with a finger to see if a steak is cooked. A healthy muscle should be raw, not well done, so if Brennan can't push down that's a sign of hypertonicity.
After this, the patient takes two tests. The first is the Sway exam, which is an app that uses the accelerometer in an iPhone or iPad to measure reaction time and balance to the millisecond. For example, in one exercise patients hold the iPad to their chest as they balance on one foot. The app, which has been approved by Health Canada, can be used by coaches as a way to test athletes post-injury, but it has to be registered through a health professional first.
Finally, the patient is sat down in front of a computer in a quiet room for Immediate Post-Concussion Assessment and Cognitive Testing, or ImPACT, which was developed by researchers at the University of Pittsburgh Medical Center. The program records medical history before testing memory and reaction time with a series of exercises.
The pediatric test for kids aged five to 10 years differs slightly, with the ImPACT exam is done on an iPad framed as a series of matching and memory games for kids to play.
Combined together, the exams give Brennan a picture of a patient's normal brain functions. The tests are little help post-concussion if a baseline wasn't previously performed prior to the injury — making it all the more important that baseline tests are done before an athlete begins play — but Brennan says they give health care professionals objective results to work with.
Just relying on typical symptoms like nausea and dizziness, he says, aren't enough.
"You've got to take the symptoms out of it. It's an important part, but it doesn't give you an accurate representation of how your brain is functioning," says Brennan. "There's where we start seeing that Second Impact Syndrome. People aren't actually recovering. We think they're good because it's subjective-based. 'I feel great. It's awesome.' Get back out, [bump your head,] you're right back to where you were. You weren't recovered. You weren't. You just thought you were, and we didn't have the testing to be able to say objectively your brain is here."
The Brennans offer the complete test for $30 per athlete for organizations and $40 for individuals, which means they are taking on a loss every time they perform it. Still, they are often stunned when people complain about the cost.
"Someone looked at me and said, 'Oh, it's a bit much isn't it?'" says Michael Brennan. "I was like, 'How much do you pay for your kid's skates? Your kid's hockey stick? It's your kid's brain."
They're also of the opinion Nelson's sports organizations need to take more leadership on concussions. The Nelson Minor Hockey Association pays for baseline testing for all its athletes, which the Brennans wish more organizations would do.
"Parents have to buy into that to get it completed, but I really feel like the organization should be [saying], 'Listen, we see this is an issue, we're trying to do our best to prevent this. We're offering the sport but we're also offering safety along with it,'" says Kristen Brennan.
Michael Brennan hopes Nelson understands the severity of concussions. He believes concussion research has made several breakthroughs in recent years, and that what he does is more in line with public service than just health care.
So when he makes the drive to the Okanagan to speak with the concussed athlete and her parents, he isn't worried about what he'll say.
"They've been through every other avenue with no success, so I feel like we're bringing something new to the table," says Brennan. "So for me it's hope, because I want to help her. She's a kid. I've got kids, and she's a good athlete, a good student. I want her to have her life back, I want her to play with her friends."
(Correction: A previous version of this story incorrectly stated the pediatric exam did not include a physical or the use of the Sway app. In fact, both are also included in the exam.)