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 workday and wet and rainy outside so I appreciate you joining my zoom will link you earlier. So I apologize if it continues to be so but hopefully not. Um So today I'm going to be talking about sports but concussion and I want to really focus on giving you some keys for primary care. I am a primary care sports medicine and some family medicine trained and then I did extra training in sports medicine and this is something that I see in my office. 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 path of physiology 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 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 in 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 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, 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 the concussion patient. Uh, we also know that it results in neuro pathological 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 going to 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 because 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 will go over and in some cases though it 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 path of physiology and 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 external sharing and this external sharing leads to an indiscriminate release of neurotransmitters. So we have indiscriminate release of neurotransmitters at those axons. What this leads to is a complex neuro metabolic 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, two 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 ion influx is 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 the 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, 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 isn't Children specifically for 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 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 concussion 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, but the most predominant age group that we see sports-related concussions are in that younger teenage, so 12 to 17 years old with 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. And then it's interesting when you break it down by, um, by background that non hispanic whites had a higher percentage compared to non hispanic blacks, asians and hispanic populations. And while there may be under reporting or that maybe 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. Um, just out of curiosity, you can just nod your head because I can see some of you on zoom. How many of you know what an athletic trainer is not? Yes or no. Okay, I see some mixed reactions. They're so athletic trainers are really great allies to have. They are basically health care 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 me 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, which causes some issues for us in concussions, which I'll talk about a little later. But if you ever see a patients who is in high school or even in college that has a concussion, I would ask if they have an athletic trainer because there'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 and important to keep in mind in context of those epidemiologic numbers that we saw earlier. So now that we have an understanding of what a concussion is, how it happens and 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 the case. So let's say that we're at high school football came. It's near the end of the second quarter and this 16 year old star running back its tackle, he's slow to get up the athletic trainer runs onto the field to evaluate, clears him from a neurological when he 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 your 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 individuals should do? So when we talk about sad line management, evaluation of concussions, um the first thing you want to do is evaluate your C. A. B. S. Or as I learned at A. B. C. S back in the day, right airway, breathing circulation, do a secondary survey to make sure the scene is clear and safe. 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 or the athletic trainer and position 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 it's a little better now. But you know, kids historically would want to try to sneak back into the game. 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 dramatics questions. Now, these are a series of memory questions that have to do with the game and the situation that they're in, I'm like Albert. So I always like to show scores of California and stanford Gober's. 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 last 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 can lead to quicker recovery. So this was a study that was published back in 2018 that looked at 30 universities and four military academies. So around 500 concussed athletes and they basically asked two questions. So number one, um, did the athlete immediately report concussive symptoms and then number two 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 a dark line there and if they had no to one of those questions, then they were considered to be in that delayed delayed removal group there. And what they found was that the immediate removal group had a 39% lower likelihood of missing more than 14 days and then at 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 removed that athlete from play. We've updated coached and we're monitoring the athlete on the sidelines for any development of symptoms. And it was towards the end of the second quarter's a half times 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 the 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 uses something called the scott five. So scott stands for the sports concussion assessment tool and it's currently in its 5th 5th edition and this is designed for individuals who are over the age of 12 years old. Again, I can see your head. So why don't you just not? How many of you are familiar with the scott five or have heard of the scott five before. Okay, so kind of a mixed bag too. And this is something that we use both on the sidelines but is really helpful to use in clinic as well. So I recommend 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 greatest symptoms 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. You know, one, you know what type of symptoms they're having and then to how bothersome it is for them. And so we'll take headache. For example, they can basically rate how bad their symptoms have been on a scale of zero being none and then six being very severe and 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 to get as a baseline or you know, if your 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 check their symptoms over time, which is really, really helpful. The other components of this cat five 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 A and O. Times four 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 will take this one that says elbow, apple carpet saddle bubble and then they have to repeat it back to you in any order three 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 gonna 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 these in order to you because they've memorized it. So there's also a 10 word list that you can use to which is a little more challenging. The other component of this cat five test 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 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 one and then if they miss one then they get zero points 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 m best 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 buff but I'm sorry that that's not me. But basically what the modified balanced scoring system does is a test balance with their eyes closed, hands on hips and they'll 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 and 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 heirs they have in those 20 seconds. And those areas include opening their eyes, removing their hands off their hips, lifting their foot off the ground, um moving their foot out in a deduction or abduct and 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 and acutely concussed when their balance is all wonky and off and clinic. You know this is a nice eric's pad. But in clinic I just use like a pillow, one of the patient pillows 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 this cat 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 it's really helpful to get more objective measures for a concussion. And this is a very useful tool. 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 child scott five. So the scott five is used for patients 12 years and older, but if they're younger then you can use the child scat five. The only difference is it includes both the child and the parents report instead of month. It's in reverse order. They say the days in reverse order and then they don't include any of those orientation dramatics questions. And then for the balance component, since they're not as coordinated, they don't do the single leg stance when they're younger. So that's only for ages 10-12 or or older than that. Um, and these are all available for you online. I have a resource slide at the end of my talk, but if you just google scat five, you'll see the british Journal of Sports Medicine. Has it? The american Academy of pediatrics has it, I think a FP 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 bombs testing or vestibular ocular motor screening. And this assesses five areas of the vestibular system as well as the ocular system. Again. Shake up 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 five different things that we really test for. So the first one is, um, smooth pursuits were basically, I'll have the individual just follow my finger. Kind of like your cranial nerve age test that you, But you just go in different directions and you're looking at 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 read 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 stack odds. So basically what this is and you can try this as you're sitting there. Um, I put my fingers out partial, my hands are getting lost in my blurred background, but in front of the athlete about a little over 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 and have them look up and down as quickly as they can. And then again asked if that causes any of those symptoms that I had mentioned earlier, if they're able to tolerate that, 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 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 six 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 var or vestibular ocular reflex. So this is where you can use the popsicle stick allies 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 and beats 100 and 80 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 do right. Um But again, you're asking if that help if they develop any of those symptoms and then the last one is probably the most dynamic test. This is the vision motion sensitivities. So they'll sit with their thumb out in front of them and they're going to rotate their whole body back and forth while staring out 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 bombs testing and vomits item that has a total symptom score of greater than two, increases the concussion probability by at least 46%. And then that near point convergence distance, if it's over or equal than equal to or greater to five centimeters, then it increases our concussion probability by 34%. Um, and you know, I mentioned that our experts concussion experts met recently in Amsterdam, I believe that they're going to come out with this cat six soon. And I think that the bombs testing is actually going to be included in this Cat six. So 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 evaluate concussions. Let's talk about how long it takes for recovery. So let's say you know we have that high school athlete we evaluated on the sidelines and we diagnose them with the concussion. The first thing I like to do is give them a hand out 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 loved one over the next 24 to 48 hours if they do have a concussion. And then it also gives some recommendations 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 C. I. F. 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 24-48 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 the common question I always get is like, how long is it going to take me to recover? And so we know that the typical recovery time for adults is around 10-14 days and then Children and adolescents because their brain is still developing can be a little bit longer. So up to four weeks. And then I like to always give counseling if it's a younger athlete in council the athletes and families, and this can go for really any individual that, um, you know, most patients who have a concussion don't have difficulties that last more than 1 to 3 months post injury. And then every, 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 going to 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 going to 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 for my student athletes, they first need to return to learn and then return to sport or, you know, for 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 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 there's really four 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 they're 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 at home or you know doing some work stuff while they're at home. So that can include, you know, checking their work emails are 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 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 student athletes. I think it's especially important because we need to break that lazy athletes 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 or having partial days of attendance can be helpful. Um writing them a note that allows them not frequent breaks if needed or modifying their work so that they avoid any sort of visual or auditory stimulus and then obviously leaving them out of pe until they they're able to return back to full physical activity. And then for younger athletes there's great resources again available on the California interscholastic federation website. And then template ID handouts that are really nice where you can just go through and check off the accommodations that they may need and then all you know, I spoke about this a lot. But in California, the C. I. F. Is another great resource and they also have stuff that's available in spanish too. So this is the Q. R. Code. Um and hopefully you will get a copy of my slides, but 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 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 seven days after being diagnosed by for being diagnosed with a concussion by a physician. Um And they can only return after completing that. Return to play protocol and certified individual such as an athletic trainer or physician or unidentified 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 uh evaluate athletes for concussions, but unfortunately because they're not recognized as a health care professional in California, they can't diagnose the concussion. So if you see someone and you're the first position seen a younger athlete, then just know that even though they're symptom free, if you're the first position that's seen them, they can't return back to any sort of activity per California law any sooner than seven days. Also mentioned that 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 24-48 hours of rest, then they're they're clear 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 clear 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 they're sitting there 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 and 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 because 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 sport specific exercise. So this can be, you know, running or incorporating more cutting drills or anything that is sports related and more related to whatever activity that they're doing after. They're able to do those sports specific exercises, then they are clear 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. They can also start doing resistance training at this time. So weightlifting. So if they do a lot of weight lifting, then you can say, yeah, you can try going back into the weight room. I tend to have them avoid doing more dynamic weight lifting things or, you know, like hit exercises, which includes like burpees or stuff that makes their head go on multiple levels. I have them start with this very basic weight lifting things first once they're able to tolerate that and 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 support. Um So that's kind of the protocol that we go through. And this is outlines on the C. I. F. Website and um I also have dot phrases that I use for my patients which is really helpful. So I'll put that in there A. B. S. 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 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 four 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 individual has what I call persistent post concussive symptoms and what that's defined as is any symptoms that last longer than two weeks and adults and then over a 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 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 and the interval I usually see those patients are at is every 1-2 weeks. And so for these more persistent prolonged type patients will 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 specific bucket of symptoms that our patients, um, our concussion Haitian tends to fall into. So, you know, largely this can be like more vestibular type symptoms or ocular symptoms where their vision feels off for 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. It can be more headache, e 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 to specialists if necessary, 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 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 the practical management of concussions and how to do a very brief physical exam for sports related concussions in the outpatient setting. So, a really great article. Um and what I like in regard 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 talk about those more cervical genic patients where they have neck pain and then may have what we call late 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 with emotional ability or have really bad anxiety or depression. There are some patients that have more autonomic or physiologic symptoms that persist and those can be kind of non specific but often they'll have like positive Ortho static so they feel lightheaded when they get up or the classic things we think of or just have like profuse flushing and sweating that occurs. And then there's more of the vestibular ocular type which I see quite often in clinic where they have 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 treatments. So for the cervical genic type um I often refer them to physical therapy to help with some soft tissue and range of motion and different exercises. And then I also recommend them doing sub maximal 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 concussions can help with vestibular ocular therapy as well. And then again with these types of patients, I like to prescribe sub maximal aerobic exercise for the mood type patients and obviously all of you in primary care very well versed in this unfortunately. Um but it can be really challenging to deal with this and really takes a multidisciplinary team and individualized therapy. Um So referring them out to therapists or mental health providers is what we tend to do and then again prescribing that sub maximal aerobic exercise and then that last bucket for the more autonomic or physiologic type symptoms. We just tend to prescribe sub maximal aerobic exercise. So you're probably thinking like well that's all great, but like what's the deal with this sub maximal 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 official effects on the autonomic nervous system and can help us cerebral blood flow regulation. And then um it also facilitates brain neural plasticity 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 there's been a lot of research coming out of buffalo from dr Leddy and he created this 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 worse 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 two minutes. And then they also ask for any development of symptoms and then they stop once the patient develops more than three points of symptoms, so they get a point for every worse thing symptom and then a point for every new symptoms. So once they have three or more the test is stopped and then they record what heart rate that occurred. And we use that heart rate to help taylor 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 that 80% of what that identified heart rate was. And we start with a little lower times around 15-20 minutes. And then we gradually increase that target heart rate over time by 5-10 beats per minute. And then we continue to repeat that process until they can achieve around 85-90% 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 Between stage 2-3. So stage two was when they're able to do that stationary biking and then stage three 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 Taylor that. And we know that the sub symptom threshold aerobic activity can help with concussion recovery. So this is the Kaplan meier curve. This is a study that was published in 2019 that looked at the difference between aerobic exercise. So early aerobic exercise and 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 Aerobic Exercise Group was able to recover on an average of 13 days 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 aerobic activity especially early on can be helpful for concussion recovery. So in summary, I know we went through a lot of things. So we talked about the definition of a concussion and some of the path of physiology and epidemiology 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. We went over some of the common tools that you can use to evaluate a concussion and help you manage a concussion in clinic namely the scat five and the bombs testing. 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 return to play program. I want to leave these resources in your slides as well. This 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 C. D. C. Heads up has a really great website with great resources for you and for patients to look at. 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. But then here at UCSF we also have a sports concussion program. We see concussions at mostly at the san Francisco office. Um And and then one of my colleagues dr Bergen is at Redwood shores which is on the peninsula, so he's able to see concussions there. But certainly any athlete, you see any individual has a sports related concussion. 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.
