While I’m thrilled mild traumatic brain injury in sport is finally getting the attention it deserves, falls and concussion in the elderly is at risk of being lost in the shadows.
I understand the drama of high impact collisions in sport does grab our attention and headlines quite readily, but there are many older Australians who are suffering falls and concussions, even when they don’t seem to hit their heads.
In many ways, this is a silent condition and sometimes it takes someone like me, a neuro-vestibular physiotherapist, to join the dots and work on both remedial and prevention strategies.
In this article, I want to “make some noise” about one common cause of falls among older people, the often misdiagnosed or not diagnosed Benign Paroxysmal Positional Vertigo (BPPV), thereby highlighting the consequences of falls, which might not seem obvious at first glance.
And I will also argue that you will need more than one specialist working with you after falls because the injuries can be complex and you need people with expert insight; there’s no room for a Jack of all trades, master of none with the increased knowledge available in the 21st Century.
The malignance of Benign Paroxysmal Positional Vertigo
Benign Paroxysmal Positional Vertigo or BPPV is rightly described by the Mayo Clinic as, “one of the most common causes of vertigo, which the sudden sensation that you’re spinning or that the inside of your head is spinning.”
However, there is a telling point made in the Mayo Clinic summary, namely:
Although BPPV can be bothersome, it’s rarely serious except when it increases the chance of falls.
This is the first point to note in relation to concussion, that BPPV becomes serious when it leads to falls, and this is because falls can and often do result in concussions. I’ll explore more of those ramifications later in this article.
However, it is pertinent to also note, that what makes BPPV particularly much less “benign” than its name implies, is that it can be a common consequence of falls.
That’s right. BPPV can lead to falls which can lead to concussions, but BPPV can also arise because of falls.
All too often the older dizzy patient is not accurately diagnosed with BPPV and are therefore advised to see any physiotherapist instead of a neuro-vestibular physiotherapist.
It is this blind spot in the diagnosis of BPPV that has prompted me to write this article to raise awareness.
Our older patients (and healthcare system) cannot afford “guess work” any longer, especially because this inner ear condition is most common among older people and specialist diagnosis requires a specific framework that neuro-vestibular physiotherapists bring to the table.
Another great American institution of health and medical research, Johns Hopkins Medicine, gives this useful outline of the initial process of BPPV diagnosis:
Diagnosing BPPV involves taking a detailed history of a person’s health. The doctor confirms the diagnosis by observing nystagmus – jerking of the person’s eyes that accompanies the vertigo caused by changing head position. This is accomplished through a diagnostic test called the Dix-Hallpike maneuver.
Once again, we see that our unapologetic position of exclaiming the absolute importance of taking down your detailed health history, is crucial for all diagnoses involving dizziness and balance disorders.
A pain in the neck: Understanding falls and concussions in the elderly
As I’ve mentioned before, I welcome the attention being directed to sports-related concussion, older people falling over, or other people falling over at home or work, can sustain concussion and/or traumatise their upper cervical spine without their heads actually hitting anything.
Let’s allow this sink to in. You do not have to hit your head when falling over to sustain concussion and/or traumatise the upper cervical spine. The fall is a linear acceleration-deceleration injury which means the brain can be traumatised. It is like a whiplash injury.
When we fall over, it’s the linear acceleration/deceleration (shearing) force that causes injury, irrespective of a blow to the head. The dramatic change of speed can traumatise the upper spine, like a whiplash injury, traumatising the brain in the process.
The complexity of the injury demands a multi-disciplinary team approach. You will need to have a team of people around you to make sure your symptoms/problems are addressed by people with the right experience.
When it comes to falls and concussions in the elderly, one hat does not fit all
Who should be in your treatment team? Well, that depends on your specific symptoms, which will demand specific sets of expertise.
Concussion is a neurological disorder, which means you are going to need a neuro-vestibular physiotherapist because they have specialist, in-depth knowledge and skills for treating injury to the central, peripheral, and autonomic nervous systems.
On the other hand, your neuro-vestibular physio will want to collaborate with a musculoskeletal therapist because they have in-depth knowledge and experience of the musculoskeletal system.
Of course, there could be many other practitioners involved because when you sustain a fall, irrespective of a blow to the head, your neck and your jaw (temporomandibular joint) can be traumatised. This could result in a broken nose, broken teeth, facial lacerations, broken hip, broken ankle, broken shoulder, or even a broken wrist.
When you take these variations into consideration, you’ll see why, apart from your neuro-vestibular physiotherapist and musculoskeletal physiotherapist, you might also require support from these professionals:
- Neurologists
- Neurosurgeon
- Occupational therapists
- Dentists
- Orthopaedic surgeons
- Oral and maxillofacial surgeons
- Prosthodontists
- Neuropsychologists
- Clinical psychologists
- Ophthalmologists
- Neuro-ophthalmologists
- Ear, Nose and Throat surgeons
- Orthoptists
- Optometrists
There might well be other professionals required; it depends on your unique situation.
Final thoughts and an important question
I have been seeing the results of (and treating) such injuries for many decades and I urge general practitioners, medical specialists, and people in the wider community to pay very close attention to these factors when they slip or fall.
I urge all my fellow practitioners to ask: Did the person strike his/her head in the process or not?
If we can start taking this more seriously on the domestic and workplace front, then allied health practitioners, friends, and family will all become better equipped to look for the symptoms of concussion and BPPV, when they learn that a person has fallen over, no matter whether or not their head made direct contact with anything.
REMEMBER concussion is a serious and complex injury of the BRAIN and needs to be treated accordingly. It is not a torn hamstring muscle.