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Sports Medicine ECHO: Sport Related Concussion Update – 6/22/17

Good morning everybody! Hi! We’re gonna do,
we’re gonna do a little concussion update today and it’s not a very long
talk. Does anyone have any questions or cases before we start? Okay well we’ll get going. There are a couple links on the website that go over the new, I’m not going to call them guide lines because they don’t want
them to be guide lines it’s just the new information and then there’s a new sideline and combination office form called the scat 5. So you know, I think,
one of the problems with concussion is we’ve had so many different forms and so many different formats and so many different things to do and honestly, if you just want to use this one form now I think it’s perfectly adequate. So, there’s a couple links on our website right on our website if you want to get those documents and then I linked them in here, too. You know they, they update that we just did concussion in September and I was gonna actually have someone come
talk on golf injuries and then he called me and told me he actually has a
golf tournament to play in. So I’m going to try to get him in August or September but the new the new information on the sport related concussion, it just came
out in April. It’s not earth shattering but I think it’s a little bit simpler and there are some changes so if you taking care of kids you know or adults out there with concussion I think that things are getting a little bit easier we still don’t have a lot of research a lot of information but I wanted to go
through this with you. So basically we’re going to go through that new information. So, like I said about every three to
four years there’s a big conference where they get everyone together and they talk about concussion and then they come out with this consensus statement on, gee what should we be doing? The interesting thing about this conference was they actually had some people there who were interested in the
research on chronic traumatic encephalopathy and the long-term changes
and problems that we think may be related to concussion. So they have those
folks there I think that was the first time and what really, what they’re saying with this consensus statement is this isn’t the hard and fast guideline this isn’t supposed to be a standard of care or legal standard of care, it’s just something to help you as you go through and take care of folks with concussions so they’re, what they’re really saying with this guideline is
it’s still up to you as a clinician to use your best medical judgment on how
you want to treat these folks. So, this time they decided there were going to be eleven R’s and you know recognize the first one recognizing a concussion, that’s the hardest part. It’s easy if the kids coming off the field walking sideways and doesn’t know who you are, no brainer, that one’s out but there are a lot of times when it’s not really clear and we need a little bit more time and what they’re saying with this guideline is go ahead and try to take a little bit more
time don’t be rushed to put them back in. If you think again there’s a possibility of a concussion, do some further evaluation even if it means they might not play that day. And then they’re talking about removing them, evaluating them, if you’ve decided they have a concussion they need to go through the rest rehabilitation. We’ll talk a little bit about when to refer, how long it takes to recover, how to return to sports, and reconsider they’re
talking about elite athletes and children again we’ll review that. Residual effects and sequelae and then what do we do for prevention and risk reduction. And like I said unfortunately there’s no
earth-shattering news here we need more research we don’t have it but we’ll go
through again I, you know, we’ve got, we’ve done sports related concussions probably three or four times by now I would say so if you’re tuning into these lectures you know the definition but i’ll just review it so we’re all on the same page usually a direct blow to the head, face, neck, elsewhere in the body. The impulsive force transmitted to the head, brain gets moved around and the brain doesn’t like that you get this fairly rapid onset of what we call short-lived and pyramid of
neurologic function. So really concussions are somewhere in the four week or less range for the most part. I do think it’s important to note
that when you think someone has a concussion, oftentimes that first five or ten minutes I wasn’t sure. And they seemed pretty good and they could talk to me and they could say the things I wanted them to
say and oftentimes I’d wait just I don’t [inaudible] give them ten or twelve minutes and I’d go back and retalk to them and then it became very clear to me that
they did have a concussion. So, those first couple minutes, you know, it just
happened, they’re walking off the field or the court or wherever you are it’s not always super clear that they have a concussion yet, their brain hasn’t come to the point where, all the chemical neurotransmitters and the glucose theory and all that’s happened so give yourself a little time if you’re not sure it often becomes very clear in ten to twenty minutes and then all of a sudden
they’re you know off like this and you think to yourself, boy I’m glad I didn’t put him right back in. So, if you’re suspicious give yourself a little bit of time because it can take a little bit longer than you think for some of that
to show up. This typically due to functional disturbance rather than
structural injury. It’s probably changing we probably just don’t have the tools to identify the structural injury at the micro level. But as we get some of the
new MRIs and brain flow studies and things it probably is indeed structural it’s just what we would call minor head trauma because with the tools we
use like cat scans and MRIs you really don’t tend to see anything. So, probably in the future we”ll be better at saying, yeah there is some type of structural
injury here too. There’s this wide range of clinical symptoms which can fool you and again, you may or may not have a loss of consciousness. Typically though the
good news is these things resolve kind of in a sequential course and we’ll talk a
little bit about the prolonged symptoms in some cases. So, they started looking at
things like, how do we diagnose a concussion and how do we prevent it? One of the first things they came up with were that they looked at a lot of these
biomechanical studies because what people have been doing is putting helmets on folks who play sports that require helmets and then they’re trying
to see what, what is it that causes the concussion? You know, is it a direct force head on? Is that the torque? Is that the twist? Is it an acceleration? Is it a g-force?
What is it? And they’re looking at the linear and the rotational acceleration and what we really think is a lot of it is rotational acceleration or that torque. So, you can imagine I can hit somebody head-on and this is a pretty
hard part of my brain and brain might go back and forth but as I fall down and boom the side of my head hit somebody’s knee, and then I get the twist in
addition to the impact you can imagine the brain does a little bit more and so I think there’s probably a pretty big rotational component to this, which makes
sense and is why just putting a bigger stronger helmet on doesn’t really help because it doesn’t help you know if you’re twisting your head I could have a
helmet this big but I can still get my head to rotate fast enough to cause a
problem. And that also makes sense when we talk about prevention of concussion there’s some studies that neck strengths out. So you can imagine if I have a little tiny pin neck that I can twist easier than one of the folks like this who you know the no necks so, that rotational component is important and so some of the newer helmet systems that are coming out me and the NFL was testing one has something for the rotational component but what they’re, what they’re really saying with this is they’re looking at these helmets and looking at
the accelerations and looking at the video systems and everything is really variable and we can’t really correlate. So, if a parent comes in and says should I buy my kid that $500 helmet? The coach of the team says, should we put sensors in
everybody’s helmet and pull everybody out that has a hit over a certain
g-force? The answer is no, it doesn’t correlate at this point and those heal- and systems aren’t supported but lots of well-meaning parents will you know, are buying this stuff or schools are buying into it. You know, the guardian caps, the things that you put on top of the helmet. Again you can say no, the studies just don’t support that stuff right now. And so let’s just, let’s get
into concussion. Again the majority of sports related concussions that’s an SRC occur without loss of consciousness without frank neurological signs and again it can be difficult to diagnose you just not sure sometimes, especially in the littler kids because they’re just not quite as good at telling us exactly what happened and then sometimes they’re not as good at describing symptoms. We just don’t have a diagnostic test yet all the things that we’re trying,
the balance testing, how fast you read, the blood markers, the spinal cord, the brain fluid markers. Just don’t have anything yet, so again, what needs to
happen is if you or somebody that’s working with you or for you or this is a coach or a parent on the sideline, say hey maybe little Johnny or Sally had a
concussion they need to come out of the game and have an evaluation by some sort of a licensed health care provider. And just depending on where you are, this could be an athletic trainer, this could be EMS, a nurse, a school nurse, a physician, a PA, nurse practitioner, somebody that you know may
be around with somebody who knows a little bit about concussions should
probably assess these folks. And I just I talked a little bit before about this SCAT 5 this is the new document so it’s a sideline concussion assessment testing document it’s got one section that is sort of for the immediate on-field assessment and it goes through the real red flags and the emergency stuff where we’re not thinking a concussion we’re thinking a more serious injury they go to the hospital and then it evaluates okay this might be a concussion what should now I’m going to give a little time and I’m going to do a further office-based or you know in the locker room kind of an assessment so this is a good form to use the first time you use it keep in mind you know they say, “gee it should be able to be done in ten minutes or less” the fellows when I would give them this and have them start out in August and September easily took them a half an hour and you know they might get it to where they could do it in fifteen or twenty minutes, so it’s not a super fast once you get to the office assessment it’s not super fast it takes a little time and you just need to realize that and the fellows keep in mind they were doing hundred or more concussions in a year so when you’re an office based practice what do you do in five or ten maybe depends on your depends on your practice but just keep in mind it takes a little bit of time and it’s helpful if you have somebody who can help you do it. But what it says is in terms of the emergent or first part is you need to look and make sure that there’s not something so serious that that’s more of a major head trauma neck trauma something else off they go to the hospital. So they’ve got the red flagged part then we’re going to talk about observable science what kind of things do you see that might make you think this person has a concussion then you want to do a little bit of memory assessment, they put the Glascow Coma score in there obviously most people with concussion, which we call a minor head injury, are going to get a good glascow score if you have something lower puts them in a different category off to the hospital and then they really want to emphasize that the head and the neck are connected to the body and you want to make sure that you assess the cervical spine. So unfilled first thing someone gets hit, goes down, not moving, looks funny, you want to get out there and check them and you just want to make
sure, are we dealing with a more serious type injury? So do they have a neck pain or tenderness, double vision, weakness or tingling, burning in the arms, of the legs, that can be a stinger if it’s on one side it’s on both sides it can, it can be a
possible cervical spine injury some kind of a cervical stenosis something that is congenital, etc, etc. Severe or increasing headache, seizures, or convulsions again you can have those fairly commonly with concussions and they’re scary they don’t always mean there’s something bad but it’s enough that it makes me send them off for an evaluation. Loss of consciousness again especially if that’s prolonged deteriorating
conscious state sometimes you can watch them sit there and they get worse and worse the few subdural hematomas that we’ve had that’s exactly what happened I actually sent them down to the ER with an athletic trainer, athletic trainer called me after about a half an hour and said “gee I hope the ER doc comes soon because now he’s not making sense that he’s mumbling and he’s slurring his
words” I said I’ll call right now well get that looked at so again as you’re watching on things can deteriorate over time vomiting more than once and then again kind of personality changes they get restless, agitated, combative, stuff
like that we need to look at them. So you get out there maybe they’re lying motionless oftentimes they have balance and gait difficulties they’re incor– uncoordinated, they may be slow especially if it’s a kid you know kind of looking at you like who are you, that blank or vacant look is really common they don’t respond appropriately don’t know what they were doing what was happening what was their particular part to play
you know maybe in the play or you know what’s happening in the game and again, the ones I’ve missed a couple concussions along the way and I’ve missed them because I was focused on the facial trauma, facial injury, I can suture that up and get him back in the game I’m so proud of myself and then I watch them out there going, ahh, and I think I totally missed the concussion because I got focused on something else so make sure even if there is a neck facial trauma something like that, do the concussion evaluation too because it usually means they got hit hard enough that that would be a possibility. So as far as the stuff stuff you can do quickly on the sidelines if you’re seeing them or they brought them right into the hospital or the urgent care make an appropriate or pertinent to what they’ve been doing so you know, where are we, gee we’re in Yerington, you know what half is it or what part of the game are you in um who scored last or what’s a score what team did you play last week or the last game and for the rodeo cowboys it’s often times where were you last week or what bull did you ride last week. Um so, again got at the bottom you can substitute sports specific questions they would– motocross you know well did you race last week, where? So you can make those a little specific you know did your team win, what happened, again the Glasgow Coma I just threw it in there
for you but typically most people should be in the 14 15 range anything you know that’s lower than that even a 14 that I would be worried a little bit about, what what do I need to do and should that person be assessed but they want you to do a Glasgow Coma Scale on them so it’s pretty easy if they’re fine you know they open their eyes look at you and speak to you normally shake your hand everything moves okay you’re done that’s good
but anything less than that should be sent for further evaluation and again, does your neck hurt? no okay feel it, push on it, does it hurt? no, okay now go ahead and let them move does your neck hurt? no. yes?, okay stop let’s get the backboard let’s get the collar exc– etc., whatever your local policies are and give them someplace else and then again, gee their neck doesn’t hurt, gee it moves okay, quickly check their arms and legs, everything moves normally, sensations okay, you can grab and you can wiggle your toes and push against me, you’re done, that can be a really quick assessment on the field. This, there’s always second-guessing especially on TV now, you know, you’ll see people come off and you’re like wow that guy or that gal had a concussion and then they go back in the game later and I don’t feel like
oh that was you know that was a dumb move they shouldn’t have done that but I’ve been in the position to where they’ve come off the field looking really wobbly and not walking well and for all the world I think they have a
concussion and I know I told you this story I can’t come off just like that and I grabbed his arm I’m like, you okay? how’s your head? he goes it’s not my head doc, it’s my down below region, oh, okay, so we go into the locker room and you know he’s got some trauma there and got pinched and hurt a lot he was wobbly when he walked off and we got it all fixed up with a few different maneuvers and putting back out there and I have said people text me and say, “how stupid are you to put a kid with a concussion
back out there” and you hadn’t even hit his head but you can’t you know we don’t talk to the media and we certainly don’t tweet back you know with confidential patient information, it’s not always what it seems so, if actually a health care provider does a full assessment they you know and it’s not really a concussion, they can go back in and play if you haven’t diagnosed it again, I– especially with the littler kids, you know it’s a Pop Warner football game just error on the side of the caution, they’re out. um there is sideline video review, again if you’re in a rural area may not have this or you might there might just be someone in the stands it’s doing it certainly at the higher ed most of the college levels and professional levels they have this and so what they’re trying to do is gee, did he really can hit that harder or what happened and sometimes you can actually look go back and look at the play and it may give you some additional information they’re actually using it again in some of the professional sports there’s a designated watcher who may say hey, Sally Smith got hit really hard on that play you might want to grab her and just take a look at her you want a radio down to the sideline you can go grab her and do a quick assessments so, it may be helpful again you still need to watch them a little bit because of that delayed onset
symptoms. These are the things that we think about: headache, foggy, emotionally labile, the loss of consciousness amnesia, neurologic deficit. Those may be a little more serious balance impairment often times after concussion they have an unsteady gate, kids will be irritable or crying kind of inappropriately cognitive impairment, slowed reaction, time sleep/ wake disturbance, some of these you can still occur sooner some of them occur later the problem is if you look at any one of those almost any day any teenager can have one of those right so sometimes it’s nonspecific and not diagnostic of concussion and I had a kid who was going to be held out of it she was a college player not my patient went to school somewhere else it’s going to be held out over the finals of a really important basketball tournament because she developed the headache after the game and they thought it was concussion well I helped him out a little bit and went back and talked to the physician and it turns out she and the athletic trainer, she had migraines and she’d simply gotten a migraine not for the game wasn’t you know we actually you could they look through the film and she
never did hit her head at all so again these aren’t specific and diagnostic of concussion they should make you suspicious but keep in mind people have other things that happen. Again if you think someone has a concussion though they need an emergency evaluation the first aid evaluation is there a more serious head injury, neck injury chest injury etc etc then you need to decide what’s the disposition. Can they sit on the sidelines because it’s a concussion and they’re okay to be there, should mom and dad take them home, should they go by EMS transport so first thing you want to do is check them out and then you got to make your decision of their okay it’s not a concussion you’re going back in I want to watch you a little bit longer heads more serious I need you to go off to the hospital and that’s where you can use this SCAT-5 you can do that emergency on the sideline stuff and then you can go to the further evaluation because these things can evolve and even more serious head injuries really evolved you really don’t want to say okay just go off to your dorm and sleep it off for the next six hours with nobody around, you really want to have somebody evaluating. If, if you’re on a road trip someplace and you’re going to drive on a bus four hours back is there someone that’s appropriate to evaluate them and gee, can you stop somewhere on the way if you need medical care if you’re gonna you know we have this issue in Hawaii if I’m gonna put them on an airplane I can’t pull over in the middle of the Pacific Ocean so I had to decide are they safe enough to go on an airplane and can you know have four or five hours where we can’t get to healthcare or should we leave them in Hawaii or should you leave them where you are so that happens every once in a while if you should someone who’s
traveling and again if you think they have a concussion or if you diagnose a concussion no matter who they are no matter what level athlete they should not go back in and take a chance of hitting their head again that day. So once you get through the sideline stuff what’s next? again, use that up sideline
screening for a rapid assessment that’s kind of a triage guideline where do
they fall and then you can do some additional evaluation and again they’ll their test does it takes ten minutes but plan for twenty to thirty especially if you’re not really familiar with it we haven’t used it a lot and again you don’t want to try to do this on the sidelines you see this all the time on pro sports we’re taking the back to the locker room for the concussion assessment and they have some more sophisticated testing modalities that they use but no study says it’s any better than this scat 5 and so it’s perfectly viable and vulnerable for you if you want to use a good concussion tool this is the one to use you just want to take them off somewhere and do it a distraction-free environment and have them resting. So neuropsychological the computerized testing the impact test the head minder those tests got really popular for sure in the last ten years unfortunately what happened is they say well we have the impact test it’s just it’s it’s basically a smaller computerized neuro concussion neuropsychological test so it doesn’t take the place of a
neuropsychologist doing full testing it’s us it’s again it’s a screening test but what happens a lot of places are like well we think they got a concussion we’ll do the impact test, the impact test says, yeah they have a concussion, we’ll do it again in four to five days do it again in four to five days someone reads a test says that’s done and then they get cleared to play and you gotta keep in mind this is a tool a healthcare provider needs their eyes and hands on these people and you know it’s a it’s a helpful tool but I think it got it starting to be used as this is the end all and all and school districts who think we’re gonna do this test and we don’t ever need to see how healthcare provider, I’d rather not do the neuropsychological computer test and how doesn’t see a health care provider so they’re actually agreeing on this when they’re saying hey it’s great if you have this you can do baseline testing you can do post-injury testing it’s another tool I liked it for me especially at the college level I got to say hey neuropsychologist take a look at my patient as well and it’s kind of like pulling someone in when you have a rash Hey, come look at this rash for me what do you think you always feel a little better when you have a colleague saying yeah I agree with you or hey no I know what it is it’s this or you know no I don’t agree with you we should do something different, it’s nice to have that second set of eyeballs on on it but it shouldn’t be the sole basis for management and it has evolved into that in some places so that’s just I use it as a tool if you don’t have it that’s fine you might just be a little more conservative in your return to play guidelines depending so that’s that’s all they’re saying now as I say hey it’s a tool to help you it shouldn’t be the sole basis for all of your decisions and somewhere along the way everybody all these athletes should have a neurologic
exam so we’re talking about the stuff that’s in the SCAT-5 and again that
baseline testing isn’t mandatory but what they’re saying it’s really good for is these kids have to take this in our in Washoe County school districts is impact tests well you that means you have to send something on the parents saying can can they take this test maybe it cost five dollars to take it but it provides an additional opportunity for you to do some concussion education which is a good thing so it’s almost that talking about the test and saying we’re doing it and we’re addressing concussion is important is doing the test itself but if you’re in a school district they’re a place that doesn’t have it you’ve got the scat five minutes okay
don’t have to have it on the other hand if you want to implement that kind of a plan there are neuropsychologist in Nevada that will help you is web-based you don’t have to have one in your town so you can there’s a cost to it of course you decide which one you’re going to use you can sign your school district or your team or your ski team or your rodeo team or whatever you can sign them up pay them pay the cost it’s not super expensive and then you can work with a neuropsychologist in a remote place to do the computerized testing if something looks bad or it becomes more serious that neuropsychologist is probably going
to say hey dr. Smith this this young person person needs to go in and have a more formal assessment with the neuropsychologist which is any personal
assistant. There’s lots of new things that are using for investigation and again we talked about the functional MRI some of the cerebral blood flow the you know the other types of MR studies some of the heart rate things measure of performance they’re looking at heart rate goes up faster afterward the fluid biomarkers where they’re talking about
should we be testing blood saliva cerebal spinal fluid genetic testing with looks like there’s probably some type of predisposition to some of these things transcranial magnetic stimulation are are these things helpful to us no they’re in the research realm they’re not validated for clinical use yet they’re currently helpful as research tools there’s even a sideline EEG device that you can put on and do a quick check and say hey brain waves look okay or not so there’s probably going to be some of this stuff in the future we may treat it
like we do you know rule out MI protocol well let’s check the biomarkers and let’s check them again in four hours and gee, you have a concussion or you
didn’t but we don’t have any of it yet this is one of the changes we’re moving away from lock you in the dark closet for a week and complete rest it looks like it’s probably not really helpful for a few different reasons and think about a lot of the kids that we’re taking care of are in junior high in high school and if you take them away from their sport and their friends for
the whole week you know they start feeling these are having some psychological issues too so moving away from complete rest and saying okay some some brief rest for 24 to 48 hours to bed concussion you really don’t feel
that good so do a little brief rest and then you can become gradually and progressively more active this is not go run ten miles day two of your concussion but this is will get out and go for a walk maybe we can get you on the exercise bike a little bit and it looks like it probably is helpful and actually some studies are looking at using this as treatment can we give them back
faster do they heal faster if we start doing some progressive exercise so again we’re not ready to recommend that we want them to stay below the threshold that incites their symptoms so if they go out for a walk and they get a bad headache they need to come back and not you know wait till tomorrow and try to
go along same thing you put them on a bike or a treadmill and they get symptoms just take them off so you don’t want to do super vigorous exertion but really getting them doing something fairly quickly is in the realm of the future so who should be referred? you know two weeks for adults continuing that you might want to have them see somebody who specializes in concussion and this might be physical medicine and Rehab this might be the neuropsychologist spending or dealing with this might be a neurologist that a sports medicine person who specializes in concussion you know somebody else um if it’s 10 to 14 days for adults but four weeks for children so just keep in mind we start getting nervous you know gee they’re not
better in a week they’re not better two weeks oh my gosh it’s three weeks something really bad is wrong they take four weeks and that’s in the realm of normal so certainly if your clinical judgment and you’re uncomfortable get them to somebody but if you’re comfortable and you can help the parents and the child understand this is going to take this long then a lot of times everybody settles down you just you know right off the bat this might be a month rather than oh you have back in three or four days so you can set the parameters if you can discuss these things right off the bat sort of here are the expectations and it might be that it’s four weeks it might be six weeks with the younger kids. there are lots of these confounding factors and we talked about migraines before it gets confusing if you have a player coming into a contact sport who has migraines I always when we saw the soccer players of football players with migraines I was like oh boy it’s going to be hard to tell because there are exercise induced migraines heat induced migraine you know those kind of
things happen depression you know there are changes with concussions but depression they tend to not get better by this fast. ADHD folks who already have some type of mental health issue and certainly we don’t we don’t always think about it is substance abuse now we’re not letting them have their substance and they’re withdrawing or gee they’re using their substance on top of this
brain injury it gets really confusing like what is going on and sometimes you can talk to about are you drinking what are you using you know or like I said are they withdrawing because we told them not to or we’re not giving it to them and they can’t get it so keep in mind the substance abuse part complicates this stuff. there’s really limited evidence for pharmacotherapy and as far as treatment you know it seems perfectly reasonable to say it and use some tylenol use some advil, sometimes for the post-concussion stuff that goes a couple weeks i’ll use some advil there’s just no good studies that say this helps I have a neurologist who oftentimes you would use trip temps for the headaches and again in my experience that seemed to be helpful you have somebody with terrible headaches especially if they have a migraine history but limited evidence with this with this you know what I call a guideline they don’t want to call it a guideline but this clinical consensus document says they’re just no studies that say here you use this medicine here you use the fish oil here use the tumeric or whatever’s the latest popular supplement out there none of those studies are out that says this is helpful. again if you’re not sure refer to someone health care professional who works with concussions recovery most people get better without a lot of intervention it’s still time and gee, keep
your head away from getting hit again while you’re recovering we think that’s a big deal really severe initial symptoms do predict a slower recovery and again like I said pre-injury migraines and mental health problems are risk for having symptoms greater than a month so you might set up that expectation right at the very beginning teenage years there’s a lot going on and what they’re saying is it might be a more vulnerable time period for your brain and then you have these kind of more complicated things that can happen greater risk for girls than boys draw your own conclusion about why that might be but that’s what seems to be out there in the literature and they, this physiological dysfunction that may last longer than the clinical symptoms so again in the future we may be doing some functional MRIs and EEG’s after the clinical symptoms are gone some of these folks still have some of these physiological symptoms that the cerebral blood flow seems to maybe linger after the clinical symptoms are done so this buffer zone they’re talking about is okay my symptoms of a concussion are done now today but nobody puts me right back in with the football helmet full pads in practice today we have this return to play protocol which really gives us about another week before you’re putting me back out there in the level you need to get my head so that buffer zone mail all the physiological recovery to again there’s a lot we don’t know about concussion but the return to sport should be stepwise and when they’re symptom free they can begin a symptom limited activity after 24 to 48 hours but this is not the return to play protocol stuff okay so just because at 48 hours I can ride the bike and not get symptoms that doesn’t put me in day 2 of the rehab I need to be totally symptom free and then you begin the return to play protocol so you’re thinking about 7 to 10 days to get better from your concussion and now another 7– 7 days to get back to the return to play so you’ve got you know junior higher younger kids you’re talking about a month but high school you’re still talking about two weeks so set that expectation for the coaches and the parents it’s not probably going to be a week and the state championship is in a week probably not going to have them back by then and then everybody knows and they get mad at you and go somewhere else but anyone who specializes concussion will probably back you up and so then you starting to rehab protocol each step should take about 24
hours so typically gee you made it through this step great tomorrow we’ll go to the next one we’ll go to the next one you get to step 3 gee I got a headache and I got dizzy ok we’re gonna stop for today what– we’ll go tomorrow but we’ll start you know at the lower protocol and just work you back up so again if they get symptoms you just stop that day and start at the previous key systemic level and then just go back up from there others will begin back they go. this I just put in so that you
can see it and when it what it entails we don’t have to go through all of it but you can see how it’s gradually progressive and the full-contact practice is there at the end and then they returned to normal sport play. this is important too because they’re going to school right especially if you’re taking care of folks similar at the you know the professionals maybe not but certainly the college kids I take care of and if it’s high school or junior high or earlier they’re going to school too they may have symptoms and have problems so you know again don’t don’t confiscate their cell phone and not let them look at a computer they live with this they’re going to get depressed and have some problems with that but hey we might limi at the time screen time TV time computer time studying time depends on how they do but again there’s a guideline for returning to school I do think it’s important to note that they should be back to school before they go back to their sport so I’m not going to hold them out from class but oh you can go practice so you’ve got to be back in
school and doing your school stuff and then we’ll get back to sports. this reconsider is that gee, should we treat elite athletes differently should we try to
get them back faster and they’re saying no they really should follow the same exact guidelines as everybody else and trying to get them back faster or ignoring symptoms or getting them in there with symptoms it’s going to be detrimental to them in the long run we really don’t know much about the littler kids the five to twelve year age group these kids the way they oftentimes get concussions yeah I’m usually not playing football hard enough to get a concussion what’s happening with them is they fall off their bike the motocross their skateboard the monkey bars something like that and they hit their head but you’ll see these and again just take plenty of time with them adolescence again we don’t have a lot of studies in those age groups and we need some more studies but expect a duration and you can set the parameters for the parents and the child this might be this will probably four weeks that you’re going to be out of here or whatever sport it is schools really should have some type of a sport related concussion policy so when you call or write a note they know okay this kid hit some limited activities and certainly there has to be some communication to the athletic director the coach this kid is not supposed to be at practice and playing then again you know the parents might be in there too but I’d have some good experience with parents and some that aren’t so good about getting their kids back too soon and so again your part is education but really you should have some type of communication with the school or that team directly so that they know what your your ideas and guidelines are and again they said right there probably shouldn’t be going back to sport before they’re going back to school. okay this is a big deal you guys have heard about this right chronic traumatic encephalopathy and for sure the pro football players who died oftentimes you know they’ve died young or something bad or worse, and this happens, suicide, etc and they’re donating their brains the problem is the sample and the sample size, so all we have are a small number of these guys mostly who had problems you know we don’t have a brain of everybody who’s played in the NFL for the last forty years and that’s really what you need to do to know what the incidence is and is it related and so we have to be cautious and it probably is not a great idea to get your head hit forty times and have 40 concussions but it doesn’t automatically mean if you have one or two compressions you’re going to get chronic traumatic encephalopathy so more studies need to be done the potential is there, you have a kid whose had five bad concussions and they want to go back and rodeo motocross football I would strongly say let’s talk them about not having anymore maybe you need a different sport but the true incidents of this stuff is unknown and whether it’s even really related to the head trauma is unknown so although you read you know the media you get you read hey you get a concussion this is what’s going to happen to you and there’s people that are really passionate about this on both sides but the truth is that studies aren’t there the cause and effect relationship between sports related concussion and chromatic chronic traumatic
encephalopathy is not there it’s not a cause-and-effect relationship and you need to keep in mind with a lot of the people who’ve played pro sports whether you want to hear it or not, alcohol drugs performance-enhancing substances are huge and it’s hard to tease that out from everything else so some of the lifestyle things are there so if I can tell you right now is we don’t have a direct link keep it in mind and I do think it’s bad that have your head hit a lot but if I have had a couple concussions myself do I anticipate that I’m going to get chronic traumatic encephalopathy, no. the relationship between this repeated concussion over and over and over again that’s also less clear but probably a little more worrisome if you have a lot of bad concussions and these sub concussive impacts so what they’re talking about is these kids you have you get hit a lot and they’re looking a lot of the football linemen to maybe get it 30 or 40 times, hit their head 30 or 40 times in a game never enough really to have a true concussion we don’t know if that leads to some of this it might it might not again studies aren’t there so take that with a grain of salt it’s not for sure that you played professional football you’re gonna get this. I have a risk reduction what happens when someone comes in for their pre-participation physical and they’ve had six concussions already and you’re gonna clear them for girls soccer which is a high-risk concussion sport that’s we need to have a talk because we do think a past history of concussion probably gives you a little more likelihood to have a future of concussion and it may put some of these in a high-risk category and it may be and it may be someone that so high risk you say we should either change your sport or we’re not going to allow you to keep playing and that happens you know I have disqualified a number of students from sports and sometimes they’ve gone to another school and gotten cleared to play and you know again this is a clinical judgment it’s great to sit down with a student and depending on how old they are with their parents even if they’re old maybe with their parents and talked about if you’ve had five or six is it worth it to keep having more we don’t know exactly what might happen to you as far as chronic problems but I do think it’s not great to have those kind of head injuries over and over and over previous symptoms did it take them six months to get over a concussion how long how bad were their symptoms and how many, those are important have you had a previous spine, cervical, facial injury a bad one maybe that they also had a concussion with that they already had five or six concussions and had two bad facial injuries you know they’re getting they’re getting them that realm of how many is too many this disproportionate impact versus symptom severity so gee I had my first concussion then it took a
truck to run over me and the next time a fly swatting me on the side of the helmet had a concussion you know they start getting concussions with less and less trauma you need to think that person is really susceptible they’re brain may not like this maybe we oughta consider not playing this sport or not doing this or doing something else and again you want to educate the
athlete and discuss modification of playing behavior or sport you know there are some kids who and hopefully the coaches are teaching them but you know that teaching them to get their head out of the way not fly in there with your head down which really can cause a neck injury and you know just those kids who are really gunners as far as hitting heads and maybe you can discuss modify what they’re doing. prevention the evidence is limited in sports and always use helmets because we aren’t going to take the helmets off and do the study right you have to play football without a helmet let’s see if you get more concussions or not so the problem is we just don’t have those studies to be able to do there, there is this skiing snowboarding the helmets really do reduce risk of head injuries so if you have a kid or you’re counseling children or parents or young adults on skiing and snowboarding they should be wearing helmets for that sport and that’s not mandatory because you know you just don’t pay your lift ticket and up you go but if if you’re the physician or healthcare provider counseling them they should be wearing the helmet for those two sports the mouthguard, there might be a little trend toward a protective effect in collision sports certainly it helps with dental injuries so yes they should be wearing their mouth guard don’t tell them it’s going to prevent a concussion but it certainly prevents them having their teeth broken and
knocked out so their mouth guard should be in there’s a study that no body checking in youth hockey until they’re greater than 13 does help so that was a rule change it was helpful there’s a small study doing this vision training and that probably has to do with being able to see someone coming at you and get yourself out of the way so you don’t have the impact um they have that a lot with limited contact in youth football and there’s less head contact which is probably good but it’s really unclear if it actually reduces concussions again just studies aren’t out there you can imagine how hard that is to do in Pop Warner football and and having concussions are not that common anyway so just having the documentation and the research isn’t there they have looked at different things as far as fair play rules and hockey where they change the rules a little bit tackle training without helmets and pads and football which kind of makes sense, and then and rugby football tackling technique there’s no study that says that actually helps prevent concussions although you might think it does and I think it’s good not to hit your head when you don’t have to there’s just not a research study that says this this is helpful it still might be helpful we just can’t say it is. they talk about the knowledge and so just talking to your students and your parents about concussions coaches administrators I think the biggest thing is just to be able to recognize it and get that person out of the game and evaluated that’s probably you know one of the key things that’s important for concussion and that really means having someone around the sidelines that knows what to look for and you know especially here in the rural area that may be few and far between if you’re at the college level you have six athletic trainers and usually four or five physicians hanging around and if you’re in junior high in Winnemucca I don’t know you know who they might have there that day but it is important to get the word out and education may lead to the improved identification we think if we can identify people pull them out not return them until they’re feeling better and maybe not let them get ten concussions that probably is good for their brain long term and then just a fear playing sport ethics of not trying to hurt people and and following the rules because a lot of the rules are meant to try to help decrease concussions. so in conclusion the science is incomplete I think you can see they pull back a little bit on some of this stuff you know the straight grass everybody has that computerized testing these different far– because you know
that stuff there’s just not evidence for it out there so it still recognize it pull them out give them time before they return to school in their sport and if you’re not sure get them to somebody who specializes in concussion but in the end the computerized testing all the other fancy things it’s really up to you as a clinician to say I think this is a concussion and I’m going to do the appropriate thing here so it’s really left up to you on an individual basis. Here’s the statement if you want to read it and I think that’s SCAT five you know, there have been a lot of different forms out there in the past that’s probably a good form to use you’ve got it for the sideline and if you want to use it in your office some of the things could be done by your ma or your nurse or your front desk again like I said there’s a little part for the sideline for the emergency stuff and then there’s a little bit more formal evaluation that you can do in the office and you can use the for a follow-up as well so see all
that stuff the mediator on field assessment and we went through that can you keep going as and look and there you go so now we get you know now you get into the office somebody else can help you fill up a lot of this and the symptom evaluation the student or the patient actually does themself and then keep going down you’ll see this stuff takes a little while that’s why I’m saying even I need to do it a lot I tell my my nurse for my medical assistant I’ll be in there for 20 minutes you know don’t worry if you don’t see me so you go through all this keep going down and then there’s even a little section for concussion injury the advice that you can cut off and and give to the parents or whoever’s watching them and the instruction tells you just how to do some of this stuff so again I think it’s a pretty good form to use now they’ve put everything all in one place and that’s really what we like and want so if you want something to do an official concussion assessment that’s the one you
use I think at this point. Does anybody have any questions about that? it’s a little simpler so you know it’s not quite as overwhelming and I think it’s nice to know you don’t actually have to have the computerized testing if you don’t have it already but if you want to have it let me know and I can always help you with that if you have questions about these kids or want to know who to send them to just get in touch with me. thank you

Cesar Sullivan

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