Okay, we'll go ahead and get started. Welcome to Virtual Didactics with the AAP. My name is Sterling Herring. I'm a PGY3 at Vanderbilt. And for those of you who are joining us for the first time, this is an effort to help support and expand upon didactics that are already being offered at your local institutions. We'll get into that in just a minute. I think there's going to be a little bit of delay in folks joining us today. We transitioned from the Vanderbilt platform to the AAP platform, so there's a new link and that sort of thing you may have noticed. I think there's going to be a little bit of delay in participation today. First and foremost, before we get started, again, I want to recognize that a lot of folks, professionally or personally, have been affected by COVID, and we want to certainly express our support and recognition of those people. So if there's anything we can do to help you, please let us know. So again, the goals of this are to augment didactic curricula that are already going on at your home institutions, to offload faculty that are being pulled in a lot of directions right now, just logistical challenges, to provide additional learning opportunities for residents or fellows or students, other trainees who have been pulled off schedule for a variety of reasons related to this virus. And then, of course, to develop more resources, kind of think outside the box and continue to progress in terms of resident and trainee education, and then just offer general support during this difficult time. So housekeeping-wise, we're trying to keep everybody audio-muted and video-muted. Sometimes that's hard. There we go. Thanks. It's a team effort. So we're trying to keep everybody video and audio-muted, just in terms of preserving bandwidth and reducing distraction. So far, that has worked very well for the past few lectures. If you have any questions at all, you can send them to me via chat, and I will present them to Dr. Icorino at appropriate times. If you have any questions, you can find us via email or Twitter. Our information will also be at the end of this. And I encourage you to come back every day. We have lectures scheduled every day at this same time, noon Eastern, and we're in discussions with folks to expand that to an additional slot at 1 Eastern, if there's interest there. Without further ado, let's move on to our presenter today, Dr. Alexis Icorino from Spalding is going to give us an exciting lecture on TBI. There you go. Should be unmuted. Can you hear us? I can hear you. Can you guys hear me? We can. Great. So, I'm going to share my screen, hopefully. Sorry, folks, give me one minute, got to get off full screen mode. There we go. Okay. We see your screen now. Hold on. Okay, how does that look, Sterling? Okay, great. Hi, everyone. Thanks for having me again. Really enjoy the opportunity to talk to you all. My name's Alexis A. Garino. I'm from Spaulding, a TBI physiatrist, and the overwhelming majority of my work is in concussion. So we're gonna talk about early clinical care and sideline care for sport concussion today. Hopefully this will be relevant to a lot of you. You've already heard the housekeeping rules, but I'll just reiterate that this lecture is being conducted for remote resident education during the time of COVID-19. So the purpose of these slides is solely for your education. Shouldn't be reproduced or duplicated. Sterling, I'll try to pause at various intervals so we can field a couple of questions. I left my email at the end for anybody who has further questions. You can reach out to me. I get some funding to do work for sport concussion and for mild TBI. So we're gonna talk about a couple of things. We're gonna define sport concussion as best we can. There's some limitations to our ability to do that. We're gonna talk about pathophys. We're gonna look at the acute presentation. We're gonna talk about how to assess the injured athlete acutely. And then we're gonna talk about developing an initial plan of care. Okay, the definition of a concussion, I'll tell you right now, there's like 50, 60 plus definitions circulating out there depending on what organization you talk to or what area or specific interest group you come from, whether it's sports, whether it's the lay public, whether it's the military. I think for the purposes of this discussion, we can use the AMSSM definition. This is a traumatically induced transient disturbance of brain function. It is caused by a complex pathophysiologic process. And we'll look at some elements of that, although the bottom line is that we don't completely understand the pathophysiologic process that occurs during concussion, which is one of the challenges in both diagnosing and treating this condition. General trends. 3.8 million sport-related concussions per year in the US. In the US, again, it depends on how you define sport. Is that competitive sport? Is that recreational activities? Note that because oftentimes concussion can be a mild injury with mild symptoms, it can go unreported. We've gotten a lot better at reporting as a nation and as a healthcare system over the past decade or so. The CDC and other groups have really gone far to educate people about concussion, parents, athletes, coaches, athletic trainers. And so the number of concussions grossly is on the rise, but that's likely a function of reporting and not necessarily a function of the injury itself. There are certain sports that concussion is more common. Again, those sports that have better reporting systems and are more structured will be better represented in this area. Sports where concussion is less reported in general will be lower, but I think the important point is that all sports can have concussion reporting. So for example, we just reported a case in New England Journal of Medicine of a sailor with concussion. I up in Boston happened to see a fair number of sailors who sustained concussions. Where my colleagues in the South are gonna see a lot more football players. Some of our colleagues across the pond will see a lot more rugby players. So it really just depends on where you are. Any of your athletes are at risk, although obviously collision and contact sport more than some others. Okay, pathophysiology. So general concepts. There are really two forces that get exerted on the brain during a traumatic injury. One is gonna be translational or linear acceleration or linear forces. And the other are rotational acceleration or angular forces. So your linear forces are your anterior posterior forces and then your rotational forces are rotation. Most injuries in sport to the head will have some components of both. You can't really have isolated linear forces or isolated really angular forces. So you're gonna have some contribution from both these types of forces on the head. However, concussive injuries are likely more responsive to rotational acceleration. Okay, and the brain tissue deforms more readily in response to these rotational or shear type forces than other biological tissues because of how they're made up. So when we think about concussion, we really do think more towards the idea of rotational motion or angular forces. What happens in the brain? So again, this is still a little bit of a black box. There are lots and lots of folks working on this. And I'm noticing on my screen that some of my citations have been cut off. I apologize for that. I don't know how it's showing up to all of you, but if you have questions about citations, you can send them on and we can send them to you. So one part of the pathophysiology is likely this neurometabolic cascade. This is something that we might have the best understanding of in terms of pathophys. So when the brain experiences concussive headaches, head injury, you get this sort of indiscriminate blocks of neurotransmitters, of ions across cellular membranes. And the big neurotransmitter that you wanna know is glutamate. That's the one that we most associate with altered neurotransmission and TBI in general. When you get alters in glutamate, you get this excitotoxicity excitation a cell can cause both calcium influxes and potassium outflow. This really alters the normal ion fluxes of the cells. And in response to that, we know there's a increase in our ATP pumps. If you're thinking back to your pathophysiology days, you get this depletion of ATP, which creates what is classically termed, and I'm using air quotes, an energy crisis or a metabolic crisis within the cell. And if the cell can't keep up with trying to maintain its stability, you can see leaking of the cell membrane and potentially cell death. There are a number of other physiology changes at work in concussion. We're not gonna go deep into them here, but some of those are around hemodynamic changes. So blood flow changes to the brain. There can be usually microstructural changes, again, in part related to this neurometabolic cascade. Early in the injury, so like immediately after it occurs, you can see some electrophysiologic changes. Although if you did an EEG on somebody who was concussed, you'd be unlikely to see anything. So there are a host of pathophysiologic changes, but this neurometabolic cascade is the one that's best characterized. How long do these changes last? So again, these are estimates mostly based around animal data, but if you look at changes in neurotransmitters and changes in ions, we're looking at usually minutes to hours potentially. Now, we do know that some changes in cerebral blood flow may last longer, and there are even groups looking at long-term cerebral blood flow changes. But as a whole, we think that for most people with a concussion, you're gonna see changes to the neurometabolic cascade on the order of days to one to two weeks. Of course, we know symptoms last a lot longer, and understanding why symptoms don't necessarily resolve when these neurometabolic changes are thought to resolve is still a point of question in the concussion and TBI community. How do these people look? So what are your signs of concussion? So if you're gonna be doing some sideline work, or if you perhaps just watch a lot of football on the weekend, you're gonna see people who take a blow and they get up with what we might talk about, Bambi legs or that gait instability, they're wobbly for a few steps. They can have a blank, vacant, maybe befuddled stare. Folks ask the same question over and over again. They can have slowed speech, slowed responses, poor command following. Think of this in your maybe football player who runs to the wrong sideline or doesn't follow the next play when it's called out. There can be some brief confusion. People can be amnestic to the events leading up to or immediately after the injury. And there can be a loss of consciousness, although I put an asterisk there because less than 5% or so concussions, four concussions are actually gonna have a true loss of consciousness. And that's certainly not required and not gonna be the norm for most concussions. Symptoms, headaches, dizziness, nausea, even an episode or two of vomiting, feeling foggy, feeling sort of in a dreamlike state initially. And then in the initial days following the injury, those symptoms can persist, although often new complaints can appear, including difficulty concentrating, particularly around school activities or provoking symptoms with trying to get back into exercise, which we'll discuss a little later. I'm gonna pause really briefly. Any questions coming through, Sterling? Not yet, no. Okay. Let's move on to the sideline assessment. So I pulled this information from the NFL Head and Neck Spine Committee. So this obviously is, it's a good layout, although some of it's geared towards professional sports. Which will be a lot different than those of us who are on the sideline at potentially a middle school soccer game or a high school or even most college sports. So if you are on the sideline, you know, you observe or see a player have an impact to the head, or you see some of these signs that look like a concussion could have occurred. In professional sports, there are lots of people looking out for these signs that can pull people off the field. But in our other sporting groups, it's gonna usually be a coach, a parent, or the athlete, or potentially a trainer, if they're available, who's gonna be pulling these people to the sidelines. And certainly if you're there, you can make the call to pull people off the field. You remove a player immediately if any concussion is suspected or signs of concussion are seen. You know, if a player is down on the field, certainly there's gonna be a direction to stabilize that person in the field. But in your isolated concussive event, usually your athlete's gonna be able to walk off the field. There are some hard no-go signs over here in red, right? So people who lose consciousness, people who are confused or amnestic should not go back, period. And remember, when you're triaging on the sideline, you're not necessarily getting into the weeds on concussion. You're just trying to make a go or no-go decision, right? So, can somebody return to playing right now, or do I need to get them away and do a further assessment, right? So, you're not trying to slam-dunk your concussion diagnosis, you're just trying to get people out of play who could be concussed versus knowing that they're safely ready to take their helmet or their equipment and head right back in, okay? So, so you have your hard no-go signs, right? And then you have some softer signs, right? They observe some of the signs and symptoms we talked about. We're going to review some questions to quickly ask on the sideline. If you're fortunate enough to have video review, that might help you, or you do a very quick focus neuro exam about their spine or just observing their speech or gait or their pupils and decide, are they ready to go back out, or do I need to look at them further? Am I suspicious? If you're suspicious, you want to move that exam away from the sideline and then conduct further assessment, which we're going to talk about, and decide whether somebody needs to be, just rest in the locker room, can they return to play, or do they need further evaluation in the ED setting, something like that, okay? So, we're gonna, we're gonna review that here. So, what are your clinical tools to use on the sideline? So, the number one is your clinical impression, okay? If it walks like a duck and it talks like a duck, it's probably a duck, okay? If it looks like a concussion to you, it's best to pull people off and not let them go back, okay? This next tool you're going to use is the SCAT-5, which we're going to review, which is the sports concussion assessment tool. There are components of the SCAT-5 for balance, including the BESS, and then there are some computerized sideline assessment tests for balance that some groups have utilized, and I'm going to make a disclaimer about those. There are also vestibular and ocular testing platforms, the vestibular ocular motor screen, the King-Divick, there's some computerized visual tracking softwares out there that people are trying to utilize on the sidelines. Again, your clinical impression is number one, okay? These tests, while helpful, have varying performance issues, okay? So some people, particularly your very high-level athletes, will perform very well on the SCAT-5 balance testing, visual testing, but could still have sustained a concussion, and some of your, perhaps your younger athletes or your less high-performing athletes might not perform well on the SCAT-5 on a normal day, right? So your clinical impression trumps all these other things. Moreover, the FDA, you know, released a warning last year that there is no single test that can be used on the sideline to diagnose concussion or certify that somebody is not concussed. So while there are lots of fancy tools, iPads, and balance measures that are being purported for sideline use, no single item is available that can tell you whether somebody is concussed or not on the sideline, and we should use those new technologies sparingly and as part of a larger clinical decision, okay? All right, so the SCAT-5, this is the most commonly used sideline assessment, right? It's a standard concussion assessment tool. It's able to be completed on the sidelines. You don't need any special equipment to do it. It's designated for ages 13 and older, and it can be administered by any health professional, so you can administer it, a trainer can administer it, a PT can administer it, so that makes it widely usable. Ideally, it's designed to be given at rest at least 10 minutes after play. That's very hard to do in a fast-paced sideline environment, but that's ideally how it's set up to be conducted. It's not a standalone diagnostic tool, so an abnormal test does not necessarily indicate concussion, and you'll see when we go through it what I mean by that, and similarly, a quote normal test in the presence of other clinical symptoms may also mean that somebody is still concussed, okay? So there's no cutoffs here. It's not like if I score a 50, I don't have a concussion. If I score 49, I do have a concussion, okay? Again, the SCAT-5 also gives you these red flags and observable signs. Maddox questions we're going to go through, it asks you to do a GCS and a cervical spine assessment, take a symptom score, do a cognitive assessment, a neuro screen, and some memory testing. So I've cut and pasted from the SCAT-5 the pieces, and this is available for distribution. It's downloadable. It's a PDF. It's from the British Journal of Sports Medicine. I left a link at the end of the talk for it. So again, these are your red flags. These are your hard no-go signs that you want to definitely remove the patient from play, and in most cases, you're going to be escalating care to an ED or at least medical observation. These are the observable signs listed in the SCAT-5, and you want to take down if any of these have occurred. Your Maddox questions are your sort of orientation questions for sport, okay? Seeing if patients are oriented to what's going on in the game right now and can be conducted very quickly on the sideline. Your GCS also very, very quick on the sideline, right? If you have an athlete who walks off the field and is talking to you and is responding normally, they're likely going to have a GCS of 15, right? You all should absolutely be committing the GCS to memory for purposes of boards and other things. I feel like it's always one of those things that gets asked about. Remember that people who have concussions have a GCS of 15 or 14. People who have GCSs in the 13, 12, 11, you're no longer in the realm of concussion. We're thinking more about somebody sustaining more severe intracranial injury, okay? So people are not in the GCS 14, 15 range. We're no longer really talking about concussion. You should be thinking about more severe intracranial pathology. You want to conduct a cervical spine assessment, okay? Is the neck tender at rest, and can they move it actively, and is the limb strength and sensation normal? Again, these are quick things that you're looking at, but don't forget about the cervical spine in your assessment. Okay, so those are the things you're going to conduct fast on the sideline, and then, you know, if you have any of these no-go signs or any of those initial items are giving you concern, or again, your clinical impression really suggests someone had a concussion, you're going to remove them from the sideline, and you're going to conduct a little bit further in-depth evaluation, and these are some of the cognitive components of the SCAT-5. So you can read through these, and again, this is widely available for you to look at. You're going to conduct some sort of immediate memory testing. You're going to conduct some sort of working memory testing. Here's an example of a digit spanning, okay? You're going to do some orientation questions. Again, you're going to do some working memory tasks. Here, it's months in reverse order, and then you're going to do a delayed recall, right? So your immediate memory words, are they going to be asked after a period of time goes by? Again, any of you who sees athletes know that some of your athletes are going to do great on this, even after they've sustained a head injury, and then you're going to have other athletes who couldn't digit span to six on their very best day, okay? And so that is why there are no specific cutoff scores for diagnosing concussion based on these various items. One of the best things that you can have is actually pre-season testing in a lot of these areas, and that's really hard to do for a lot of school districts to have the bandwidth to do a SCAT pre-season. If you are fortunate enough or interested enough to work in professional sports, a lot of folks will have baseline cognitive testing. That's some of the most helpful because, again, there's going to be wide variability on people's ability to conduct immediate and delayed recall, digit spanning, those sorts of things even on their best day. Okay, the next part of the SCAT-5 is a post-concussion symptom scale. Okay, so this is used on the sidelines, but I also, in my own practice, use it as an in-office tool. So this is a seven point Likert scale of concussion symptoms. The patients rank them from zero, I don't have this problem at all, to six, meaning the problem is very severe. Again, this is a self-report measure of symptoms at the time of the event or, again, used in the office perhaps for a monitoring symptom recovery. This gives you some qualitative measure of symptoms, although you need to remember that most people on an average day do not have zero symptoms, and so I'm going to shift forward because these are the symptoms in the post-concussive symptom scale. And I can tell you that most athletes, particularly your teenage athletes, will not be zero on this scale even when they're not concussed, right? So feeling fatigued in a day, feeling like you had trouble falling asleep, feeling more emotional, feeling like you might have some sensitivity to light if you've been doing screens all day long, right? So most people are not zero, okay? Again, this is where some baseline information might be helpful, but you might not always have it, okay? So there is, while it can be that not everybody's zero on the scale, even at baseline, there is high internal consistency, okay? So reporting day-to-day by a patient is relatively consistent and useful in tracking people's symptoms. Okay, so there's your post-concussive symptom scale, and so that is the SCAT-5, okay? Those are all the components. Again, very good to use this. It has components you complete on the sideline. It has components that you can complete in the locker room or after you've decided to remove someone from play, and it's trackable in terms of the PCS and some of the other components. You can complete them the following day or in the ensuing days to determine if people's performance is improving. All right, so you've removed your player from play. You've diagnosed them perhaps with a concussion. Now you're thinking to yourself, well, do I have to image these people, okay? So concussion is a clinical diagnosis. We just went through how to make it, right? Imaging is not needed to make this diagnosis, okay? People have a concussion, and you get a CT or an MRI, you will most likely see nothing. So then who does need to get imaging in the acute phase? In the acute phase, it's somebody where you're concerned for something that's more significant than a concussion or a mild TBI, okay? So do they have an intracranial process that is going to trigger a neurosurgical referral, and in that case, you want to image people, right? So these are the people who are doing poorly on the GCS, less than 14 or 15. These are people who are having persistent symptoms, and we're going to review the criteria for this. These are people you're sending to the ED to potentially get imaged, or you're seeing them in the first couple of days after in the clinic, and you're thinking that they have symptoms that may suggest some sort of intracranial pathology more significant than concussion, okay? But your concussed patients don't need imaging to be diagnosed. Okay, so there are some criteria for how to image people. So sorry, guys, this is what happens during the pandemic. Your two-year-old walks in on your lecture. Pardon me for one second here, folks. We've all been there. We'll take a brief bio break. Again, if anybody has any questions, you can send them to me, and I will pass them along at appropriate breaks. Appreciate those questions that have already been asked. I will pose them as soon as it's appropriate. Okay, I'm so sorry, everybody. This is real life here in nature of the epidemic, right? Okay. So. No jumping at this time, no jumping. Yeah. Yeah. So, so who are you going to image? Okay, so there are criteria for this. If you are working in an acute environment like the sideline, for our colleagues in the ED, there are criteria for who to image. Again, the positive of imaging, you don't miss anything. The negatives of imaging, it's expensive, you get incidental findings, CT is your most common imaging modality and your fastest, right? And there is some risk of radiation. So let's look at who we image. Okay. So this was taken, so there's two kinds of criteria, one for kids and one for adults. Okay. So the kid criteria, what they use in the ED is called the PCURN criteria, and you can look that up, but this is from a paper we wrote where we created this algorithm based on PCURN and some other data on who to image. So in kids, again, we're mostly going to be looking at kids over two, but for you guys in PD rehab, kids under two are probably considered a higher risk group. So if you're triaging a kid under two with a head injury that looks concussive, your threshold for imaging then would be lower. But for your kids over two and your sideline folks, you know, if you have people with GCS less than 15, any signs of basilar skull fracture, right, so these are your battle sign, your raccoon eyes, any alteration in mental status that is not quickly resolving, these are your high risk folks, okay. Some more moderate risk symptoms, again, vomiting, particularly, and again, in my practice, I always go with twice. I don't know why, but if you vomit more than twice, I really feel like that's a problem. If you just get hit and you puke once, anecdotally, guys, I think, okay, I can tolerate that as long as everything else is looking good, but if I have anybody who has persistent episodes of vomiting, I'm thinking about getting them scanned. Loss of consciousness, severe headache, and then what we call severe mechanism of injury, okay, so people who are moving very quickly, fall from a height, struck by a high impact object, this is your intermediate risk group, okay, that you want to image. And then everybody else is sort of in a lower risk category, where you might consider just an observation, all right, that's your PD criteria. Your adult criteria, there's two groups of criteria that are most used, one is your Canadian CT head rules, and the other is your New Orleans CT head criteria, and these are not sport specific, so these are actually rules that are used for any head injury coming into an ED, okay, but again, they have a similar flavor to what we just talked about, so, you know, GCS, less, 13 or less, loss of consciousness, amnesia, confusion, very concerning symptoms, dangerous mechanism of injury, any signs or concerns about skull fractures, suspected basilar skull fractures, this is the emesis greater than two, and then your older folks, again, less likely in sport, but in the general world, in the general public, and the New Orleans CT head criteria are quite similar. This is not going to be, drug and alcohol intoxication is not going to be common in sport, but outside of that, think of those folks as being higher risk, and certainly anybody with a seizure is likely going to want to get imaged. Okay, what imaging are you going to do? So CT is fast, and is going to tell you whether you have a neurosurgical emergency, okay, and so CT is the mainstay. Now we just, a couple of us put out a little clinical correlate paper in JAMA where we talked about the fact that in, particularly in kids, it could be very beneficial to get a CT because you're reducing the risk of ionizing radiation, and you can pick up more subtle abnormalities, so perhaps there are some traumatic axonal injury, small microhemorrhages that you can't see with CT that you could pick up there and may make you think more about monitoring more closely or potentially even hospitalizing those kids overnight. Our large academic center at MGH has the ability to do rapid sequence MRI. That's not what most people have, though, and so your mainstay is CT scan, okay, in an emergent situation. It's going to show you what you need to know to decide if you need neurosurgery to come see a patient. Again, this is in the acute environment, okay, we're not talking about persistent concussions and folks in the late stages. Okay, so you have your concussed athlete, you know, let's say you didn't send them to the ED because they didn't have any of the signs we just talked about, but you need to give them some ground rules, and you need to maybe give the parent some instructions for what to do over the next couple of days, or you're going to be seeing them in the office in the next couple of days, so how do you know that people are better, okay? There is no single objective marker of clinical recovery, okay, so no blood test, no imaging study, no electrophysiologic study. Practically speaking, okay, when people have no symptoms, when they are able to exercise and participate in their usually daily activities without symptoms, and when their exam has normalized, they are better. Now, we don't know because we cannot measure pathophysiologic recovery, right, so we use clinical recovery, signs, symptoms, and response to activity as a proxy for pathophysiologic recovery, right, if you look better, we think you are better, but you should all know that we cannot say with certainty that if people clinically look better, they are better, and so this is why we have some pause in getting people back to play very quickly, because it could be that the pathophysiology lags behind the clinical recovery for some people, and so this is often why we opt to return people back to play more slowly or more cautiously, because the clinical and physiologic recovery can be disconjugate and difficult sometimes to measure both, so bear that in mind. So we just said this, clinical recovery is abatement of symptoms, normalization of your exam, and tolerance of physical and cognitive exertion without symptoms, and that recovery, while pathophysiologic and clinical recovery can be disconjugate, you also need to remember that recovery is often dependent on patient reporting, so your athlete who's very anxious to go back and may under-report may not be ready to go back, and then you'll have people who are over-reporters, okay, who may complain of a lot of persistent symptoms for a very long time, right, so under- and over-reporting can complicate the assessment and your determination of clinical recovery, one of the challenges and arts of doing concussion care. How fast do we expect people to get better, okay, so these are some older papers, but a lot of our professional and college athletes in sport, okay, around 14 days, now nobody's better in one day anymore, and that's because our return to play staging is five days, and we'll show you that, so nobody should be going back within one day anymore, okay, on average, on average, high school students take longer to get better than your college students and your professional athletes, and most athletes recover within a month, now outside of athletics, recovery times for acute concussion can be longer, but for athletes, most seem to feel better and meet that clinical recovery criteria within about a month, again, not everybody, but most. Treatment for concussion in the early phase, okay, so globally, you need to understand that treatment for concussion is consensus-based and evidence-informed, what do I mean by that? I mean that what I'm going to present to you in terms of treatment, okay, is information that's been put together by large consensus groups on concussion in sport, and there are a variety of them, probably the most notable is this fifth consensus statement, or consensus statement on concussion sport, which was the fifth international conference on concussion sport, which was in Berlin in 2016, but there are a number of other groups that get together, so we have limited research on which treatments or which return to play protocols are best, but we use the information we do have to form these consensus states, okay, so just bear that in mind. So the first thing you want to do when treating the acutely concussed individual is to provide them education about concussion, okay, this is your first treatment, okay, you need to let the patient, the parent, the coach know that the symptoms of concussion are very common, okay, that concussions themselves are common, and that most symptoms are easily managed and will typically abate with time, okay, so reassurance, all right, regarding rest, so we used to think that prolonged rest was good for concussion, and I have a whole lecture on this, so I'm not going to take a deep dive, but we now know that you probably should not be resting people for a long time, okay, so probably 24 to 48 hours of quote rest, followed by a gradual resumption of activity in a mountain intensity, okay, so first starting back with normal daily activities, and then proceeding back with more challenging activities like school, work, and physical activity. The most important thing why people are recovering is that they avoid activities that would increase the risk of another head strike, okay, the reason we pull people out of play and we recommend early periods of taking it easy or resting is because, not because something about being in the dark or being completely away from stimuli is good for concussion, but because we're trying to remove people from activities that would risk another head injury event, right, we're trying to avoid overlapping injuries. This is a summary one of my colleagues put together actually about rest and concussion, okay, so you can see that the consensus statement on concussion in sport we just talked about over their five consensus statements has really changed what we mean by rest, okay, so they used to say, you know, 20 years ago no activity, complete rest, and then since then the recommendations have been lightened to the point now where it's been discussed that we really don't have sufficient evidence to completely rest people, okay, that the amount of time we get people to rest and the type of rest that they do is very poorly defined, and it's likely that just a brief period of rest, again a few days, is what's needed before we get people back into some of their usual daily activities, okay. So for our student-athletes, the big question will be, well, what do I do about school? So this is from the fifth consensus statement on concussion in sport, it is a consensus on return to school activities, okay, I can tell you in my practice we use something similar to this, although not exactly the same, so you want to get people to be able to do some cognitive activity at home, and then when they're feeling up to it, begin to engage in school itself, anecdotally, again in my practice, I find that the longer kids are out of school, the harder it is to go back, so even if they're in school for a brief period of time with modifications, I often advocate for them to get back in a school-like environment as soon as they're feeling up to it. You want to provide some accommodations around school in the early period, and again it can just be as simple as a brief note to the school that the patients concussed and should be given some accommodations, up to a more detailed letter saying what those accommodations are, you know, no taking tests, no gym class, you know, be able to take rest breaks, all those sorts of things, but you want to give some guidance about returning to school. Every kid is going to be different in what they tolerate, okay, so you can't always give a full return to school guidance initially, it's going to be a work in progress, but you can give some ground rules to the patient and the parent and some general recommendations to the school. In our area, in New England, most schools have their own protocols already in place for how to manage concussed children. We have, we use something in our clinic called an exposure to tolerance model for recovery in school, and I'll just very briefly go into this for the sake of time. So when we think about returning a kid or to school, or this can also be used in a return to work situation, we want to think about about having people do a little bit of activity and then take rest breaks, okay, so a patient has an injury, okay, where's my mouse, and this is their baseline level of function up here, right, and this is how much activity they're doing on the y-axis, and what we want to see is that over time they slowly increase their level of function, get back to their baseline, okay, but usually it's not this smooth of curve because patients' symptoms tend to go up and down, okay, so what usually happens in my clinic and what I warn patients about is that they're going to try to do, if you look here at our little symptom curve here, they're going to try to do some activity, and their symptoms are going to go up a little bit, and that's okay, okay, so I warn them when you get back to school you may experience some headache, some light sensitivity, whatever it may be, all right, and when you do get those symptoms, okay, we want you to take a little rest break, okay, so that's where the level of function kind of flattens off here, and then as the symptoms go down, we want you to increase your level of activity, okay, and if the symptoms go up, you take a rest break, and then you increase your level of activity. Now for a lot of patients, they'll start to feel better, and they'll increase their level of activity to the point where they actually get kind of severe symptoms, right, that's the sort of a trial and error, they keep exposing themselves to more work and more work, and then they say, whoa, I got a lot of symptoms, that's kind of my threshold right now, and that's okay, that is not dangerous, we reinforce that that's that's not dangerous, but what we want patients to do is then take a rest break or reduce Their level of activity back to a place where they don't get really high symptoms Okay, so we don't actually want them to go all the way back down To doing nothing or shutting themselves back in and resting. We just want them to return to a level of activity That's below their threshold where they don't get severe symptoms Okay, so so basically what I want you to take away from this is that it's not a smooth process for most people They do a little they get some symptoms. They have to back off a little they do a little more They get some symptoms and that tends to be how it goes for most people Sometimes they overdo and they have to back down a little but they don't need to go back to doing nothing Okay, so we call this an exposure to tolerance model Okay Okay, so those are certain basic ground rules around tackling school and And tackling symptoms in the school and workplace Approaches to exercise again in the acute period so you can use exercise two ways One way we use exercise in acute concussion is diagnostically So if we have people who are asymptomatic at rest But they begin to exercise and their concussion symptoms start to flare up we might think while the concussion is Not completely resolved. Okay, so you can use it diagnostically Another way you can use exercises therapeutically. So many athletes feel better when they get moving a little bit Okay, in general athletes don't feel good. If you make them rest, they feel better when they're doing their sport or activity So we can have people do some exercise again below a symptom threshold Okay as part of their recovery process so and you may add Concomitant vestibular ocular or cervical therapies on an as-needed basis based on your assessment of the patient But some symptom threshold exercise has now been shown to actually hasten recovery So we use this as part of our treatment of concussed patients What does this look like so this is the return to play progression put out by the fifth consensus statement on concussion in sport Okay. These are the phases that we want people to go through in returning to play Now you do not need people again to be completely recovered and asymptomatic To begin this process, okay, so People who have mild symptoms Okay can certainly start to do some symptom limited daily activities, right? Get up move around the house do a little bit of schoolwork those sorts of things People with mild symptoms can also take a walk or get on a stationary bike Okay again, as long as it's not making their symptoms more severe and Even folks with mild symptoms who can do light exercise might try to do some sports specific Exercise maybe lateral drills adding some movements Again, no head impact activities, but some more sports specific items Okay, as we're moving people back towards return to play We want to see that they're continuing to be able to do exercise and not having severe increases in symptoms And then they can even move on to things like non-contact training drills Now there's should be a line right here in my mind between Numbers four and five, okay People who have very mild symptoms or are not completely a hundred percent better can Engage in these return to play steps again, sequentially up until non-contact training drills Once we get into full contact practice of scrimmaging, okay This is where a person needs to be fully recovered. So they need clearance from their doctor Okay, nobody gets to go back to full contact practice or scrimmages Unless they're all the way clinically better based on this criteria we laid out before Okay So this is where in my practice people need a clearance letter between stages four and five Okay, and then once they've scrimmaged they can go back to normal gameplay so Often a question we get is how long do people have to do each of these steps? so The consensus statement wants at least 24 hours between Between each step. Okay to see if symptoms develop if people feel worse Again these are consensus Based there's no evidence that you need 24 hours. There's also no evidence that 24 hours is enough So if you have athletes that you're seeing maybe younger kids In my practice, I tend to make them do each of these steps for a couple of days In Some professional sporting organizations, you're now allowed to move through these steps in less than 24 hours each so if there is some Clinical decision making that you have to do about how quickly to move people through these but Consensus statement recommends in at least 24 hours. So one day each What you can see here is that means that if your athlete is injured on Saturday Right, even if they're feeling perfectly better the next day if you're gonna put 24 hours between each of these steps It's gonna take them at least five days to get back to being ready for game play So bear that in mind when you're dealing with managing your athletes Expectations about when they're gonna return to play I'm gonna pause here because what's gonna happen is I'm gonna run over and I Am happy to do that for those that are able to hang in but I want to leave time for questions About what we've discussed so far for those who might have to leave All right. Thank you. So we do have several questions. We're gonna do it rapid-fire So you have four words to answer each of these questions. So choose but we do need to Move through these quickly, I think Have you found any utility in the ACE or the acute concussion evaluation form or do you have any opinion on how that compares? So I think that that Both forms are very I think they're both useful. I don't know of any head-to-head Trials on them and if anybody else does please shout it out in the chat But But I think that you can use either I think that the SCAT 5 is more commonly used in sport and the one you're gonna see most It's most well adopted by NCAA and by most your sporting organizations So it's the one that if you're gonna be in sports medicine or managing concussion, you probably want to be really familiar with Okay. Thank you So sometimes on the sideline you have a limited amount of time If you can't do the entire SCAT 5 what parts do you really want to emphasize? What do you what can you not miss? Yeah, so Right there on the sideline. You're gonna want to do those first couple of things GCS clear the neck and And get those those Maddox questions in Right and that's gonna tell you if you need to do more work up or if the person can go back Right. So that's those are the things that are really gonna help you decide Do I need to pull this person out and take more time or are they really fine and they can go back? And again, but above all your clinical impression, right? If they look like they got concussed, even if they sail through those couple of pieces you can still pull them away So it is a fast-paced environment on the sideline But it's kind of your job to slow it down and saying no no I saw XYZ or you you know Didn't perform poorly on you didn't perform well on these parts and I'm concerned and I'm now gonna Step you away from the sideline as best I can whether it's just moving literally away from it or getting you into the locker room to do a little bit more assessing Perfect. Thank you You mentioned that a lot of these protocols and algorithms are evidence-informed consensus statements We have a gentleman who said that at least in his practice in Qatar He will often find that patients choose to forego the algorithm and go straight to imaging What has been your experience in terms of following that protocol versus those who kind of skip around it? Well You know, I think Like I said, there's there's pluses and minuses to imaging, right? You know imaging can open up a can of worms Particularly mr. You find all kinds of things That can that are completely irrelevant and can make patients worried That is an unnecessary worry You know and again CT is only going to show you things that are neurosurgical emergencies. So You know, I think that most in America at least I can't speak about abroad but You need to have some Suspicion That triggers you to send people to an ER and then once they generally tend to get to the ER You know Often it's our your colleagues who are making a decision about scanning in the very acute period immediately post-injury You know certainly If you want to be certain about every single patient that you're not missing intercranial pathology you CT everybody but Again, that's not going to tell you anything about concussion really right concussions a clinical diagnosis So imaging is less helpful for you there in the acute period All right, thank you, I think I'm gonna have to pause if you sent me a question and I wasn't able to ask it Please message me your email address and I'll try to pass those along to dr. I Carino and maybe we can answer some of those offline So, thank you. Dr. I Carino. I'm going to Close up just for those who have to get back Again, thank you all for joining us If feel free to stick around if you are able to and we're gonna move on if dr. I Carino's amenable. We're gonna move on kind of finish her presentation. Is that okay? Yeah, that's okay with me and again, I apologize to all of you that this is running a little bit over But I'm happy to stay on as long as others are on and we can do a little bit more All right, great If you do have to go just remember these lectures are occurring every day at the same time Keep an eye on that web page the physiatry org slash webinars as times change and as some of you notice today The hosting platform changed somewhat Feel free to reach out to us on Twitter via email And thank you all for participating. So we're gonna go back to the lecture now. You can feel free to take back over the screen Okay Okay So I think that was a good place to end because we at least got through return to school and return to play which are Your big items, but let's talk a little bit more in depth just about managing some of those early days post injury so I want to make a small comment about the stibular and ocular impairments because this is an area where We're doing more testing around this in the acute period and we know I've just listed a couple studies here that on field dizziness that vestibular ocular reflex difficulties and that convergence insufficiency are all factors that may be associated with prolonged symptoms or help us in identifying concussions, so Bear that in mind One of the tools in our toolbox is vestibular and ocular rehab, which is again looking more closely at these changes in binocular vision changes in vestibular function balance inner ear disturbances and There is no specific timeline on when to recommend patients to these things, but in my own practice I'm finding that if I have patients who have significant symptoms around vision and dizziness I tend to get vestibular and ocular rehab involved more quickly because I think that You know, we're physiatrists, right? We know early rehab is probably a good thing, even though we can't quite prove it yet in the area of concussion But the concepts behind vestibular and ocular rehab is this idea of exposure and recovery, right? so vestibular and ocular rehab is giving targeted exercises for These vestibular ocular impairments that will stress The systems a little bit. So the vestibular system the visual system a little bit In a controlled manner with the idea that over time these symptoms will become less provoking Okay, so that's kind of the general theme behind vestibular and ocular rehab It's important to keep that in mind because if you do refer a patient for vestibular and ocular rehab and you have a good Therapist either whether it's a PT or an OT doing this They're likely gonna make your patient symptomatic or your patient's gonna feel dizzy while they're there or they're gonna feel like their vision is is Either looks worse or feels worse During the rehab and that's actually by design, right? You're stressing the symptoms the systems a little bit in a controlled manner so that you can get patients to improve. So So I always warn patients about that. I say I'm going to send you to PT or OT and they're gonna do some exercises. They may make you feel a little bit worse but If you continue to do them over time, it will bother you less and you will ultimately feel better Medical treatments for concussions so you can refer to my lecture on pharmacology from last week But the mainstay of treatment is behavioral and environmental adaptation not medication There are no evidence-based pharmacotherapies and we use medications for When our other treatments are insufficient or when symptoms are severe Where do we often begin with this? So there are lots of symptoms in concussion The ones that I think you want to knock off first or pay a lot of attention to are pain symptoms Mood symptoms and sleep disturbance, right? You can imagine if your patient who is acutely concussed sleeps all day every day They may have a mood problem They may experience dizziness from orthostatic hypotension because they've been out of bed They may feel light-sensitive because they don't get out of a dark room So you can see how there are certain symptoms here that will exacerbate or induce the other symptoms and So I tend to go back to these couple To go back to these couple pain, mood, sleep as my sort of early treaters, right? So people present with All of the symptoms of concussion early on and I'm like, well, where am I going to start? I tend to start with trying to normalize their sleep, trying to help their mood, and trying to get rid of their headaches. And then a lot of times, the other stuff, the cognitive complaints, the balance complaints, not always, but often, in my experience, those things will fall into place or tend to quiet on their own. So I'm just gonna breeze through real quick some of the early treatments for those three areas. Again, there are treatments for all the areas, but I think these are areas that are common. And again, like I said, might be best to try to knock off first, right? So headaches, mild headaches are expected. Severe headaches may impact people's ability to return to their usual daily activities. You wanna go with headache hygiene and behavior modifications first, okay? In the setting of headaches that are not responsive to behavior modifications, you can consider using over-the-counter analgesics to reduce headache severity. There are no specific medications that are approved in the acute phase. Tylenol or Advil, Tylenol or ibuprofen-based products, NSAIDs are fine. There is some discussion about using NSAIDs in the first 24 hours if there's any concern of a bleeding risk. That seems like a reasonable precaution, although there's no evidence to say that there's increased bleeding in concussed patients who take NSAIDs initially, but it's reasonable that if you can use Tylenol or something else in the first 24 to 48 hours, then that's fine. I tend not to make a big deal out of it, although I've heard others really harp on not using NSAIDs right out the gate because of that very low, but obviously serious risk of bleeding. These are some of your headache medicines for people who are not getting better. Again, in the abortive phase, NSAIDs, aspirin, Tylenol, combination analgesics, triptans probably in people who are migrainers to start. These are your prophylactic medications. You're less likely to use these early on in the first couple of days, more likely to start adopting some of these in the subacute phase, and each of them have their risks and benefits. I listed some common sort of side effects below here. So sleep, normalizing the sleep-wake cycle is extremely important, and this is where over-resting can get people into trouble if they're just sleeping all the time. They may feel, they can feel cognitively slowed down. Like I said, they can get dizzy and orthostatic. If they're not sleeping, it can give people headaches. So sleep is a really important thing to get normalized quickly in the process. Use all of your usual sleep hygiene techniques that you'd employ in anybody with a sleep problem, and I've listed a lot of them here. Cognitive behavioral therapies are something you might use in a more subacute to chronic phase, but just know that there is reasonable evidence in concussion for cognitive behavioral therapy for insomnia. There's a couple of papers on it. Medications for sleep. In the acute phase, again, we wanna use environmental and sleep hygiene techniques, but some will use tricyclic antidepressants. Some people may try trazodone, prescribing it. I tend to be a fan of melatonin, again, because it's not necessarily sedating. It's just helping to regulate a disrupted sleep-wake cycle. You wanna avoid medications that would be associated with any risk of dependence or that may exacerbate comorbid symptoms. So avoid your zolpidem and other sort of Z drugs in this early period. You also wanna avoid your anxiolytics, like your benzodiazepines for sleep in this early period. I mostly tend to, again, in the acute phase, opt for something like a melatonin. Mood changes. Monitor your patient's moods. If when you tell them they can't go back to their sport right now, they plunge into a deep depression or start to get very anxious, that is critically important for you to know and to keep tabs on. It's going to affect their ability to engage in their recovery. It's gonna affect them in school, at work, and athletes do not always respond well to be taken out of play, right? Even if they get, if it's not a head injury, if it's an ACL injury. We've seen people with ACL injuries who have comorbid depression who don't do as well in their long-term recovery of their knee injuries. So keep an eye on people's mood. You might employ a questionnaire like the PHQ-9 for depression or the GAD-7 for anxiety. These are super short questionnaires that are meant to be used by any non-mental health provider. Mild and moderate symptoms. Again, use PsychoEd. You might think of employing some CBT strategies or getting people engaged with a counselor who can do that. Severe symptoms, you wanna refer to a mental health provider. Pharmacology, you're gonna reserve for people in the chronic phase, okay? Not necessarily in the acute phase because most mood changes are going to improve as patients feel better, right? You just have to support them through that early phase. So lastly, and this is often a slide that I use for non-physiatrists, but I wanted to leave it in here is who are your vulnerable groups and who is gonna need potentially specialty care, which is usually us, right? But you might wanna think if you're educating other providers about your athletic trainers, or your PTs, or your primary care docs, who are the people they need to watch out for who may not improve acutely, who may move into a subacute phase or may develop chronic symptoms? Okay, so these are your vulnerable groups. People with premorbid mental health conditions are a vulnerable group. Depression has been one of the few factors in repeated studies that has been shown to be a risk factor for prolonged symptoms. People with prior prolonged or complicated recoveries. So this is your athlete who their last concussion took them a year to get better. They're someone who may need to get into specialty care like us or a specialty concussion clinic sooner. Okay, they're gonna be at risk for prolonged recovery. People with a history of a headache disorder may also be a vulnerable group. It may not necessarily be that those people take longer to get better, but that their presentation is more complex. So they may be experiencing migraine, and it may be that you need some specialty care provider more than their trainer or their primary care to sort out what's their migraine and what is headache related to concussion. Talk for another day, but those people can be challenging. People who have had multiple concussions. So very briefly, there is no specific number of concussions for which we say, oh, that's it, retirement. It's not like, oh, you've had two, so you can't play anymore, or you've had five, so you can't play anymore. We know that multiple concussive head injuries is associated with worse on field presentation, and perhaps with longer recovery periods. And certainly for those of you keeping up with the concussion literature, we have concerns that multiple injuries could have long-term consequences, but we have no certainties on that. That said, these discussions about long-term risk or the possibility of long-term risk need to happen for kids and athletes who've had multiple injuries. So who are getting in the three, four, five, six concussion range. And that's probably best done by somebody who has specialty training in sport concussion like us, or again, if you're not in the area of concussion or not comfortable referring to a colleague who does do this more regularly. So those conversations should be happening for people with multiple injuries who are looking to go back. People with a severe on field presentation or an initial high symptom burden are a group that are at risk for prolonged recovery. And then those who are completely unable to engage. So those who in the first week, two weeks are still sitting in a dark room or have not yet done any light aerobic exercise, like take a walk or have not been able to get into any sort of routine around daily school or daily work activities at all. So they've been fully unable to re-engage. Those are likely vulnerable groups. And then finally, anybody who has prolonged symptoms greater than 30 days in the athlete group is probably someone who should, you should be starting to think about referring to specialty care, or you should be telling your trainers might need to come in and see the concussion specialist or the sports med doc. Because most athletes should be getting better within those first 30 days. And if they're not, then they're moving into sort of a chronic phase. So summary, concussion is a complex pathophysiologic process, okay? You're on a field evaluation, you want a triage. Is this a concussion versus something more severe that needs neurosurgical intervention? Recovery trajectories are variable, okay? Initial management is educating people and giving them behavior and environmental modifications. You wanna provide some early guidance on physical activity and work or school during the recovery phase, okay? Over time, again, that will evolve. So they'll have to increase their physical activity and they might have to change their school accommodations. But at the outset, you wanna give some initial guidance. And then pharmacology is used when symptoms are severe or refractory and those vulnerable groups who may get referred into specialty or tertiary care settings like many of us will be. So thanks for everybody who hung in for the extra 20 minutes, I appreciate it. These are some really great guidelines to keep handy if you're gonna treat concussion, okay? Pediatric concussion guidelines done by the CDC, they're really tremendous. This is the SCAT-5 and also we'll link you back to the fifth consensus statement on concussion support. And then some of my favorites which are the Ontario Neurotrauma Foundation guidelines on concussion, mild TBI and persistent symptoms, which very, very helpful for those who are patients who are out of the acute phase, moving into the subacute chronic phase of injury. For that unfortunate minority. This is my email, I'll do my best to get back to questions if you send them to me. And thanks again for having me. Thank you, do you have a second for a couple more questions or no? Yeah, happy to. All right. So one, any evidence for magnesium or riboflavin for post-concussion headaches? Yeah, so the magnesium and riboflavin data that I know about is from migraine. And I don't know of any evidence for specifically the post-concussive headache. I think that practically speaking, they might be reasonable things to try early on. They're generally low risk interventions with very good, if to no side effect profile for most young, healthy athletes. So I do tend to use them for athletes with headaches, usually not in the, again, acute phase for seven days, but those sort of moving into a subacute phase or those who may have some resistance to pharmacotherapy and prefer a sort of nutraceutical approach. Okay, great, thanks. Other like fish oils, antioxidants, lipoic acids, those sorts of things on neurocognitive recovery, any thoughts on that? Again, the nutraceutical literature isn't great. I think there might be a few studies out there. I think some folks in our group are looking at putting together a review on nutraceuticals. In general, omega-3s are thought to be good for the neurological milieu, but their data in concussion, to my knowledge, is limited at best, if any. Again, I think these are things that probably can't hurt people, fish oils, but I don't necessarily know that they have direct benefit on recovery. Tune in next week on a lecture on placebos, which may also answer some of your questions on nutraceuticals. I heard the lecturer is pretty fantastic for that one. What criteria do you use to clear the neck on the sideline? So in your down player, if you have a player who's down and not getting up and they've had a head injury, you're concerned about the neck, you're gonna board and collar them and they're gonna be taken off the field. If you've got somebody who walks off but has neck pain, the big things you wanna look for, remember numbness, tingling, weakness, right? Those should be sending alarm bells in your head. And inability to have the person do active range of motion for sure, or any tenderness along the spine that you palpate, particularly if you palpate a step off. One thing that I always am screening for, if people do tell me they have numbness or weakness is stingers, right? So stinger is compression, usually at the root level. So somebody gets hit and they experience numbness or tingling or loss of use of usually an arm, that can often be that they had an acute root compression, where you need to get very worried is if you have somebody who comes off the field and tells you that they've had bilateral stingers, right? So that's both my arms went numb, tingly or dead when I got hit. Because bilateral stingers is generally not a root problem, it's usually a cord compression problem. And that should be an alarm bell in your head. So if you have somebody who comes off the field and says, I had a dead arm, you wanna look at that carefully and evaluate it. But if you have somebody who comes off and says, it happened on both sides at the same time,

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