Learn about updated evaluation tools and recovery protocols for kids who sustain concussions during physical activity in this presentation by sports medicine specialist Nicolas Hatamiya, DO, and certified athletic trainer Lauren Small. Their talk on this all-too-common brain injury (up to 1.9 million pediatric cases annually) clarifies diagnostic criteria; lays out questions to ask, symptom scoring systems and exam-room tests to perform at that first clinical assessment; and goes deep on return-to-learn and return-to-play guidelines, including what's required by state law.
So I'm happy to speak to you all my primary care, sports medicine, physician, family medicine trained. But um I'm able to see young athletes including pediatric patients. And then my colleague, Lauren Small is an athletic trainer who will also be speaking. So we're tag teaming this talk and I think it's a very important talk and timely we're gonna be talking about concussion in young athletes and uh give you some updates from the latest consensus statement that was published about a year ago. And I know at least for me and my clinic here at Benny of Children's, a lot of my patients have started school or about to start school including high school, which also means that high school athletics are going to be starting. So, uh hopefully this is helpful from a timing standpoint as well. We have no relevant disclosures. So for today, we're gonna talk about a definition of what a sports related concussion is. We'll go over some of the updated tools to evaluate a concussion stuff that we use on the sidelines and then things that you can use in the clinic as well. Lauren will then jump on and talk about the key updates on how we return our athletes both to school or work uh and to athletics. And then if we have time, we can talk about prevention strategies, but really wanted to leave more time at the end to do the Q and A section. So if there's any questions throughout this talk, feel free to type them into the Q and A, we'll have a dedicated time at the end to hopefully go through those together. As I mentioned, a lot of this information is based off of the latest consensus statement. So a bunch of neurologists and sports medicine physicians um who are considered international experts usually meet on a four year basis to update our sports related concussion guidelines. They got a little sidelined for a couple years by a small thing called COVID, but they were finally able to meet in Amsterdam in 2022 and then released their consensus document last summer. So this is all the latest information for you all. So let's start by defining what a sports related concussion is. So I think the broad definition is a sports related concussion is a traumatic brain injury that's induced by my biomechanical forces, which I think is pretty straightforward and perhaps hopefully well recognized when we look at the more comprehensive definition, we know that it can be caused by a direct blow to the head, but it doesn't have to be to the head. It can be to other places on the body that causes an impulsive force that gets transmitted up to the brain. And this force leads to this complex neuro metabolic cascade. And this indiscriminate release of neurotransmitters that we suspect is what causes the symptoms that manifest as a concussion. The signs and symptoms of a concussion can present immediately and then evolve over minutes to hours. But in most cases will typically resolve within days or even weeks. But in some instances can be a little bit more prolonged. Usually when you do neuroimaging, there's no abnormality scene, right? So when you get AC T scan or you get an MRI, you're not really gonna see much uh on those scans for concussion specifically. And as you may know, concussions can range in a wide variety of clinical signs and symptoms and it doesn't have to involve loss of consciousness. And I think that's pretty well recognized now. But, you know, it's definitely different than what we thought, you know, 20 to 30 years ago where if someone got their bell rung, so to speak, but they didn't pass out, we didn't consider them to have a concussion. And we know now that you don't have to pass out or lose consciousness, so to speak, to be diagnosed with a concussion. I think perhaps most importantly is that the clinical signs and symptoms of a concussion can't be explained solely by other things such as drugs, alcohol medication use or other medical comorbidities but can it can occur concomitantly with them? Right. So, um just making sure there's no underlying pathology that's contributing, um that's manifesting in symptoms like a concussion. When we look at the epidemiology, specifically in the younger population, we know that on an annual basis here in the United States, there's around 3 million sports related concussions that occur and a large proportion of those are in the younger group. And this data is mostly using emergency room data or bigger surveillance systems. And because of that, it's likely an underestimation because we're not capturing all the individuals that may not show up to be seen for their sports related concussion. Some of the older data suggests that we have seen an increase in sports related concussions and this has continued over the subsequent decades and we likely attribute this to an increased awareness and education of what concussions are both from a provider standpoint. So as physicians or other health care providers, as well as from the patients standpoint, being able to recognize the signs and symptoms of what a concussion is. When we break down the younger demographic into different buckets, you can see that this is from the CDC on the X axis, here is age group clumped into years and then on the Y axis is percent. So this just looks at the incidence of sports related concussions based off of the age group. And not surprisingly, you see that the more adolescent population tended to have a higher percentage of sports related concussions compared to the younger group. And that's likely just because they're more active and involved with sports. We also interestingly see some differences between sex. So boys versus girls as well as some other demographics looking at, um, racial backgrounds that you can see there and that brings up some, um, you know, issues surrounding health disparities and, uh, we can have a whole talk on that in and of itself. And um we won't dive into the big details about that, but just know that those exist and that there's lots of research currently being done on health disparities in de I specifically regarding sports related concussions. All right. So now that we did a brief background and we understand some of the epidemiology, we'll talk about the updated tools for concussion evaluation and I'd like to start with a case. So let's say that you're at your own child soccer game or perhaps this is your patient who is at a soccer game and they're the all star striker and leading goal scorer on their team during a game, they're getting an elbow to the head by an opposing player and they're slow to get up and once they get up, they say they have a headache, they feel a little dizzy and nauseous. Otherwise, though once they come off the sidelines and get evaluated by either yourself or another parent, they say, oh, I feel fine I really want to go back into the game. Uh, let's say this is like the championship game and, uh, if their club team wins, they get to go to Hawaii for like the big, uh, finals game. Right? And who wouldn't want to go to Hawaii for a fun trip? So they're really eager to go back in, but they did get hit in the head even, even though they're feeling better. So, in this situation, what would your next steps be? Are you going to let them go back in? If so if, if you say yes, then you know what criteria are you gonna use? Um or are there any tools that you can use to help evaluate it? And obviously, this is the updated tools section of my talk. So there are certainly tools that you can use. So we'll go through some of those. So part of that consensus statement also included a whole suite of tools that you can use to help in your diagnosis of a concussion. Uh All of those things are listed here on the right. Um And the one that you use in the acute setting is the concussion recognition tool. Um You may have heard or been familiar with the SCAT or the specifically the SCAT five, which stands for the sports concussion assessment tool, which is now in its sixth edition. So there's child forms and uh adult forms for those 13 years or older and then there's also this other tool called the scope, which we'll talk about as well in a bit. But those are kind of the three different categories of tools that are available. So going back to that soccer player that we are evaluated on the sideline, the tool that we typically will use is the concussion recognition tool. And this is mainly to help you identify whether or not you're suspicious of if there's a concussion in that acute setting. So my general algorithm, if I'm on the field is I look to see if there's any red flags. So specifically, you're looking for any other things that might make you concerned that there's some sort of spinal cord injury, cervical spine injury, or intracranial pathology like a head bleed. And these are the red flags that I typically look for. And if there's any of these, you wanna activate the emergency action plan or call ems if none of those exist, and you can confidently rule out some of those more serious things and you can proceed to doing a sideline evaluation. Part of that sideline evaluation includes looking for symptoms that they may say or have. So in our example, the patient had headache, nausea and some dizziness, right? But there might also be physical signs that you can see just by observing them. So, are they more emotional or irritable? Are they answering your questions correctly? Uh If you know them really well, like are they acting themselves? Are they acting at their baseline, right? And sometimes they may not be and that may cue you to the concern that they might have a concussion. Part of this concussion recognition tool also includes these questions that have been around for a while called the Maddox questions. And these have been validated and can be helpful if you're evaluating someone during a game and the questions that you ask are listed there. But they have to do with the scenario that involves the game or the team specifically. And if you may not know the answer to those questions, yourselves, just remember, often there's a scoreboard that you can look at and I'm a cow bear. So, uh even though I did my residency training at Stanford, but uh I'm a cow bear at heart, so anytime I can show cow beating Stanford, I will. So, uh go bears. But there's, you know, just a reminder that you can all look at the scoreboard there. And I think if there's any question as to whether or not you're suspicious of a concussion, you should just sit them out, right? So when in doubt, sit them out and we know that that's actually important, sending them out can be really helpful. So there's been several studies that look at the impact of removing athletes from play that have a sports related concussion. So this study that was published, looked at collegiate athletes, part of this group called the care Consortium and also um athletes at military academies and they basically looked at whether an athlete was immediately removed from play or if they were removed a little bit later, right. So this graph here on the left shows um time for recovery. So days since they got their concussion and then on the Y axis here is um how far they were able to get cleared to return back to activity. So 100% equals, you know, back to full activity. The solid line is the immediate removal and then the dotted line is the delayed removal. So the general takeaway is that the immediate removal group had a quicker return or a lower likelihood of missing um substantial amount of time. And so from this, you know, we know that early removal can lead to quicker recovery but also a lower symptom burden and we'll talk about what those symptoms are. But basically the number and severity of the symptoms they have tend to be less severe if they're removed sooner. So in that acute setting, if we are suspicious of a concussion for that soccer player, you know, often the common questions I get are, well, what do we do in these 1st 72 hours or what should we look out for? And this is a great resource that's available online. This is just screenshotted from the website from the California Interscholastic Federation, which is the governing body for um high school sports in the state of California on their website, they have really great resources that you can either direct your patients to or their parents or you as a provider can actually look at and then copy and paste and create dot phrases to include in your clinical notes to them. But you know, common questions that we typically get are like, well, what type of medications can they take for their neck pain or their headaches? Right. So generally try to avoid nsaids if you can because of a potential bleeding risk and Tylenol is fine. Uh You don't have to go in and check on your child in the night and wake them up frequently. But, um, you know, obviously just make sure that they're doing ok. Uh And then it also has some other additional resources that we'll talk about in some of our future slides. But, you know, again, I think this is a great little handout that you can give to the patient as well as the parent. So after we do that sideline evaluation, uh we talked about the scat. Oh, the formatting is a little off there. That's ok. Sorry about that. But, uh you know, the SCAT, we used uh historically in the SCAT five in the acute setting as well as in the office setting. Now, we just use it more in that acute setting. So within the 1st 72 hours, it has a lot of overlap with this other tool called the scope which is the sports office assessment tool or sports concussion office assessment tool. And so we'll really focus on this because this is meant to be used beyond three days. And so I think from an outpatient provider standpoint, this is probably the tool that you will all use or try to incorporate some of the aspects from this into your clinical visit with your patients. And in this apologies again for the formatting, but uh there are things that you should do on your first evaluation with the patient and then um things that are recommended for you to do and then optional components as well, which are color coded and we'll go through this together. One new thing that was added are questions that are optional, but I think are really important that it relate to mental health and sleep. As we know, mental health can be really challenging and is very prevalent, especially post COVID. And if you think about it, there's a lot of symptoms of mental health that actually overlap with concussion. And so what this screen does is it basically does a Ph two and then a G A seven looking for both depression and anxiety respectively. And then a sleep screen asking if they have any trouble falling or staying asleep. If they're using any supplements, they have a history of a sleep disorder. And then how many hours of sleep do they get on average? And these are just some articles that uh obviously stress the importance of mental health and sleep um with concussion and concussion recovery. I think one of the most useful tools in the scope is the symptom score. And this is something that I mentioned a little bit earlier and you may be familiar with this. But what the symptom score is it is it basically lists a bunch of symptoms and I know it might be very, very small on your screen or whatever device you're watching this on. But you know, it lists all the different symptoms that a patient may be feeling or experiencing and they basically go through that and answer. Do they have that symptom? Yes or no. And then if they do, how severe is it on a scale of 0 to 60 being not severe? They don't have it and then six being the most severe. And this is really helpful because if they are a high school athlete and have an athletic trainer, the athletic trainer may have already completed this when they got their concussion. And so when they see you for follow up, you can repeat this to see from an objective standpoint. Are their symptoms getting better? Do they have less symptoms or is it less severe? And then as you follow up with them in clinic, you can track that over time. You also ask whether or not these symptoms get worse with cognitive activity, like when they're trying to go back to school or with physical activity. Um The other thing I think that this is helpful for is also looking at where their symptom burden is, right? Because sometimes they may not have all of these symptoms. It may be more focused on specific areas like more headache related or balance related or more related to their mental health. And so it can really help you better identify ways to kind of target their symptoms and help them in a multidisciplinary way. The other part of the scope includes a series of cognitive tests and one component of that is the immediate memory recall. So you'll read a list of words and then you'll have them repeat back as many words as they can remember and you'll do this three times and we can all practice. It's actually quite challenging to do. But, uh, you know, the word list here that we'll practice is jacket arrow pepper, cotton, movie dollar honey, Mere Saddle Anchor. And then you would just repeat back as many of those words as you can. And we would do that three times. And then I tell you, ok, remember as many of those words as you can because I'm gonna ask you them a little bit later. So there's a delayed recall. So, um, if you are able to look at your screen safely, you can try to look at those and try to remember them because I'll ask you them a little bit later. Another part of the cognitive test includes uh doing digits backwards. So you'll start with a string of three digits and then have them repeat them back in reverse order. So for example, if I say 719, you would say 917 and then you'll go through that and gradually increase the string by one number and then see if they're able to get that correct or not. And then you have them say their months in reverse order, starting with the last month, go to the first month of the year. And then for the child scout or the child scat uh since they may not know their months, you do days of the week after those cognitive tests, then you move on to the physical exam. So this includes doing a thorough cervical spine and neurologic exam, evaluating the cranial nerves and looking for any focal neurologic deficit. And then another recommended thing that was added to the code is checking orthostatic vital signs because we know in some patients that have sports related concussions, they've experienced more autonomic type symptoms. So, you know, when they change postures, they may get lightheaded or have their heart flutter erased, right. So, checking orthostatics can also be helpful and is now recommended some additional exams that we usually do, which is a part of this scope includes the modified balance error scoring system or the modified best. And basically what you do is you evaluate their ability to balance in three different stances and I have it listed here. Uh I always get comments. This is unfortunately not my doppelganger. I'm not that ripped, but I can only hope to be at some point in my life. But um the three stances you do are with both feet together with standing on 1 ft and then with 1 ft in front of the other and they balance in those poses with their eyes closed and their hands on their hips and as you watch them do this for 20 seconds, obviously, you wanna make sure that you're nearby in case they fall, right? We don't want to have a concussed person fall, but you're looking for how many errors that they get during that 22nd period. And an error is defined as opening their eyes. If they lift their hand off of their hip, if they put their foot down while they're balancing, or if they shuffle one of their stance, foot or legs, um those are all considered to be an air and so you'll tally those up and do them in all those different stances. There is the option of doing it on an uneven surface. So in this picture here, it's showing the person doing it on an Airex pad in clinic, you can use a pillow. This is really meant to be used for athletes that have incredible balance, right? So if you think of a gymnast that has really good balance at baseline, they may have the worst concussion in the world but is like rock solid when you test them on their balance exam just because they have such good balance and um to make it more challenging, you can add that uneven surface. I would say though my clinical practice, I rarely do that. Um because often when they're concussed, I typically will even defer this because they're too unsteady to do it. After you do that, you can do a time tandem gate. So basically having them walk over a 3 m long distance and then timing the amount of time that they take to do that. And then you can move on to the uh vestibular ocular motor system screening tests. And basically what this is is it's a way to look at the vestibular and ocular system in five different ways. And I think this is actually a really, really helpful thing to learn and to incorporate into your physical exam. Um The first thing that you will do is smooth pursuits where you basically have them follow or track your finger moving horizontally and vertically. So kind of similar to the age test as they do these exam tests, you really are asking them if they develop any symptoms. And in the literature, it specifically asks for headache, dizziness, nausea or fogginess, ok. Um After you do smooth pursuits, you do horizontal and vertical, sad. So you hold your fingers out about 3 ft apart from each other and then have their head fixed, but look as quick as they can side to side at your fingers or up and down at your fingers. The other thing that you can do is called the horizontal vestibular ocular reflex. And if you're sitting at your desk, uh you can also practice this. Um, but basically what you do is you have them either look at a popsicle stick or put their thumb straight in front of them and stare at the back of their thumbnail and then turn their head side to side or left to right and then up and down as well. While fixating and staring at their thumb, you can do near point convergence where you look at a 14 point font on a popsicle stick and have them slowly bring it towards their nose and then stop when they see two and then measure the distance from the tip of the nose to where that popsicle stick is. And then the last one you do is the visual motion sensitivity. So this again is where they're looking at a fixed object like the back of their thumb. But instead of their head turning, their whole body is actually gonna rotate side to side at about 70 degrees while fixating on that fixed object or while staring at that fixed object. Again, you're just asking to see if they develop any of those symptoms there. And why I like this is because we know that those that don't have any sort of concussion tend to have very few symptoms while doing this test. But um you know, certain ones like the more dynamic ones, the visual uh ocular reflex or the visual motion sensitivity tend to be the most predictive of having a concussion. If their total symptom score exceeds a certain number, it can increase your concussion probability by 50%. And then that near point convergence distance, if that's abnormal, that can also increase your probability that has a pretty wide sensitivity and specificity. But this is best when combined with those other components of the scope or the scat that we previously discussed. Ok. So I think this is a really helpful exam tool for you to try to all learn. Now, I would say it's similar to like when you learn the cranial nerves, when you're first learning them, it can seem overwhelming. But then once you do it regularly in practice that it becomes really quick to do. So after you do all of that, then you ask the patient, do you remember those 10 words that I told you to remember a few minutes ago? And then you'll see how many they can recall. And so if you tried to memorize those words, you can try to repeat them back in your head. Um, you know, it was like arrow jacket, pepper, cotton, saddle anchor, right? So, um, you can see how challenging that might be. There's some other optional components. So believe it or not, instead of a 10 word list, there's a 15 word list for recall. The previous scout actually did five words. But what we found was that there was a ceiling effect to that e especially if someone had had a concussion before they, and they had been through this, they would memorize the word list. So, you know, I would say like elbow and then they would just say elbow apple carpet saddle bubble because they knew the word list, right. So, uh, the 10 word list is hopefully going to alleviate that ceiling effect and then there's other things that you can do as well. Um But for the sake of time, we won't go through them for this talk. So that's all for my part. I'm gonna, um, pass it off to my colleague, Warren Small who will, uh, talk about how we return athletes to both learning and to activity. So, ok. Um, do you want to, uh, do the slides or do you want me? I'll answer for you. Just let me know. Ok. All right. So, um, there's two parts to concussion recovery. Uh, number one is, and obviously the most important because we're dealing with student athletes is the return to learn. Um, they need to be completely back to preinjury, learning activities and preinjury learning levels. Um, before any sort of sports clearance should be discussed. Second part is return to sport. So, um, once they are back into school full time and able to complete, um, you know, tests, homework, perform normally, then that's when you're can start discussing returning to contact sports type type situation. They are able to begin exercise while they are still recovering. That's one of the biggest changes that have been made in recent times is the, um, uh, is that we don't wait until they're symptom free for them to do any sort of physical activity. Um, but it is, um, there's got activity that does not significantly increase their symptoms. So that's the biggest difference. So for graduated return to learn and much like the other um, uh slide, uh having to do with like acute injury management, these are also on the CIF website. They have been updated fairly recently, I believe, um to uh go be in line with the newest consensus statement. Um, they should start by doing uh regular daily activities at home. Um It could be things like, um, reading if that's not both, if that's not bothering them significantly. Um, you know, helping with dishes, holding laundry, uh things that are relatively, um, you know, mild in terms of mental activity that is needed. Um, but that's still doing something. So they're not just sitting in their room in a dark room, not doing anything, just thinking about how they feel. Um, they start gradually increasing um activities. So they can, if they are able to, for example, read for 15 minutes, then um they can try reading for 30 minutes and go from there. Um They can also start doing homework that is um um like the easier type of homework, the homework that doesn't require a whole lot. Um when they start doing school activities, they may be able to start, um, you know, doing something that's a little bit more challenging that does require them to think but doesn't require like concentration for extended periods of time. Again. They should be starting with like 15 minute increments and increasing as they are able to, they may be able to tolerate some subjects more than others. Um That's not an uncommon thing uh when they're able to tolerate cognitive work. Um And we're talking within a few days, they really should be, should be discussion about return to school at least part time. Um We do not want to hold them out of school for extended periods of time more than, you know, a week or so just, and that's a week is honest on the longer side because there's also the social aspect of school and the getting back into normal life and sleep schedules and everything that goes along with that. Um When they are back at school, they may not be able to do very much. They may just be in class, sitting, sitting and listening, um have and having a note taker or getting notes from someone else. Uh not taking any quizzes or tests, but essentially just being involved in the school day. Um And as they are able to, again, increasing um levels of um academic activities as they can tolerate them and then finally returning to school full time. Um This ideally, you know, should be again happening within a relatively short period of time. Um Well, we're talking a few days within each other, the return to school full time may be a little bit more challenging, especially for some um students. And so part time is better than not at all. Um But there is the whole idea of they need to be back in school full time. They need to gradually start doing things like quizzes and tests and um taking notes while also listening and some of those things that involve multiple different like multitasking type activities. Um and they need to be back to full academic activities prior to returning to any sort of sports competition or contact. Um So that's key for understanding kind of when the timing of that should be happening for accommodations. Uh The the goal of accommodations is to allow them to get back into the school day and the schedule and everything like that while also limiting the exacerbation of symptoms, it is ok if their symptoms increase a little bit as long as it's not for an extended period of time. And it's not something where they are doing so much one day that they aren't able to do anything the next um so, but things like partial days or maybe, for example, they have a class that is, you know, they have pe class or orchestra or something that is going to exacerbate the symptoms. Then maybe during that period of time is when they go to the library or the nurse's office or something else in order to take a break, um when they start returning to all of their classes, um taking breaks every 15 minutes or so, just, it could even be standing in the back of the room. It can be going out and getting a drink of water coming back, those sort of things. It doesn't need to be significantly long break, but it's breaking up that period of time where they're having to concentrate, um, testing. When they begin testing again, they may need to take more breaks. They may only be able to do part of a test at one time. Um, they may need to be doing tests on uh, like written exams rather than doing a Scantron. The Scantron may be too much. There's all sorts of different um, uh, accommodations that can be made. This form again is on the CIF website, I highly recommend using it. The teachers really prefer this sort of form because there's just check off boxes versus them having to read a paragraph or whatever from a doctor saying what they can and can't do. But it's specific enough that the teachers are able to understand kind of the, the reasonings behind and like why we're doing, um, the accommodations that we're doing and what they found, what is one of the highlights of the most recent um, concussion statement is that resting and not doing anything. The whole cocoon therapy thing is not effective for sports related concussions, um or most concussions, like at least the cut, you know, it may be from an NBA or something like that. But again, still same idea, the strict rest is not, not ideal. Um, it's good to do light intensity physical activity. Um, things like going for a walk as a family, um, uh riding a stationary bike and kind of a low intensity, those sort of things um are actually very helpful with facilitating recovery, increasing blood flow, um kind of giving them something to do. It all is actually very helpful. So prescribed sub symptom, a aerobics exercise can start, um, 2 to 14 days after a sports related concussion sooner is better. Um, and it can actually improve how long it takes to recover. So it can be four days sooner. Um, on average, uh for, um, returning to like full clearance and everything like that, which four days of getting back to school sooner and getting back to sports sooner is certainly something that most of these kids are, um, wanting and needing to do and finally just, um, using their heart rate to determine their activity is a key part of, um, uh the type of activity. So there is again forms on the CIF website that talk about what light physical activity means in terms of heart rate, immediate moderate physical activity, as well as strenuous physical activity once they are back in. Well, so first we can start with the early symptom limited physical activity. And what symptom limited means is that instead of saying if you get any increase in symptoms, you need to stop. It's, if you are doing the activity and there's a slight increase in symptoms, that's ok. No more than two points out of the, the, uh, 10 point scale. Um, and it shouldn't last for more than an hour. So if they're trying to figure out whether they're doing too much, if their symptoms or increases more than two points, or if they're still feeling those increased symptoms after an hour, then it probably was too much for them to do. And they may need to take a step back, does not mean going back to absolutely no activity. It means going back to the last place where they were not having a significant increase in symptoms or symptoms that lasted for a longer period of time. And this is another chart, um, showing graduated return to sport. Um, the idea being is that the top top three are all things that are, they're able to do while they are still also returning to school. They sh and they should not begin doing any of the high intensity training drills or anything involving another athlete beside like maybe one other person until they have come back to see you and gotten written clearance, um, from a physician or um, uh NPP A that has been trained in the management of concussions. Um, because that is when there's higher risk. So at the same time, they're doing step one of return to learn, which begins to about 1 to 2 days after the concussion. Um, injury occurs, they should be beginning to do start doing some form of light physical activity. Um Also getting kind of back into the normal swing of things and then increasing. Um, this is what else about what the heart rate um, of starting with light, which is about 55% of max heart rate and then if that goes ok for a few days, then adding it up and going to moderate, which is gonna increase the heart rate more. Um, explaining to them that if they do they go up and it does significantly increase their symptoms or their symptoms last a while, that doesn't mean they're causing more damage or that it's going to extend the length of their injury. It just means that they did a little bit too much. It's ok. We're gonna take a step back, wait a couple days and then try again and then for individual sports specific exercise, this would be possibly working with the team depending upon, um, you know, the kind of team it is in the in the, you know, control the coach has over everything or also potentially um spending some time working on sports exercise with parents or one or two teammates, friends, siblings, that sort of thing, just to begin to add in change of direction, head movement, all those things that may cause um an increase in symptoms but doing it in a controlled manner. Um and they can continue to do this with symptoms after this point in time is when they should be symptom free and fully back into school, um before they progress past this stage. So once they're back to full sports, they have written clearance from their health, the excuse me, appropriate health care provider and it's very important to understand the written clearance is required by law. Um So whatever sports, um uh like authority that they are uh participating in, whether it's the high school, a club team, a recreation team, whatever the uh they need to have a written clearance note that they can give to their coach, their athletic trainer, their athletic director, whatever, whoever the person is that is kind of in charge of concussion management at um their specific team um before they can begin the non contact training drills including multiplayer drills, passing drills, things where they're with more people. And there is um an increased, you know, level of um activity that's going on. Uh If they get any symptoms when they do the noncontract training drills, then they need to return to step three, pause, couple days and then trying again. Um, the reason that we don't have them, they need to be symptom free before they start. This is because while the most, like it's less likely that they're going to injure themselves, they could potentially get hit in the head again. And we don't want to do that while they're still having symptoms. The whole business is that by now, they should be feeling back to their like normal selves. And then after non contact, then we're looking at full contact practice, which does, of course factor which sport they do does matter, um, if they are a collision, sport athlete. So football, rugby, um, uh, ho ice hockey, those sort of things, then it's recommended that they do a partial contact or like a, not necessarily scrimmaging or full contact practice, but doing a practice where that involves pads and more of a control contact and then doing another practice with full contact before they do any sort of competition or, um, uh, you know, involving members of other teams or like the highest risk activities. And then finally returning to sport is last step. Um, that is them not having any symptoms with any sort of physical activity being back in school full time, um, and doing their normal level of academic activity. And, um, then it's essentially they are cleared to return to play um and they're back to their normal selves. So there's California laws that have been in place and need to um be followed. We always like to make sure that everybody is aware of what they are, uh return to play cannot be sooner than seven days after the evaluation or diagnosis of a concussion. Um, and they have to complete a graduated return to plague protocol. So if someone gets a concussion on Friday night, they see their primary care doctor or a member of their staff on Monday, that is the date of diagnosis. It is not the date of the injury. It's going to be a minimum of seven days from that date. And they have to also complete that return to play protocol that we just went over in order to return to full sports participation. So they must receive a written medical clearance from a physician. Um, this is a key part because we really need providers to understand that we need that in writing. Um, and this student athlete needs to be able to give that to whoever the appropriate person is at their club or school. Um, and that also just because they may be symptom free, it may be a week, whatever. They still also have to complete that entire graduated return to play protocol. Uh, I'm in the meeting. Oh, he's in walt. Mhm. Sorry. Um, and then, uh, all, um, youth athletes must receive education, um, every, they must receive education, um, uh, question information sheet every year, all youth sports coaches must achieve training every two years. And if a youth athlete, meaning anybody under the age of 18 is removed from activity for a suspected concussion, they must notify the parent guardian, they cannot return the same day. Even if, for example, it's an all day um, tournament, they go to the emergency room, emergency room says, no, you don't have a concussion. They still cannot come back and play that same day. Um But notifying the parent or guardian is an essential part. And uh depending upon who is um, there uh covering the game from a medical standpoint, they may or may not be able to, um, uh, like give them do a full evaluation. If there's an athletic trainer there, then great, um, or anything along those lines. But even if, um, they are seen by somebody on the sidelines, still, they still are not allowed to return to play the same day. And the ultimate question, the question we get all the time, um, is, when can I play again? So it's making sure that they understand that there's returning to preinjury learning activities uh without any more accommodations, um, or any symptoms, they have successfully completed the return to play protocol, then they will have clearance for unrestricted athletic participation. And we have a thing again. Um, and it's important for parents to understand this kids to understand this, um because it's not going to be a, they're gonna, if they play, if they injure themselves on a Friday night football, they are not gonna be able to play in the next game. Um, we're normally looking at at least a couple weeks of recovery before they're going to be ready to, um, do any sort of, um, return to competition. 2 to 4 weeks is generally kind of the, the time frame, um, of an, the average concussion recovery um including the return to play and everything like that. So it is not something where they can get cleared and return the same day or the next day. I also recommend if you see somebody and they're having symptoms but doesn't appear they have a concussion that they still should follow that same return to play protocol before returning to sport just to be safe. Great. Thanks Lauren. And um you know, just to wrap things up here, we talked about the definition of what a sports related concussion is and went through some of the epidemiology. Hopefully, you all found some of those new tools to be helpful and you can incorporate some of those into your clinical practice. And Lauren did a great job going through both the return to learn and return to sport protocols. You know, I think those are really helpful to provide to your patients because it gives them a framework uh to look after, right? Because often I know Lauren said the cocooning method isn't effective, right? So we know like go crawl in your dark hole and don't emerge. So, or symptom free isn't the best thing. Um, but then, you know, what guidance are you gonna give or you gonna say? Yeah, well, once you feel up to gradually return back, you know, that's really open ended for them. And so having that protocol can give them a little more structure and guidance on how to do that. Uh We'll share the slides with you all. But uh this is a QR code that has some additional resources and references. Um as we mentioned in our talk, the CAF website, I think is a really excellent resource. They also have resources available in Spanish there. So if you have Spanish speaking patients, um you know, there's stuff available there for them as well too and then uh just a plug for our sports concussion program here with Benny Off Children's. We have a multidisciplinary team with uh Doctor Watkins who's a pediatric, trained primary care, sports medicine physician myself, who's family medicine, Doctor Eric Fritch, who's a neuropsychologist and then Lauren Small. Um We also have clinics in the West Bay or in the city through U CS F. Um Can you put the code back up? It's a separate concussion program there. But uh you know, those are all things that um we're happy to see and uh definitely reach out if there's stuff that we can help out with
