Sports Concussions, What You Need To Know

Sports Concussions, What You Need To Know


>>Okay, welcome everybody. Thank you for joining us. Good afternoon. Welcome to sports concussions
what you need to know. My name is Debra Holloway. I’m the educational and resource coordinator
at the Brain Injury Association of Virginia. And this webinar is being hosted by the
Brain Injury Association of Virginia and the Virginia Department for
Aging and Rehabilitative Services and this project is supported by the Health
Resources and Services Administration of the US Department of Health
and Human Services. And just real quick before
we get started I wanted to do a few housekeeping
items as everyone is muted. We are going to record this webinar
and be able to share it with others. They can take advantage of
this wonderful opportunity. And if you have questions throughout the webinar
please use the chat box and chat your questions and then at the end of the presentation
our presenters will address the questions as time allows. We also will be sending a survey out and
that will allow you to ask a question when you complete the survey if
we don’t get to your question. Okay. So now I’m going to
introduce our presenters. Our presenters today Dr. Donna Broshek. She’s an associate professor in the psychiatry
and neurobehavioral sciences and co director of the brain injury and sports
concussion institute and neuro-cognitive assessment
lab at the University of Virginia. Dr. Broshek has been a consultant to UVA
athletics team since 2000 and is President Elect of the Sport Neuropsychology Society. Dr. Shane Caswell is a professor of
athletic training at George Mason University and founding executive director of the
Sports Medicine Assessment Research and Testing Laboratory. Dr. Caswell actively works with
numerous youth league and school systems on the prevention recognition and
management of concussion in athletes. And Dr. Howard Goodkin is the Shure professor
of neurology and pediatrics and the director of division of pediatric Neurology
at the University of Virginia. Dr. Goodkin serves as the neurological
consultant to the UVA athletic teams and has been part of the brain injury
and sports concussion institute at the University of Virginia for 13 years. Thank you guys so much for joining us. There’s our contact information at the
Brain Injury Association of Virginia and the Virginia Department of Rehab Services
if you have questions after this presentation or need to get in touch with us for resources. And I’m going to turn it over to our presenters.>>Thank you so much Debra, we really appreciate
this opportunity to present this webinar and we understand that many of those
attending this webinar are school personnel so we are particularly pleased to be able
to get this information directly to you. The outline is showing what
we’re going to talk about today. We’re going to talk a little bit about the
concussion basics and the Virginia state law. Dr. Caswell is going to spend some time talking about on the field assessment
of sports related concussions. We’ll address classroom issues in
returning to learn and then returning to physical activity and competition. And Dr. Goodkin will talk about
managing headaches after concussion which is a particularly problematic system. And the role of exercise in prolonged recovery. We’ll also field some of your questions and
as Debra mentioned if there are some questions that we don’t get to she will send those
to us and we will certainly still be happy to answer those questions via
email or another mechanism. So we’re going to start by
talking about what is a concussion and this is a fairly recent definition but I think it really does a nice
job of explaining what happens. So a concussion is a pathophysiological process. And what that means is that we’re not talking
about damage to structures of the brain but more of how the brain functions. And so it certainly affects the brain and it
is induced by a traumatic biomechanical force. And another key concept here is that this force
can be caused by a direct blow to the head but many times in sports the blow might be
to the chest or to the torso causing the head to sort of have a whiplash
mechanism which transmits forces to the head causing the concussion. Typically there is a rapid onset
of short lived neurologic symptoms and these resolve spontaneously. However the resolution may take days to weeks. And in some cases the symptoms and
signs may evolve over minutes to hours so there may be some initial
confusion and then some of the symptoms may get worse
for a little period of time. But that’s usually minutes to hours. So again, these symptoms typically represent
a functional disturbance of the brain and that’s why when somebody does have a head
CT after a concussion it is typically negative. Because again, the structures
are not typically affected. Another key issue here is that a concussion does
not necessarily involve a loss of consciousness. Certainly some do but many concussions do
not involve any kind of loss of consciousness but more of alters consciousness
or lack of awareness. When these symptoms follow a sequential course
and we’ll talk more about those symptoms. In a very small percent of individual have
a very prolonged post-concussion pattern where their symptoms persist. So if you look at this slide, this slide
was actually created by Dr. Goodkin and he very nicely separated out the
symptoms into the various clusters. And one of the clusters are the somatic symptoms and these are the physical
symptoms of concussion. Includes headaches, nausea,
difficulty with balance and coordination as a feeling of dizziness. And sensitivity to light and sound. Another core group of symptoms
are those involving sleep. And after a concussion people may
have difficulty following asleep or sleep may be very fragmented or disrupted. They may sleep too much or too little. And this disturbance in sleep can contribute to
the difficulty with thinking because sleep is so important for good cognitive functioning. There are also mood changes that can occur
after concussion and these can take the place, or consist of irritability
but also emotional ability. So people may cry very easily
or get angry very easily. Just sort of anything you feel
the brakes kind of come off and you might feel things more
quickly and more intensely. Reduced frustration tolerance is very common
and that’s really having a short fuse to things that might be normally mildly irritating
can cause one to lose their temper. And then certainly some athletes experience
sadness or depression or symptoms of anxiety. The cognitive symptoms include
the feeling of fogginess, just sort of generally suppressed
brain function and cognitive fatigue. Just feeling sort of like your brain is tired,
like you don’t quite have your usual horsepower. And then also difficulty with
attention and memory deficits. So at the time of concussion
what typically is seen is a lack of awareness of surroundings and confusion. And if you look at the young man in this
picture you see that sort of vacant stare and that’s a very classic sign of concussion. Just sort of not being aware of where you
are, not really processing information. Other common symptoms include
nausea or vomiting. Headache, memory problems, not knowing
where you are, what game you’re playing. Dizziness and vertigo and Dr.
Caswell will talk a little bit more about how this young man would
be assessed on the field. So this slide really shows that what
happens at the time of a concussion is that there is a mismatch between the
brain’s demand for energy or glucose and the body’s ability to deliver that fuel. So at the time of concussion
there’s really a metabolic crisis. And the brain is needing more glucose, more
energy to cope but that energy is not able to be delivered and so you can see that this
creates a sort of energy crisis within the brain and if you look at the slide you can see
that this pretty much resolves by day 9, 10 and we know from various
research studies that have been done that in certainly college athletes,
typically concussions resolve by about day 10. So this really sort of nicely mirrors that. This is a very complicated slide and the
purpose of showing this one is to show you that at the time of a concussion there
is a lot going on at the cellular level. So again we don’t typically see structural
deficits in the brain after a concussion. Unlike more severe brain injury where there
might be structural damage but here it is at the cellular level and again it
is essentially the brain is not able to produce energy and there
is a metabolic crisis. So as I mentioned, when we think
about healthy college age athletes, having their first concussion typically
their symptoms recover within about 5 to 10 days and that’s a full recovery. However kids generally take longer to
recover and some may take 30 days or more. So it’s really important
that we are more conservative in the management of younger athletes. We tend to hold them out longer
because we really want to make sure that they’ve returned to their full baseline. The Lystedt Law is one of — is
the first state law in the country to mandate sports concussion
management for youth athletes. And you can see in the bottom corner of
your screen a picture of Zach Lystedt. He was a high school athlete and played
football as well as some other sports. And he was playing in a high school football
game and sustained a hit and had a concussion and was pulled off the field
very briefly, he returned to play and shortly thereafter he had another
hit and he crumpled to the ground and he had a very, very devastating injury. You can see him there in his wheelchair
actually looking pretty healthy. He had months and months of rehab
and a very, very serious injury. And he and his parents worked with the
Governor of Washington State to pass this law which mandates that no student athlete can
return to play, to their game after a concussion until they have been evaluated and
cleared by a health care professional. So this became the model for other laws
across the country and it’s the model for Virginia Senate Bill 652 which mandates
concussion education in all public high schools for coaches, student athletes and parents. And also mandates that there be policies
and procedures for managing concussions. The student athletes and parents
will receive annual education and the really key aspect
here is that any athlete with a suspected concussion shall
be removed from play or activity and shall not return the same day. If a concussion is suspected they must be
evaluated by a health care professional and you can see here the health
care professionals identified as providing this clearance and that includes
a physician, physician assistant, osteopath, athletic trainer, neuropsychologist
or nurse practitioner. The state law also mandates that
prior to beginning or return to activity they must have
recovered, they must be symptom free. And it requires written clearance
for return to activity. So the health care professional who evaluates
them must also provide written clearance. And the good news is that there is now a
version of the Lystedt Law in all 50 states that protects youth athletes and mandates
some kind of concussion management plan. So I’m going to turn it over to Dr.
Caswell now who is going to talk to you about assessing concussions on the field.>>Thank you Dr. Broshek. And hello everyone that’s on the webinar today. My purpose today is to provide
an overview of the process that the health care provider would use when
an assessment needs caution on the field and often this is an athlete trainer. The best way to evaluate a
concussion is continually evolving. There are two primary goals of a concussion on
the field assessment and first is to identify if there is a medical emergency that’s
occurring that requires immediate referral. The second is to prevent further harm. Regardless of who is conducting this evaluation, what health care provider,
there are four key principles. First there is an evaluation
of symptoms and a history. There should be an assessment on balance, there should be an evaluation
of cognitive functioning memory. And then a neurological examination. The foremost commonly used tools by health
care professionals include the standardized assessment of concussions. Symptom assessment scales of which there are
various types and models of symptoms assessment. And Dr. Goodkin can talk a
little bit more about that later. The balance error scoring system or the BESS
and the sports concussion assessment tool 3 or the SCAT 3 which pulls many
of these aspects together. So when we’re evaluating someone oftentimes we
begin with a set of questions that are designed to collect information regarding
the short term and short and intermediate term memory
function of the individual. So questions such as where are we? What quarter is it right now? Who scored in the last game or practice? Who did we play in the last game? Did we win or lose the last game? And these are called Maddocks style questions when you see your practitioner
doing these on the sideline. And next is the standardized
assessment of concussion or the SAC and this tool tests orientation,
memory and concentration and it can be scored out
of a total of 30 points. And it’s important to identify that this
tool, and all of these tools in fact, are only a part of a sideline assessment. They do not function as a stand
around concussion evaluation tools. This particular tool assesses orientation,
immediate memory and concentration. Orientation is assessed through five
questions very similar to the Maddocks scale. Immediate memory is assessed by 20 points where
individual recite words such as elbow, apple, carpet, saddle and bubble over three trials. And they are asked to recall
those words over a period of time and assess how many they can recall. And then concentration. Asks the individual to recite a sequence
of four numbers in reverse order. And from that we can come up with a
score to help practioners gauge whether or not someone is demonstrating
systems of a concussion. It’s commonly accepted that balance is often
affected by concussion and Dr. Kevin guskiewicz at the University of North Carolina
developed that balance error scoring system which tests balance and other common
postural symptoms affected by concussion through having individuals stand in
three different stances on both a solid and a soft surface with their eyes open
and closed and then we measure the number of errors that these individuals have. Such as touching their foot to the floor,
putting their hands on their hips etc. And this gives us an understanding
of how their balance is functioning. Most recently in Zurich 2013 at a
concussion conference an International panel of world renowned experts put together what
they believe is the most recent version and best version of a concussion
assessment on the sideline today which is the sports concussion assessment tool
or the SCAT 3 and this particular tool attempts to provide and objective standardized
measure by pulling together the Maddocks, the SAC and the BESS and it’s to be used by
medical professionals and there are versions. One for individuals that are greater than
13 years of age and another for individuals under the age of 12 or the child
version of the SCAT 3 and as you’ll see over on the right hand side of the
screen there’s a number of tools that the health care provider can use on the
sideline to assess symptoms, to look at whether or not the individual may have suffered a spinal
injury, to evaluate balance, coordination, to assess cognitive and physical evaluation
and then ultimately to provide a score. I think it’s important here to
say that regardless of the tool that is used proper concussion assessment
on the sideline needs to be performed by an appropriately trained health care provider and it relies largely upon
their best clinical judgment. So when they are evaluating these
individuals on the sideline that they suspect of suffering concussions
some elements would indicate that we should immediately refer
these individuals on for greater care. And such is deteriorating mental
status, a suspected spinal cord injury, any evidence of a potential skull fracture. If symptoms are progressively worsening
or changing such as a new headache, any unusual behaviors, if they
seem confused or irritable, they cannot recognize people
or places that they should. Any weakness, numbness or tingling. Difficulty standing or walking, if
they seem unsteady, challenging — difficulty speaking or understanding directions,
any type of persistent nausea or vomiting, and seizures should be referred immediately.>>Now we’re going to talk a
little bit about returning students to academics after their concussion. So in a lot of talks at this point we progress
to talking about returning students to activity, to athletics and activity but one of the
key issues is that it is extremely important that students be returned to the
classroom and able to function in the classroom before they are
cleared to return to their sport. And if you think about it, the student
has had a concussion and they cannot sit in their classroom reading a book,
they’re certainly not ready to be back out on the soccer field or the football field. So with athletics and academics it’s really
important to think about the kinds of symptoms that people have after a concussion. So if you think about having a headache,
fatigue, dizziness, feeling sensitive to light and noise, not sleeping and ringing in
your ears, in addition to having trouble with attention, concentration, your memory
not working as well as it does typically, processing information more slowly
and also completing tasks more slowly. And then imagine trying to be in the classroom. So during recovery these students often
need some temporary academic adjustments. And the critical issue here is to
have an immediate period of rest and that’s typically two or three days and they
may actually need excused absences from school for a couple of days initially while
they have the most acute symptoms but then they’ll need an individualized plan to
balance work and respite from their symptoms. And then we’ll talk a little bit
more about that in the next slide. And I also want to call your
attention to the fact that students who have pre-existing learning disorders and
or ADHD may have a more complicated recovery and that’s because they are already
dealing with difficulty with attention or slow cognitive processing
speed or other academic issues. So when we think about academic adjustments
there are a lot of things that can be done on a temporary basis to aid the student athlete
in returning to their academic schedule. So as I already mentioned they
need a brief period of rest with some initial excused absences
but then ideally we really do want to reintegrate them back into the
schoolroom as efficiently as we can. But they may need some periods
of rest while at school. And depending on the school this may be,
you know, going to the nurse’s office and particularly if there’s a physical education
component not having them participate in that but maybe sitting quietly in
the nurse’s office that period. Some schools are able to use the library
to allow the student to just sit quietly. And sometime we recommend just a
shorter day for a couple of days. Maybe going in the morning
if that’s their better time or arriving late and attending
afternoon classes. It can be extremely helpful
to relax when time demands. This may include giving them extra
time on timed tests in the classroom. Extending deadlines for various projects
and then staggering or delaying tests. Probably all of you have had the experience
of having multiple tests at the same time, all on the same day or within the same week
and finding a way to work with the teachers to stagger these so the student can
space them out can be very helpful. Another issue is having the student
resume work but only do partial work. This may involve doing parts of homework
assignments, allowing them exposure to course summaries and notes from the teacher. And another thing that can be very helpful is
to allow them or have them take tests or quizzes but reduce the value of this
particular test or quizzes that are happening while
they are still symptomatic. Also it can be very important to be
mindful of the light and sound sensitivity. In modern classrooms there are many
smart boards and computer equipment so reducing the background lighting
on those can be very effective as well as turning out overhead fluorescent lights. And minimizing exposure to loud sounds. So that may be excusing them from
things like band and school assemblies. And Dr. Caswell is now going to talk
about returning athletes to activity.>>So one of the most challenging decisions
that are made following concussions, when is it safe for someone to return to play. And a lot of thought has gone
into this and much research. One of the key tools that is used is
a progressive return to play protocol which you can see on your
right hand side of your screen. Regardless, the athlete must be
asymptomatic at rest and with exertion and be provided written clearance by an
appropriately trained health care provider of the listing that Dr. Broshek
mentioned earlier in the presentation. Then the athlete must progress
through all of these stages and being symptom free throughout this
progression prior to being returned to full non-medically supervised competition. I think it’s also important to indicate
here that they must complete full return to school activities prior to returning to play. And it is specifically identified
in the latest edition of the student athlete protection
act in Virginia. And so this is very much a teamed decision. Full return to all school activities
first before returning to play. So the return to play progression can
be affected by a number of factors. Such as the previous history of
concussion, duration and type, severity of symptoms, age
and sex of the athlete. The sport activity in which they are
participating and then individual traits such as a learning disorder or
psychological factors that they may have. Regardless, the return to play
decision should be a team decision. With stakeholders from the
school, medical community and home. And only after a complete
resolution of all signs of symptoms should they begin
the return to play progression. Regardless of medical clearance suggesting
earlier return to play the athletic trainer or health care provider on site should be
monitoring this individual for the return of any signs and symptoms and
making the decision whether or not this individual should be
reevaluated or potentially rest. At this time a symptom checklist can be
very helpful for the athletic trainer or whoever is working with the athlete
to be able to compare symptoms before and after exercise on a daily basis
and document how these symptoms trend. I think we need to resist the tendency
to minimize symptoms within our athletes and tell them to just suck it up. I think that we need to minimize that. We also should not hesitate to delay
progress or even go back a stage. And throughout the return to play progression, because this is a team based decision it’s
very important that all stakeholders, teachers, administrators, parents and the
medical professionals continue to observe the patient’s
symptoms and meet as part of a concussion management
team about that student.>>So this is Dr. Howard Goodkin and I again
want to thank everybody for joining us today and sticking with us at least
halfway through this webinar. As we already heard from Dr. Broshek there are
a number of symptoms soon after concussion. Dizziness, balance issues, fogginess. But of these the one that
is most common is headaches. And unfortunately for some headaches
will persist long after the time period where we would expect somebody to get better. Indeed, headaches and many of these post-concussion symptoms can be
present in a small minority of patients. Three months or longer. In terms of headaches that predisposes
someone to long term headaches after a concussion had been evaluated by Dr.
Heidi Bloom at the University or Washington. She looked a emergency department records from
across the country of not only sports concussion but all types of traumatic brain injury. Moderate traumatic brain injuries
to severe traumatic brain injury. One thing that came out of her study was that
injury severity made a difference and that those with sports concussion were more likely to
still be complaining of a headache three months after the injury than were those with
moderate or severe traumatic brain injury. Those with loss of consciousness
or amnesia as part of their traumatic brain injury were more likely to still be complaining of
a headache three months out. And as we’ve already heard, pre-morbid
conditions really are very important on how you do after a concussion. Those with pre-traumatic headaches were likely to still be having headaches
three months after the concussion. Those with a the family history continue to
complain of headaches three months out and those with psychological issues such as ADHD were
more likely to still be complaining of headaches by three months after the injury. Age played an important part
in the adolescents seem to take longer to recover than the children. And gender was also another important
factor with girls more likely to have headaches three months
after the injury than were boys. And some of these factors were still at play 12
months after but the number of children still with headaches at 12 months out were
much less than at three months out. So headache is usually the reason that sends
a child or an adolescent with a concussion to the neurologist and as part of that
assessment that do I certainly want to learn about the headaches, the frequency,
the severity, the characteristics. Is it a pounding headache or a squeezing
headache and how has it been changing over time. As we’ve already learned
headaches are just one part of the entire post concussion syndrome complex
so I start asking about vertigo, neck pain, sleep problems, how are they doing in school? How is their mood? I review for any stressors in the household
or the school and it’s not uncommon to find many stressors in
every adolescent’s life. I’m very interested in fluid intake. I ask about drug or alcohol use but as
you know those answers are always no. I don’t do that type of stuff. I certainly ask about predisposing factors such
as pre-injury headaches and pre-injury function. I take a very careful medication history. I want to know what they’ve been using to treat
their headaches because often what can happen is that we get into a withdrawal syndrome
of medication overuse headaches. And the best thing I can do is to ask them to stop the medications they’ve
been using for their headaches. I asked about pre-injury headache and function
as previously mentioned and I like to learn about family history and then
examination is critical to determine if there is anything that’s concerning me as a
long term effect on their neurological function. We already heard from Dr. Caswell
on those are red flags that we look for soon after the injury had occurred. Red flags that would make us want to have the
child evaluated in an emergency department. Some of those red flags include
altered mental status, papilledema which is a swelling
in the back of the eyes. Abnormal eye movements and asymmetries. At the time that most of these children arrive
in my office, if they were to have any of these from their injury these should be long gone. But I continue to look for these in
case there is another factor at play for the headaches other than the concussion. I look for a progressive
pattern of the headaches. Again, I’m trying to understand is there
something other than the concussion which may have led them to my office. I look for increased headaches with straining,
coughing or sneezing which can at time indicate that there is a mass, lesion
or a tumor in the head. I ask about sleep relatedness
of their headaches. Headaches that waken you at night again
are a red flag to me that something other than concussion could be going on. As are explosive or sudden onset of
severe headaches long after the trauma. And all of these are an indication to me
that head imaging or an MRI may be necessary. But the important part that I want
to emphasize here is that it is rare that head imaging is part of a concussion
evaluation even when they get the neurologist. That as Dr. Broshek mentioned
this is a functional injury brain, not a structural injury of the brain. So really only in limited cases is head image
a clear role in the assessment of somebody who has a post-concussion syndrome. Treatments in the acute phase of the post-concussion headaches
can include acetaminophen and non-steroidal anti inflammatory drugs. Usually we ask people to avoid these in
the first 24 hours because of the effect that they can have on platelet
function or bleeding. Triptans. These are drugs that work
on the serotonin system of the brain and are very important for migraine headaches
and can be used but there are concerns for some that they actually make the headache worse. And dihydroergatamine is another drug that
works on the serotonin system that can be used to help the person who has had prolonged
headaches although this requires hospital admission. Sometimes we place somebody who has had
prolonged headaches after a concussion on a preventative or prophylactic medication. These include triyclic antidepressants
such as amitryptiline. Two of the anti seizure medications. Valproate and topiramate and
anti-hypertensive’s such as beta blockers. Some find that vitamin supplements such as
magnesium, riboflavin, coenzyme Q10 as well as the root of the butterbur
plant can be helpful for treating prolonged headaches
after concussion. And then muscle relaxants actually do have
a role especially for those who present with ongoing whiplash type injuries or
cervicalgenic headaches or muscle tension in their necks which may be also
the precipitant of the headaches. And also as I already noted
that we need to be aware that when we use too much pain medication
we actually can make headaches worse and not better. Other treatments that we pursue when
the headaches are going on for too long after a concussion include physical
therapy to regain neck mobility. We can use nerve blocks on the occipital nerves
that travel through the neck and the back of the head which sometimes can
be injured during a concussion and lead to neuropathic pain. Psychotherapy and biofeedback certainly
have a role in headache management. Not only after a concussion but everybody with
chronic daily headaches to deal with stressors or to understand why the headaches persist. And then we’ll also talk about a very
important role of exercise in those who present with prolonged headaches. This is a study I’d like to highlight because it really emphasizes the
importance of why we are all here today. And the importance of knowledge and transporting
that knowledge that you have about concussions to your students and to their parents. This was a study in which they compared those
who received an information booklet about what to expect after a concussion and a one
week visit with the concussion team. Compared to those who were basically sent
off and told to deal with their concussion and not surprisingly those who were
informed, those who had contact with the health care provider did much
better and their headaches were better, their irritability was better, judgment was
better and sleeping difficulty was better. Just with this simple intervention of receiving
an information booklet and having contact with somebody educated in concussions. So we can make headaches better
just by informing people of what to expect after the injury has occurred. So I’m going to turn emphasis right now
and go back to this question of rest. We’ve heard from both Dr. Broshek and
Dr. Caswell that rest is very important and needed following a concussion. And why is that? Well, as we’ve already heard the brain remains
metabolically challenged after the concussion. There is that increased energy demand and
that decreased energy of flow which results in dysfunction at the cellular level
and that makes the brain more vulnerable to injuries soon after the concussion. Therefore it makes sense to keep people out of
play from the athletic field because we want to protect their head because there’s an
increase risk of a second concussion during that period of vulnerability and we know that
from good studies done with NCAA athletes done by Dr. Kevin Guskiewicz who Dr. Caswell already
referred to regarding the balance testing. There’s also a rare complication of having
a second concussion soon after the first. During this period of vulnerability
known as second impact syndrome. Where a second concussion can
lead to severe dire consequences. Although rare, we’re certainly
want to do our best to prevent this from ever happening to one
of our student athletes. So I want to bring in a little bit science
and to highlight the work of Grace Misback who is a concussion scientist at the
University of California Los Angeles and she asked is rest really important using
an animal model of traumatic brain injury known as the fluid percussion injury and in this there
is a hard puff of fluid that knocks the animal in the head and she took some of these
animals and she allowed some to exercise on a running wheel soon after the injury
occurred and she prevented another cohort of these animals from running on the
exercise wheel for up to six days. And what she found is in those that were
allowed to exercise, those who had free access to getting back to their daily routine, she noticed that there were decreased
molecular markers of elasticity. Translating this there were
decreased evidence of those things that help us learn and remember in these graphs. She also saw an increase in neuro inflammation. Now neuro inflammation isn’t always bad but
there certainly elements of neuro inflammation that further can hurt learning and memory. And so when she looked at the whole animal level
when she tested her animals cognitively those who were allowed to exercise
during this acute phase of the injury had a worse cognitive outcome
than those that were prevented from exercising. So this supports that rest really
is a requirement after a concussion. But we don’t know is how much rest
do our students athletes need. There is a recent study published by Thomas
and colleagues in which they compared five days of rest to those who were just told to
rest which typically meant one to two days. And when they compared the outcome of those
who were prescribed strict rest for five days versus those who were prescribed
liberal rest for one to two days, what they found was the strict rest group
missed more school, had more daily complaints of post concussion symptoms and in the end there
was no difference in outcome when you did one to two days of rest or whether you
followed a five day strict rest almost [inaudible] protocol. See, I think this boy here
represents the problem with rest. You can see that he is pouting, has his head
down and thinking to himself I hate rest day. And what we’ve learned from concluding
people from prolonged periods of time is that they become socially isolated, their
parents prevent them from using the internet, playing video games, logging into
their Netflix account and texting. So they become very socially isolated. This means they have time to think about their
post-concussion syndromes and worry about them. We’ve kept them out of school
and missing school, especially when you’re a high school
athlete thinking about your AP exams and what college I’m going to and every
day you’re falling further behind leads to further worrying about your post-concussion
symptoms and when it’s going to get better. And indeed we also set up parent child
conference because the parent wants — the child wants to be using their video
games and their iPads and what have you. So the parent is trying to keep them away. So the problem with extended
rest is that we increase stress. And we know that stress in this case
can actually prevent these children and adolescents from getting better. So if we compare that last child with these
children who are being allowed to exercise and all have smiley faces we begin to see that
there is an important role of some exercise as traumatic brain injury treatment. And this very busy slide is just
a slide of the number of positives or benefits of physical activities. Physiological functioning of the body and
examples of where exercise has been shown to have a good positive effect
on health outcome. And Dr. Grace Griesbach back where I
previously mentioned chose to look at well, what if after a little bit of rest I let
some of my animals begin to exercise and what if I keep other animals from
exercising completely? And she found that after that acute phase
those animals that she allowed to begin to exercise actually had increases of
molecular markers of neuroplasticity. Those markers they tell us that the cells
are being allowed to learn and remember. She saw increases in those markers in
those animals that were allowed to exercise versus those animals that were
still prevented from exercising. She saw that oxidative damage which is part of
the cascade of things that happen in our brain after a concussion but by allowing those animals to exercise they were protected
from this damage. And more importantly for us as doctors
and educators and neuropsychologists and athletic trainers is that
those are animals that were allowed to exercise actually had cognitive improvement
over those that were maintained on a rest basis. We’ve seen this in people as well. Majerske in 2008 noted that
moderate levels of activity in humans were associated
with the best outcomes. In a study of children ages 10 to 17 years
with post concussion syndrome for four weeks after injury once they were
allowed to begin to exercise in a supervised matter all showed
rapid improvements in their symptoms and here is just another study done in adults
where they looked at the role of exercise and those with prolonged post concussion
symptoms such as headaches, dizziness, cognitive fatigue and fuzziness
and exercise helped many of these people get back to their daily routine. So where are we today? We know that rest is certainly part of what one
must do after a concussion but how much rest and when to begin exercising
are very important questions that we don’t have the full answer to yet. But what is important is that what
we do know about concussion is that everybody presents differently and what
one person needs in rest may be too much for another person and the exercise that one
person may be too much for another person. So as Dr. Caswell mentioned, getting
over a concussion is a team sport. It requires the teachers, it requires
the physician, it requires the parents. It requires so many of these to help these
kids get back to where they should be which is in the classroom and on the playing field. So with that we’re going to end the
formal part of the webinar and we do hope that you have questions and
we’re most happy to answer those.>>Okay thank you very much. This is Debra again. You have a few questions come in. One person asked if you guys could speak
a little bit to the difference in recovery from males and females who sustain a
concussion and if and why there is a difference.>>That’s a great question. And we actually did a study here at UVA
looking at high school and college athletes and we did find that females took a little bit
longer to recover and reported more symptoms but also had more findings on
objective cognitive testing. So some people have suggested that the
reason females report more symptoms is that they are just more comfortable reporting
symptoms and more open about that compared to males who tend to minimize or deny. But certainly our findings which have also
been replicated at other sites have shown that females do seem to have more symptoms and
do have a little bit longer period of recovery. There are lots of hypothesis about why this
might be and I don’t think we really know fully yet why females may have a longer recovery. One reason that is hypothesized
is that they may — with the same amount of force they may have
actually a little more force transmitted to the brain resulting in a
little bit more severe concussion because female athletes tend not
to spend as much time developing and strengthening their neck
muscles as male athletes. So maybe that they don’t absorb as much force and therefore more force is
transmitted to the brain. Also there are certainly hormonal differences
which have been hypothesized to play a role. And so we don’t really know why it is. And so this goes back to
our very important message that all concussions must
be managed individually. Males and females may have
different recovery curves and different ages have different recovery
curves but there are so many individual factors that can play a role and as long as you manage
an athlete individually then we can get them safely back to academics and athletics.>>Great. Thank you. We had another question for Dr. Caswell. How proficient are emergency rooms, physicians and pediatricians you feel
at diagnosing concussions?>>How proficient. So I think what you’ll see is that there
is an increasing level of proficiency but still a broad array of expertise and
knowledge in the primary care setting as well as in the emergency room
settings regarding a concussion. I think the concussion law
in Virginia in particular and educational initiatives nationwide have
been very positive in getting all practitioners up to speed on the best care for concussion. But unfortunately to date there is probably
still a very broad array of knowledge and expertise depending upon which physicians
you go to and what emergency room you choose.>>I would add that that’s not only
limited to emergency room doctors but pediatricians and sadly even neurologists. Dr. Broshek and I did a study a few years ago
where we sent out a survey across the country and found that practices for concussion
and knowledge of concussion varied widely. I agree with Dr. Caswell that
with increasing publications and attention that those gaps are closing. But with all physicians no matter what type
we need to be very careful and make sure that they do have some understanding
and that’s why in the law it — Virginia State Law it clearly says
health care providers with knowledge in concussions and education in concussion.>>Okay. Thank you. We have another question from
school personnel when writing policy and educating the public should they
use the term concussion or brain injury?>>That’s a great question
and when we’re talking about sports concussion I think our
bias is to use the term concussion. Concussion generally conveys to most people
that this is a transient, temporary alteration in brain function and we
expect people to get better. While it is certainly the most mild of the
injuries on the spectrum of brain injury talking about a brain injury really
implies more persisting deficits so we really like to use the term concussion.>>Okay great. We have one more question about
handling a situation at school if a student is still experiencing
headaches while reading. Any suggestions on how schools
could handle that situation.>>So this — if you think about what happens
when reading, it’s a good setup for those who have had a concussion
who experience headaches. Your neck is down and you’re putting
additional strain on those muscles as well as you’re asking your eyes to converge. And so in those children who are
having headaches limited to reading, one I ask them to try to prop
the book up and the other is that we do a very careful examination of they
eye movements and those convergent movements. Because just as we saw that there are
balance difficulties after concussion one of the other things that the brain has to
balance is moving those eyes in towards the nose and actually the part of the brain that
does that is very much related to the part of the brain that let’s us
stand up when we are on one leg. So in those cases we work very closely
here at the University of Virginia as do other concussion programs with
occupational therapist or vestibular therapists who can work then with the child to get their
convergence eye movements back to normal and in some cases we need to use prism glasses. But this is a common complaint and
should be assessed by the neurologist or the pediatrician for problems
with eye movements.>>Thank you. We had another question come
in about pain relievers? And how to track improvements if
you’re using them to treat headaches.>>So how — was the question
how to track these?>>How do you track improving headaches
if you’re using or improving symptoms if you’re using a pain reliever of some kind.>>Uhm. So I’m not — I’m going
to talk around the question because I’m not sure I fully understand it. But certainly pain relievers have a role
and tracking relies on good communication between the parents and the physician
about how much is being used. I don’t use narcotics or anything that could
be abused on an outpatient basis with any of my patients be it after a
concussion or chronic daily headaches. The question has always been can you go
back to play if you are still on something like tryceclic anti-depressant that
is masking of the headaches and again, that’s part of that decision that I make with
the school, with the school athletic trainer and based on an individual history of whether
all we’re doing is masking that post concussion or whether it’s been a long
standing problem with headaches and we’re actually treating headaches. But again, tracking is open communication always
between the child, adolescent and the parents and the physician making decisions when to
stop using those pain relievers also depends on each person, how they’re doing. But I find that most people as
soon as they get back to going and feeling well stop their pain
relievers and sometimes forget to call my office to let me know. And I hope that answers the question.>>Thank you. One last question. How proficient are ct scans in
diagnosing and treating a concussion?>>CT scans don’t diagnose concussion. Concussion is a clinical diagnosis. If somebody were to get a CT scan that
would be because they were worried about some other additional injury
to the brain over a concussion such as there being a subdural hemorrhage
or any other type of bleeding in the brain or CT scans are used to rule
out other conditions. They don’t make a diagnosis of concussion. And we want to minimize the use of CT
scan in our children and adolescents because there are good studies showing that
although the risk of radiation is low the dose of radiation is low and the risk of
future brain cancer is low, it’s not zero. So a CT scan should only be used in an
emergency basis where the physician is worried about something other than a concussion.>>Okay. All righty. We have one more question come
if for observation post injury. Should an individual be kept awake for
several hours following the injury?>>I think that that was a common practice
years ago and I think that today we know that that’s not entirely necessary to do. So I think it’s important following a concussion
someone has an opportunity to rest and that as long as they are not showing any
signs of more significant head injury that it is fine for them to rest.>>Okay, great. Thank you. We had a few questions come in
about a specific case or scenarios so those individuals can contact
us at the Brain Injury Association of Virginia to get that information. And thank you all so much for joining us. We really appreciate it.>>Thank you and thank you to everybody who took
the time out to listen to this webinar today.>>Thank you.>>Thank you.

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