Focused on the needs of children and adolescents, this guide from Nicolas Hatamiya, DO, clarifies definitions of sports concussion; explains what’s known about the pathophysiology; offers numerous tools, tips and resources for evaluation and patient education; and describes how to guide patients through recovery, including offering a likely time frame and techniques for stepping up activities to ensure a safe return to play.
Well, thank you for the kind introduction and thank you all for joining. I know it's uh after your work day and wet and rainy outside. So, um, I appreciate you joining. My Zoom was lanky earlier, so I apologize if it continues to be so, but hopefully not. Um, so, today I'm gonna be talking about sports, but concussion, and I wanna really focus on giving you some keys for primary care. I am a primary care sports medicine and so I'm family medicine trained, and then I did extra training in um sports medicine, and this is something that I see in my office as well. So I have no relevant disclosures. And so for today, we're gonna be defining what a concussion is. Hopefully, by the end of this, you should understand the pathophysiology and epidemiology. Uh, you should be able to explain how to do a sideline evaluation. And I understand that, you know, many of you may not cover, um, any sort of events, but I think it's important to understand what happens on the sidelines before the athletes come to see you in clinic. And then familiarize yourself with different tools to evaluate a concussion. Understand what the typical timeline for recovery is for these concussions, and then feel comfortable prescribing a return to learn and return to play program. So, let's start with the definition of a concussion. So, what is a concussion? The broad definition is a sports-related concussion is a traumatic brain injury induced by biomechanical forces. And let me grab my little laser pointer here. So, this is the definition that's based Off of our last big consensus paper that was quite old, it was in 2016. And they usually meet on a four-year basis, but because of COVID, they delayed that, and they actually just met in Amsterdam back in October, so we'll have a new consensus statement coming out soon. But the broad definition, I don't think will change much, so that's what the broad definition of a concussion is. Now, if you look at the more comprehensive definition, we know that a concussion may be caused by either a direct blow to the head, face, or neck, or elsewhere on the body with an impulsive force that's transmitted to the head. This typically results in rapid onset of short-lived impairment, uh, mostly of neurologic function that resolves spontaneously. But in some cases, these symptoms may evolve over a number of minutes to hours, which I'm sure you've all seen if you've taken care of a concussion patient. Uh, we also know that it results in neuropathological changes, but the acute clinical signs and symptoms are mostly a functional disturbance rather than a structural injury. And so, if you ever get any neuroimaging, there's likely no abnormality that's gonna be seen on that. And concussions result in a wide range of clinical signs and symptoms that may or may not involve loss of consciousness. And this is something that's really important because back in the day, we used to say, well, you didn't get a concussion cause you didn't pass out, but we know that that's not necessarily true. And resolution of these features typically follows a very sequential course, which we'll go over. And in some cases that can be prolonged, and those are some of those more challenging concussion patients that you may see. And what's really important is that uh concussion, any of the clinical signs or symptoms shouldn't be otherwise explained by other things like drugs, alcohol, medication use, or other injuries or comorbidities. So, that's the broad definition and then the comprehensive definition of what a concussion is. Now, let's talk about some of the pathophysiology and the epidemiology. So, how does a concussion happen? So we talked about the mechanism of how it happens, and, you know, we honestly don't really understand completely how a concussion happens, and most of our understanding is from animal models. But what's theorized is we know that there's a force that happens to the brain. This results in axonal shearing. And this axonal shearing leads to an indiscriminate release of neurotransmitters. So we have indiscriminate release of neurotransmitters at those axons. What this leads to is a complex neurometabolic cascade. So, we have mitochondrial dysfunction, reactive oxygen species, and unchecked ion influxes, which this graph illustrates here. So, this shows you the percent of normal of each of these different ions over minutes, hours to days, and you can see that quote unquote, indiscriminate release of all of those different ions. And what this leads to is this mismatch that occurs, and you get this period of vulnerability after this acute concussion. So, those, when we get those unchecked uh ion influxes, what our body wants to do is try to maintain homeostasis, right? And in order to maintain homeostasis, we need energy. And for energy, we get energy from glucose. And so, we know that in that acutely concussed phase, there's a really high demand for glucose because of those unchecked ion influxes. But at that same time, there's a decrease in cerebral blood flow, and that leads to that mismatch, which further leads to this energy crisis that we feel precipitates the symptoms that result in a concussion. Now this is just a very Obviously, simplified version of what happens, uh, but it's in a nutshell of, you know, what we suspect happens during a concussion. Now, let's talk about some of the epidemiology. So, it's estimated that around 1.1 to 1.9 million sports-related concussions occur annually in the US. This is in children specifically who are 18 years or younger, and it's using emergency room data and a bunch of other health surveillance data. And this is likely an underestimation because some symptoms may not seek care, so those um surveillance systems don't really capture those who never sought care for a concussion. What's interesting though, is that there's been an increase in concussions seen, um, and this is older data, but from 2001 to 2009, there's been about a 61% increase in concussions reported. And this is largely likely due to an increase in education and understanding of what a concussion is, both from patients and providers. Here in the United States, some more recent data shows this is broken down again for younger populations, um, but The most predominant age group that we see sports-related concussions are in that younger, uh, teen age, so 12 to 17 years old, with, uh, less often in the younger age group. If you further break down that data, you can see that boys tended to have more concussions than girls. Uh, and then it's interesting when you break it down by, um, by, um, background that non-Hispanic whites had a higher percentage compared to non-Hispanic blacks, Asians, and Hispanic populations. And while there may be underreporting, uh, or that may be the data, we also know that there's some health disparities that exist around concussions. So, um, schools who have athletic trainers tended to have a greater number of athletes diagnosed with a concussion compared to schools without one. just out of curiosity, uh, you can just nod your heads cause I can see some of you on Zoom. How many of you know what an athletic trainer is? Nod yes or no. OK, I see some mixed reactions there. So, athletic trainers are really great, uh, allies to have. Um, they are basically, um, healthcare professionals that are in a bunch of different settings. So high schools, um, with professional teams, college teams at all levels, and they're trained at providing care for musculoskeletal injuries and focusing on injury prevention for athletes. And they're really great at helping. Manage concussions in athletes. Unfortunately, California is the only state in the entire United States that does not recognize athletic trainers as being certified healthcare professionals, um, which causes some issues for us in concussions, which I'll talk about a little later. But if you ever see a patient who is in high school or even in college that has a concussion, I would ask if they have an athletic trainer because they'll be a great ally for you to have. Um, some other health disparities are that white athletes had more knowledge of concussions and symptoms compared to African Americans, except those who had access to an athletic trainer. So another big plug for athletic trainers. And then African-American children are significantly less than their non-Hispanic white children or counterparts to present to the emergency room for a concussion. And interestingly, they're also less likely to be diagnosed. And then concussed children are more likely to receive academic support if they have commercial insurance or if their parents' primary language was English. So, um, you know, I think this is really important in a big growing area of research, especially for us in the primary care sports realm, uh, and important to keep in mind in context of those, uh, epidemiologic, um, numbers that we saw earlier. So now that we have an understanding of what a concussion is, how it happens, and uh some of the epidemiology, let's just talk about some sideline evaluation and what happens on the sidelines or when someone sustains a concussion and they're seen by somebody out in the field. And I'd like to start with a case. So let's say that uh we're at a high school football game, it's near the end of the 2nd quarter, and the 16-year-old star running back gets tackled. He's slow to get up, the athletic trainer runs on the field to evaluate, clears him from a neurologic standpoint, and feels he's fine to come off the field. But when he comes off, he says that he has a headache, he's very sensitive to the light and sound. The coach yells, shake it off, we need you. You're a star running back. And then he looks at you and says, Is he good to go back in? So, what are your next steps if you encounter this? Or what do you think that individual should do? So when we talk about sideline management and evaluation of concussions, um, the first thing you wanna do is evaluate your CABs or as I learned it, ABC's back in the day, right? Airway, breathing, circulation. Do a secondary survey to make sure the scene is clear and safe. Uh, and also that there's no other injuries. And then obviously, you want to evaluate the cervical spine and rule out any sort of head bleed. If there's any concerns about that, then usually the emergency action plan is activated. But if there's no concerns, then we proceed to do a sideline evaluation. On the sidelines, you may have seen if you watch any college or professional sports, there's usually these little tents set up where the um athletic trainer and physician can go in there to evaluate the athlete in a more private location or relatively private location, I guess you can say. But what I like to do is hold the athletes' helmets, remove them from play. And the reason why I hold their helmet is because uh it's a little better now, but, you know, kids historically would want to try to sneak back into the game. Um, so if you have their helmet, then they're less likely to do that. And then I really want to know what the mechanism of injury was. So did I see the mechanism of injury, or is there a video review available? Or, you know, in some settings there's someone called a spotter who is available at the game to specifically look for concussions or impacts that might be concerning for a concussion. So talking to them will be really helpful. Then I do a neurologic exam, mostly to rule out any cervical spine injury or any serious intracranial pathology. And then another thing I like to do is ask what are called the Maddox questions. Now, these are a series of memory questions that have to do with the game and the situation that they're in. Uh, I'm a Cal Bear, so I always like to show scores of Cal beating Stanford, Go Bears. Um, but these questions are, you know, easy ones that you would think of. So it can be as easy as, you know, What venue are we at today? Do you know which half it is now? Who scored in this last match? What team did you play last week? Or did your team win the last game? And for a lot of these, if you don't know the answer, just remember you have the scoreboard to look at, and you'd be surprised that many athletes always forget they can look at the scoreboard. But this is the quick assessment that I usually will do on the sidelines. And if there's any doubt in your mind whether the athlete has a concussion or that individual has a concussion or not, sit them out. So when in doubt, sit them out. And this is really important because we know that early removal from play uh can lead to quicker recovery. So this was a study that was published back in 2018 that looked at 30 universities and 4 military academies. So around 500 concussed athletes. And they basically asked two questions. So, number 1, did the athlete immediately report concussive symptoms? And then number 2, was the athlete immediately removed from play? And if it was yes to both of those questions, then they were classified as being in that immediate removal group, which is the dark line there. And if they had no to one of those questions, then they were considered to be in that delayed delayed. Uh, removal group there. Now what they found was that the immediate removal group, um, had a 39% lower likelihood of missing more than 14 days. And then an even lower likelihood, 47% lower likelihood of missing more than 21 days, right? So the general takeaway from this is that early removal from play can lead to a quicker recovery for concussed individuals. So now let's continue with that case. So let's say we've removed that athlete from play, we've updated coach, and we're monitoring the athlete on the sidelines for any development of symptoms. And it was towards the end of the 2nd quarter, so halftimes coming up. So, is there anything else that we can do? And the answer is yes, of course there is. So, usually what we do is further evaluation, specifically further neurocognitive testing. And this is best performed in a locker room or a quiet area, somewhere that's distraction-free, where we can really provide a comprehensive evaluation. And the tool that I always like to start with and use is Something called the SCAT 5. So SCAT stands for the Sports Concussion Assessment Tool, and it's currently in its 5th 5th edition. Uh, and this is designed for individuals who are over the age of 12 years old. Um, again, I can see your head, so why don't you just nod. How many of you are familiar with the SCAT 5 or have heard of the SCAT 5 before? OK, so kind of a mixed bag too. And this is something that we use both on the sidelines, but is um really helpful to use in clinic as well. So I recommend um trying to incorporate this in clinic or have your staff help you fill this out too. And the very helpful thing, so there's, you know, on the field assessment questions, but in clinic, these are things that are really useful, specifically the graded symptom scoring. Now, I mentioned that there's a wide range of symptoms that can manifest from a concussion. And so, basically what this does is it has the individual rate the severity. Of their symptoms. So you know, one, you know, what type of symptoms they're having and then 2, how bothersome it is for them. And so we'll take headache for example, they can basically rate how um bad their symptoms have been on a scale of 0 being none and then 6 being very severe and then they go all the way down this list of all these different symptoms that we see with concussions and then you total the number of symptoms they have and then the total symptom severity score. And this is something that's really helpful to, uh, to get as a baseline, or, you know, if you're a student athlete or whoever you're seeing was seen by someone like an athletic trainer, they may have filled one of these out, and then you can repeat this to track their symptoms over time, which is really, really helpful. The other components of the SCAT 5 include cognitive screening. So, one component is orientation, and I know this may show up small on your device or screen that you're looking at, but basically those are the simple like ANO times 4 questions that we ask people. And then it also tests for immediate memory. Um, and for this, you'll read them a list of words. Um, so, for example, I'll read them a list of words. We'll take this one that says elbow, apple, carpet, saddle, bubble, and then they have to repeat it back to you in any order 3 times. And then they'll have to remember those words, and I'm going to ask them that a little bit later for delayed recall and see how many of that word list they can remember. Um, so for you all who are listening, those are going to be your words to remember, elbow, apple, carpet, saddle, bubble, and I'm going to ask you that in a few minutes, so we'll see how many that you can remember. I will say that if you see an individual who's had a concussion in the past and may have gone through all of these word lists, they can spew out all of these in order to you cause they've memorized it. So there's also a 10 word list that you can use too, uh, which is a little more challenging. The other component of the SCAT 5 tests concentration, and this is looking at um having them repeat digits backwards. So, you know, you'll read them a string of numbers. So, for example, if I say 719, um they'll repeat it in reverse order. So they'll say 917, and you go down the list, and then it increases in the number of digits that they have to repeat back to you. And then the other component for concentration is having them say their months in reverse order, starting with the last month of the year and then moving towards the first month of the year. And if they get it all right, then that's normal, or you give them a 1, and then if they miss 1, then they get 0 points. Uh, and then we do a neurologic screen. Um, and a big component of this neurologic screen is something called the modified Balance Air Scoring System, or MBES testing. And, um, this is kind of what it looks like, and this isn't a photo of me. People always ask, I wish I was that ripped and buffed, but I'm sorry that that's not me. But basically, what the, um, modified balance scoring system does is it tests balance with their, um, Eyes closed, hands on hips, and they'll um stand in different stances for 20 seconds. So, they'll stand with their feet together, they'll stand on their non-dominant foot, and then they'll stand in tandem stance with the non-dominant foot in the back. And they're going to stand again, hands on hips, eyes closed for 20 seconds, and you're going to calculate how many errors they have in those 20 seconds. And those errors include opening their eyes, removing their hands off their hips. Lifting their foot off the ground, um, moving their foot out in AB duction or abduction, and, uh, you'll total those numbers up. So, you know, that's another helpful thing to do in clinic if you're able to. You can also do it on an unsteady surface, which is a little more challenging in the acutely concussed when their balance is all wonky and off. In clinic, you know, this is a nice AX pad, but in clinic, I just use like a pillow, one of the patient pillows, um, and have them balance on that. But I rarely do this. Most of the time, I just do it over the ground. And then the last part of the scat is that delayed recall. So, um, I don't know, you can try to repeat those, those words that I told you a few minutes ago and see how many you remember. Um, it can be really challenging, but they were elbow, apple, carpet, saddle, bubble. So you have the athlete or individual repeat those words back to you and see how many they can remember. And so you'll total up their total SCAT score, and um it's really helpful to get more objective measures for a concussion, and this is a very useful tool. Uh, but again, this shouldn't be used as a standalone test to diagnose a concussion or measure recovery. Um, there's really no great tool out there, but these are all things that can help guide your recovery and decision making as you go through it. I'll also mention, I don't know how many of you see younger kids, but there's also a, a child SCAT 5. So the SCAT 5 is used for patients 12 years and older, but if they're younger, then you can use the child SCAT 5. The only difference is it includes both the child and the parents' report instead of months. In reverse order, they say the days in reverse order, and then they don't include any of those orientation or Maddox questions. And then for the balance component, since they're not as coordinated, they don't do the single leg stance um when they're younger. So that's only for ages 10 to 12 or or older than that. Um, and these are all available free online. I have a resource slide at the end of my talk, um, but if you just Google SCAT 5, you'll see the British Journal of Sports Medicine has it, um, the American Academy of Pediatrics has it, and I think AFP has it up there as well too. The other test that I find really helpful to do in clinic or if I'm assessing for a concussion is something called VOMS testing or vestibular ocular motor screening. And this assesses five areas of the vestibular system as well as the ocular system. Um, again, shake of heads, how many of you have heard of this or are familiar with it? Yeah, not a lot. So, um, this is actually something that's really quick to do. So, there's 5 different things that we really test for. So, the first one is, um, smooth pursuits where basically, I'll have the, um, individual just follow my finger, kind of like your, um, cranial nerve age test that you do, but you just go in different directions and you're looking at, um, whether or not they develop any symptoms during any of these tests, specifically looking to see if they develop Any headache, dizziness, nausea, or fogginess, and then they can rate that on a scale of 1 to 10. But usually I just ask if they develop any of these symptoms or not. Um, so starting with smooth pursuits as they follow your finger around, you can see if they develop any symptoms and just document that. If they're able to tolerate that, then I move on to horizontal and vertical saccades. So basically what this is, and you can try this as you're sitting there, um, I put my fingers out, uh, partially. My hands are getting lost in my blurred background, but, uh, in front of the athlete about a little over a shoulder width apart. And then I have them look back and forth between my fingers as quickly as they can. And then, um, I also do that in a vertical fashion. So up and down, I have them look up and down as quickly as they can. And then again, ask if that um causes any of those symptoms that I had mentioned earlier. Uh, if they're able to tolerate that, uh, then I do near-point convergence. So, the textbook where the literature all says that there's a little 14-point font on a popsicle stick. So we have these already printed out, uh, in our clinic. And then you have them bring it as close as they can and let you know when they see double. And then you mark the distance between their tip of their nose to where that popsicle stick is and document that. And anything less than 6 centimeters is considered to be normal. And then the last two things, and you can try this as well, um, that we do are something called VR or vestibular ocular reflex. So this is where you can use the popsicle stick eyelash like to have them stick their thumb out and straight in front of them, kind of like this, and they stare at the back of their thumb, and then they turn their head back and forth at a rate of 100 beats, 180 beats per minute. And they're staring at their thumb, staring at their thumb. And if you do that, I mean, it is a little challenging to do, right? Um, but again, you're asking if that helps if, if they develop any of those symptoms. And then the last one is probably the most dynamic test. This is the vision motion sensitivity. So they'll, um, sit with their thumb out in front of them, and they're gonna rotate their whole body back and forth while staring at their thumb. Um, and, you know, this is something that may seem challenging to do, but it's actually pretty quick to do in clinic and you get a lot of useful information from it. And so, what we know is that those who don't have a concussion have very few symptoms with VOM's testing. And, uh, VOM's item that has a total symptom score of greater than 2 increases the concussion probability by at least 46%. And then that near point convergence distance, if it's over or equal, then equal to or greater to 5 centimeters, then it increases our concussion probability by 34%. Um, and, you know, I mentioned that our, uh, experts, concussion experts met recently, uh, in Amsterdam. I believe that they're gonna come out with a SCAT-6 soon, and I think that the bombs testing is actually gonna be included in the SCAT-6. So, um, again, another useful tool for you to use in clinic when you're assessing concussed athletes or patients. So now that we know kind of how to evaluate concussions and some of the tools that are available to help us um evaluate concussions, let's talk about how long it takes for recovery. So let's say, you know, we have that uh high school athlete, we evaluated on the sidelines and we diagnose them with a concussion. The first thing I like to do is give them a handout either to the patient themselves or to their parent or guardian. Um, this is from the California Interscholastic Federation. And it's a nice handout to give to the parents that talk about different things to expect for their um loved one, over the next 24 to 48 hours if they do have a concussion. And then it also gives some recommendations, uh, in terms of, you know, medications to avoid, what they can use, um, and then different resources for them to reference if they need to. And this is all available online too, if you look at the CIF website. So when we talk about how long it takes, I think it's really important to understand what the standard management for a concussion is. And usually it's rest for the 1st 48 hours. And what rest is defined as is getting adequate sleep, adequate hydration, and then optimal nutrition. So for those 1st 24 to 48 hours, you're just gonna have them do the basics of human function and try to recover as much as possible. So sleep, hydrate, and eat well. And a common question I always get is like, how long is it gonna take me to recover? And so we know that the typical recovery time for adults is around 10 to 14 days. And then children and adolescents, because their brain is still developing, can be a little bit longer, so up to 4 weeks. And then I like to always give counseling if it's a younger athlete, uh, and counsel the athletes and families, and this can go for really any individual that, um, you know, most patients who have a concussion, uh, don't have difficulties that last more than 1 to 3 months post-injury. And then Every person's recovery from a concussion, so every person's concussion is different. So just because they've had a concussion once doesn't mean they're gonna experience the same exact symptoms or recover the same or just because they had a friend who had a concussion doesn't mean that they're gonna follow that same trajectory. Every concussion is very unique. Another another question I always get is, you know, what is recovery? And really, recovery is defined by two key components. So, it's um return to learn or return to work, and then return to sport, or return to whatever activity that they want to do. And I always say that um for my student athletes, they first need to return to learn, and then return to sport. Or, you know, for uh more older individuals, they need to be able to return to work and doing their cognitive things before they're able to kind of get back to doing their activities. And so, uh, you know, how do we return athletes to school or how do we return them to work? The principles are generally the same. It's a very gradual graduated return to learn or work protocol. And uh there's really 4 different stages that we go through, and this is a very busy slide, so we'll kind of go through each one individually. So, the first thing that they should be able to do is just do their usual daily activities. So, their typical activities around the house. Um, they can try to start increasing some things like reading or texting or doing some screen time, but at very, very low amounts and then gradually build up that up over time. And as they're able to tolerate more of this, then they can kind of progress to the next step, which is doing, you know, Homework or reading or other cognitive activities outside of the classroom, um, at home, or, you know, doing some work stuff while they're at home. So that can include, you know, checking their work emails or trying to do work projects, um, at home before they go back into the work setting and try to increase their tolerance of that cognitive workload. Once they're able to do that, then they can go back to school or go back to work part-time. Um, so, you know, they can go back for a partial school day or have more frequent breaks throughout the day, and then slowly increase the amount of cognitive activities that they do. And once they're able to tolerate that, then they can go back to work or school full-time, and, uh, certainly catch up on any missed work that they need to do, um, or, you know, any, uh, tests or exams, um, that they may have postponed. And I think it's really important to provide academic accommodations and work accommodations for our patients that we're seeing. And for our student-athletes, I think it's especially important because we need to break that lazy athlete stereotype. And so there's a lot of areas of accommodations that you can provide either at school or in the workplace, which includes, you know, attendance, so having them off school in the beginning. Uh, or having partial days of attendance can be helpful. Um, writing them a note that allows them to have frequent breaks if needed, uh, or modifying their work so that they avoid any sort of visual or auditory stimulus, and then, um, obviously leaving them out of PE until they were, they're able to return back to, um, full physical activity. And then for younger athletes, there's a great resources again available on the California Interscholastic Federation website, and then templated handouts that are really nice where you can just go through and check off the accommodations that they may need. And then I'll, you know, I spoke about this a lot, but in California, the CIF is another great resource, and they also have stuff that's available in Spanish too. So, this is the QR code, um, and I hopefully you'll all get a copy of my slides, but um you can definitely use this as a great reference point. So now that we talked about kind of the return to work slash return to school, let's talk about how we return individuals back to activity. And this is very similar. It's a very graduated return to play. So there's, it's a stage protocol where they have very progressive return to physical activity, and then the key is they have to spend at least one day at each of these stages and then monitor for any symptom development. And then I'll also talk about uh some important laws that have been passed in California for our younger athletes. So if you're seeing anyone less than the age of 18 with a concussion, a sports-related concussion, um, they can't return to activity sooner than 7 days after being diagnosed by for a Being diagnosed with a concussion by a physician. Um, and they can only return after completing that return to play protocol. And, uh, certified individuals such as an athletic trainer or physician or an identified concussion monitor must sign off on each stage of the return to play protocol. So, this is important because, you know, I mentioned that athletic trainers can be really helpful and strong allies for us to Evaluate athletes for concussions, but unfortunately, because they're not recognized as a healthcare professional in California, they can't diagnose a concussion. So if you see someone and you're the first physician seeing a younger athlete, then just know that even though they're symptom-free, if you're the first physician that's seen them, they can't return back to any sort of activity per California law, uh, any sooner than 7 days. I'll also mention that uh all coaches in California have to receive training on concussions, and there's a free course available through the National Federation of High School Associations. So now let's talk about what that gradual return to sport looks like. So again, another busy table, but we'll go through it individually. So after that 1st 24 to 48 hours of rest, um, then they're, they're cleared to do what I call symptom-limited activities. So this is just the reintroduction of normal activities of daily living. So they can walk, they can go do things around the house, and their symptoms should not worsen with any sort of activity. If they're able to tolerate that, then they're cleared to do light aerobic exercise. So this includes walking. I like doing stationary biking, um, something that can get their heart rate up a little bit, and they can monitor for symptoms. The reason why I like stationary biking is because it's a very controlled environment, right? So, um, they're sitting, they're still, and they're just Essentially doing cardio. A treadmill can be helpful, but a lot of times on a treadmill, there's a lot of head jostling going around. So if they're concussed, then that can cause them to have worse symptoms. And then running over ground, you know, they get a lot of that visual stimulus coming in, and we don't really want people to bike or run outside in case they fall or have something happen cause we want to avoid that repeat head head impact. Um, and basically, they're able to do this as long as they're not worsening or developing any new symptoms. And if they're able to tolerate that, then we clear them for sports-specific exercise. So this can be, you know, running or incorporating more cutting drills or anything that is, uh, sports-related and, and more related to whatever activity that they're doing. After they're able to do those sports specific exercises, then they are cleared to do non-contact training drills. So, if they're a part of a team, then they can resume joining practice, but only participate in non-contact drills. Uh, they can also start doing, um, resistance training at this time. So weightlifting. So if they do a lot of weightlifting, then you can say, yeah, you can try going back into the weight room. I tend to have them avoid doing more dynamic weightlifting things or, you know, like HIIT exercises, which includes like burpees or stuff that makes their head go on multiple levels. I have them start with just very basic weightlifting things first. Once they're able to tolerate that, then they can go back to full contact practice or full contact activities. And um the biggest part here is really to assess their psychological readiness. So if they've been out for a while, or, you know, for that, you know, high school athlete I gave the example of, if he had a really bad head impact, he might be more afraid or timid to go back into the game. So, really just kind of talking to them to see if they feel ready to go back to doing full contact is something that's really important. And if they tolerate full contact practice or whatever activity they're doing, then they're cleared to go to return to sport. Um, so that's kind of the protocol that we go through, and this is, uh, outlined on the CIF website. And, um, I also have dot phrases that I use for my patients, which is really helpful. So I'll put that in their ABS so they have something to reference and kind of go through. And again, this is where an athletic trainer is really helpful if they're available because they can walk the student athlete or that individual through this whole process, but certainly you can do that as well as a physician. So the other big question I always get asked, uh, is, you know, when can I play back in the game or when can I fully go back? And so, in order to go back to playing the game, I say they have to first complete that graduated return to play protocol, and then be back in school or work without any symptoms, and then they're cleared to return back to the game. So that's kind of what I say to all of my student athletes or people that I see for concussions. Now, I'd like to just talk about some of those athletes who have more persistent symptoms, which I know can be very challenging. So, I'll talk about another case. So, we have a 21-year-old collegiate female water polo player who suffered her third concussion about 4 weeks ago. She has a history of two prior concussions that were uncomplicated, and she's just had a persistent headache with mental fogginess and difficulty concentrating. Um, she's able to tolerate her schoolwork without any breaks, but she hasn't been able to progress to any sort of physical activity. Um, she has a normal cervical spine exam, normal neurologic exam, and her vestibular ocular exam is normal as well. So in this case, this um individual has what I call persistent postconcussive symptoms. Uh, and what that's defined as is any symptoms that last longer than 2 weeks in adults and then over 1 month in children or adolescents. And for these particular patients, if you encounter these in your clinic, you may consider referring them to a multidisciplinary concussion clinic. So either myself or my colleagues, uh, or another concussion expert just because it can be a little more challenging to take care of. Um, but if it's a more acutely concussed patient, then certainly, you know, you should see them sooner. Uh, and I, the interval I usually see those patients are at is every 1 to 2 weeks. And so for these more persistent prolonged type patients where they have symptoms that are lasting for a while, I like to evaluate for a concussion subtype. And this is an emerging concept, but basically what we do is we look to see if there's a speci a specific bucket of symptoms that our patients um Our concussion patient tends to fall into. So, you know, largely this can be like more vestibular type symptoms or ocular symptoms where their vision feels off or their balance is off. It can be more cognitive-related where they have that persistent mental fog or they're not able to really get back to any of their schoolwork or, you know, work in general. Uh, it can be more headachy or like neck pain or a combination of both. Or, you know, mental health is a huge thing too. So maybe it's more anxiety and mood-driven. Um, and based off of this, we tend to try to specialize their care depending on these domains, and I have some examples of this afterwards, and then refer out, uh, to specialists if necessary, um, based off of this. But, you know, more research is warranted on really how to address this area. And this is challenging too, because, you know, concussions have many overlapping clinical profiles. But again, I think the biggest thing is really to identify that predominant physical sign and symptom, and then try to put it in, in some sort of bucket. Um, I'd like to draw your attention to this article. This is a really interesting article that was published a couple of years ago now that looks at, um, the practical management of concussions and how to do a very brief physical exam, um, for sports-related concussions in the outpatient setting. So, a really great article. Um, and what I like in regards to these persistent concussive symptoms is they really break it down into four big concussion subtypes that I really Think of in clinic and I think that this has been really helpful for me. So, you know, we talked about those more cervicogenic patients where they have, you know, neck pain and then they have what we call weight exercise intolerance. So that means they're able to get up to about 70% of their heart rate, um, and then start getting symptoms. Um, and this is contrasted to early exercise intolerance where they really can't get their heart rate at all before developing symptoms. And, you know, those types of patients may have more mood type symptoms, uh, with emotional ability or have really bad anxiety or depression. There are some patients that have more autonomic or physiologic symptoms that persist. Um, those can be kind of non-specific, but often they'll have like positive orthostatic, so they'll feel lightheaded when they get up or the classic things we think of, or just have like profuse flushing and sweating, um, that occurs. And then there's more of the vestibular ocular type, which I see quite often in clinic where they have, um, a lot of vision issues and dizziness. And so it's helpful to think of those buckets like I mentioned because we could target our treatment. So for the cervicogenic type, um, I often refer them to physical therapy to help with some soft tissue and range of motion and different exercises. Uh, and then I also recommend them doing submaximal aerobic exercise to help with their symptoms and recovery. For that vestibular ocular bucket, um, I refer them to do vestibular ocular therapy. So there's some great vision specialists here in the Bay Area that can help with that. And a lot of physical therapists who are well versed in managing, um, concussions can help with, um, vestibular ocular therapy as well. And then again with these types of patients, I like to prescribe submaximal aerobic exercise. For the mood type patients, and obviously all of you in primary care are very well versed in this, unfortunately. Um, but, uh, it can be really challenging to deal with this and really takes a multidisciplinary team and individualized therapy. Um, so referring them out to a therapist or mental health providers, uh, is what we tend to do. And then again, prescribing that submaximal aerobic exercise. And then that last bucket for the more autonomic or physiologic type symptoms, uh, we just tend to prescribe submaximal aerobic exercise. So you're probably thinking like, well, that's all great, but like, what's the deal with this submaximal aerobic exercise that you're talking about? Are you crazy? Um, and we know that, you know, exercise can actually be helpful for concussion recovery, which is counter to what we used to think. So, we know that exercise has been Beneficial effects on the autonomic nervous system and can help with cerebral blood flow regulation. And then, um, it also facilitates brain neuroplasticity, specifically with cortical connectivity and activation, and it can improve our spatial memory. And the reason we think this is because during exercise, you have an increase in BDNF or brain drive neurotrophic factor, which is used for neuron repair after injury. And so, um, there's been a lot of research coming out of Buffalo from, um, Doctor Leddy, uh, and he created this, uh, buffalo concussion treadmill test, which is a validated test to measure the amount of aerobic exercise that's safe to perform, even in that acute phase after a concussion. And the goal of this is to really identify a sub-symptom threshold. So, basically, the level of activity that they're able to do without developing more symptoms, um, so that they can participate in some sort of physical activity. And so how this looks is, um, we put the patient on a treadmill and physical therapists can do this too. And they gradually increase the exercise intensity. And during this time, they're taking serial measurements of heart rate, blood pressure, and the rating of perceived exertion every 2 minutes. And then they also ask for any development of symptoms. And then they stop once the patient develops more than 3 points of uh symptoms. So they get a point for every worsening symptom and then a point for every new symptom. So once they have 3 or more, the test is stopped and then they record what heart rate that occurred. And we use that heart rate to help tailor uh exercise program for them. So how we use the buffalo concussion treadmill test is we identify what that symptom-limited threshold heart rate value is. And then we have them start doing some aerobic exercise at 80% of what that identified heart rate was. And we start with a little lower time, so around 15 to 20 minutes. And then we gradually increase that target heart rate over time by 5 to 10 beats per minute. And then we continue to repeat that process until they can achieve around 85 to 90% of that heart rate value without provocation of any of their symptoms. And once they're able to do that, then we can continue down that return to play protocol. So, if you remember that table I talked about earlier, this is Kind of between stage 2 to 3. So stage 2 was when they're able to do that stationary biking and then stage 3 was when they were cleared to kind of do more sports-specific activity. So if they're stuck in those stages because they're going out and exercising and getting really symptomatic, then this is a really helpful way to kind of fine tune and tailor that. And we know that the sub-symptom threshold aerobic activity can help uh with concussion recovery. So this is the Kaplan-Meyer curve. This is a study that was published in 2019 that looked at the difference between aerobic exercise, so early aerobic exercise in concussed athletes, and then um athletes who just got a stretching program, so no, um no aerobic exercise. And what they found is that The, um, aerobic exercise group was able to recover on an average of 13 days, uh, versus the stretching group took a little bit longer, so around 17 days to recover, which was statistically significant. So, the general takeaway from this study is that the exercise group had a quicker recovery than the stretching group. So, another plug for why, uh, aerobic activity, uh, especially early on can be helpful for concussion recovery. Uh, so in summary, I know we went through a lot of things. So, um, we talked about the definition of a concussion and some of the, uh, path of physiology and epidemiologies of concussion. We talked about, you know, how sideline evaluations occur and kind of what goes on before some athletes may see you in clinic. Uh, we went over some of the common tools that you can use to evaluate a concussion and help you manage a concussion in clinic, uh, namely the SCAT-5 and the BOMS testing. Uh, we talked about what the typical timeline for recovery is, and then how to prescribe a return to learn or return to work, and then a return to play program. I want to leave these resources in your slides as well. These are the two position and consensus statements that we have. And again, a new one should be coming out soon. And these are free, available online. Uh, the CDC Heads Up has a really great website with great resources for you and for patients to look at. Uh, the University of Buffalo has a really, really great website that has videos on how to do some of those physical exams. So I encourage you to check that out and take a look. And then here at UCSF we also have a sports concussion program. Um, we see concussions at mostly at the, um, San Francisco office. Um, and, and then, um, one of my colleagues, um, Doctor Berrigan is at Redwood Shores, which is on the peninsula, so he's able to see concussions there. Uh, but certainly, any athlete you, um, see or any individual who has a sports-related concussion, um, we'd be more than happy to see in clinic. Here are my references, um, and then I'm happy to answer any questions at this time.
