Chapters Transcript Current Management of Sport-Related Concussions in 2025 Dr. Mark Halstead presents on how to manage sport-related concussions. Sounds good. Thank you. So, um, a couple of things, uh, I always enjoy getting to come back down here. It's been a while since I've actually done an early birds, and, uh, for me being in an orthopedic department, early birds is kind of a, I chuckle when, when we talk about early birds here at 8, since we're usually doing our lectures at 6 or 6:30. So, an 8 o'clock start lecture is actually refreshing to me. So, uh, we'll, uh, we'll have a little bit probably more awake, uh, Doctor Halston today. Um, so, um, I put up this picture here, uh, partly because I've been doing a little dabbling in AI, um, and I was, uh, I tried to create a picture for one of my slides. Uh, asking about, um, created, uh, a picture of a neck injury from football from a collision. And this is what I got, which is kind of interesting, um, when you look at it because I, I don't know where one of this person's body parts are. Looks like we have two people mixed together. This is what's frequently referred to as hallucinations in AI. Um, so I just put it up there as this may be how you feel about concussions, is a little confused, uh, feeling like some things kind of mold together. Uh, we may not have all the pieces, uh, that we need, uh, in order to, uh, appropriately treat, uh, concussion, the way we talk about things in 2025. And as I was mentioning before the lecture started, um, I've given this talk many a times over 20 years and Um, I, I would probably cringe a little bit if I listened to my talk, uh, what I did at the start of my career because we manage things very differently now than what we used to 20 years ago. So hopefully, we'll have concussion be more clear, maybe everything will be out of focus uh when we're all done with this, but we'll, we'll see how things go. So the first question I always pose here is, is how do you manage concussions currently? Um, this is, again, another AI generated image. This one's a little bit better. I asked for uh having a concussion patient in a dark room. Um, and is it that how you treat it? Do you recommend having kids be in a dark room with no stimulus, uh, which is 20 years ago, which was kind of the recommendation, cognitive rest, physical rest. We recommend not doing anything because too much stimulation to your brain is gonna hinder your recovery after concussions. Well, we figured out like a lot of other conditions in medicine, that's not really the best approach in order to treat a concussion. We've learned that from back pain. Bed rest was never a good idea. It's probably just not a good idea in general just laying around in a bed most of the time, as far as treating, uh, any sort of medical problem. But, uh, definitely concussions, that's not the way to go. So if you are recommending to patients that they should be in a dark room and they shouldn't be getting any stimulus, and just rest as much as possible, and that's gonna get you better, well, the evidence shows that's probably not the case and probably actually will hinder their recovery rather than help facilitate it. Concussions are a challenge. Um, you know, we're talking about things, even if just looking at a general pediatrician trying to figure out all the stuff that you have to keep in tune with, um, and obviously, me being someone who deals a lot with concussions, having this much literature since 2001, I just put this on here, cause that's when the first concussion statement actually was released in 2001. And when we look at things, 24 years later, there has been a total of now, um. There you go. Uh, 8,643 articles, with the vast majority of those being in the last decade and a half. So that, that's a lot to keep up with. Now, unfortunately, there's a lot of not great literature out there in the world of concussions. Um, but in the big picture things, there, there is, it's changing all the time. And this is actually a little bit interesting graph too, cause if you We look at most of the other conditions out there. If you look at kind of around just a couple of years ago, we see that kind of post-COVID lull in research being published, and then it started to pick up again. And we're already seeing a big robust amount of literature already in this year alone, uh, on concussion and sports. And that's just sports-related concussions. That's not even looking at, um, concussion in general. So, before we kind of go into the nitty gritty of treatments, um, I think it's helpful to talk about a couple things that I think uh we're probably using terms a little bit incorrectly. So first, we try to avoid the term post-concussion syndrome. It doesn't describe much. Um, it's not an acute diagnosis. I see this coming from ER diagnoses all the time, uh, that someone has post-concussive syndrome. Um, I don't know what that really means, honestly, we actually, in the world of concussions, we use people that have prolonged symptoms, so that's defined as longer than 6 weeks after a concussion injury. Um, that they have, um, persistent symptoms of concussion. That's how we describe it. We don't, we don't call, we don't put anything as post-concussive syndrome. Um, if we just go by timelines or what are expectations for a concussions, so 50% of, and this is again, our pediatric population, 50% of kids we see with concussions generally are feeling back to normal within 7 to 10 days, but that also again means 50% or not. By 4 weeks, 70-80% have fully recovered, and then there are still a lingering amount, depending on which literature you look at, between 5 and 10% that have issues that last beyond 6 weeks. So most, most kids are gonna recover within 6 weeks of their injury, but there are some things that can sometimes cause a more prolonged, um, uh, uh, symptom profile. It may not always be the actual concussive injury that's causing their persistent symptoms. And then the other thing I would just ask is, is just please avoid putting qualifiers when you're describing things to patients that they had a mild concussion or a severe concussion, OK? You're arbitrarily describing something based on your own personal kind of feelings about that. There is not actually descriptors that we have that defines what's a mild concussion or a severe concussion. When I talk about it with patients, I say, you're either concussed or you're not. OK? So I tell them, it's like you're pregnant, you're either pregnant or you're not. So it's not an in between, although in the third trimester, most women would argue they're severely pregnant. So, so in the big picture of things here, we wanna don't put those qualifiers on it because it also creates false expectations for the injury. If you tell someone it's a mild injury and they've had a brain injury. Well, that sometimes downplays the injury. I get lots of patients in my office. I've had many mild concussions over the years. Well, that's a problem, OK? Um, when you've had multiple concussions over the years, regardless of whether they've been mild. So they may have mild symptoms, they may have severe symptoms, but that doesn't predict what their, uh, duration of their recovery is gonna be. So, so just, again, you either had a concussion or you didn't, and that's kind of the way I would leave it, uh, rather than putting qualifiers on it. So what are some reasons that athletes might not be improving from a concussion? Well, they may have an associated neck injury. Those are super common. A lot of concussions are whiplash mechanisms. So if you're not looking at the neck, you better start looking at the neck, cause that's one of the things that we oftentimes uh see as something that we need to be treating better. Uh, they may have underlying depression or anxiety, or they may develop depression or anxiety, sometimes from the recommendations that we make for patients as far as treating it, because of the fact that they've lost their ability to do their sports and activities. They're told to do things that aren't very exciting, like, again, staying in a dark room or not going to school or what have you, and especially this time of the year with kids with school, they're getting a little anxious about their finals and things like that. So again, that could be a challenge for uh someone and that can heighten their symptoms and it may be related to anxiety because those symptoms actually overlap. If I gave a symptom checklist to who has anxiety and compared to someone with a concussion, they may have a very similar profile and they may look concussed even though they haven't had a concussion. They may have an injury to their vestibular system, so the system that controls your sense of balance and dizziness. So that's a common thing, and so that may be contributing to that. We see a lot of what are called ocular motor deficiency. So my colleagues at uh CHOP, uh, show that 70% of kids after concussions have some degree of ocular motor dysfunction. And so that could be just simply watching how their eyes move when you do simple otraocular movements or some other tests that we'll, we'll talk about very briefly, uh, later in the talk. Whereas you're looking and their eyes don't sync with each other. They're kind of going out of, out of order with each other. 1 may be going one way, the other one goes the other way. They may get a stagnous with some of that. So, so when we're looking at those things, that can cause troubles with blurry vision and dizziness, and headaches. Uh, they may have troubles with sleep, uh, disorders, uh, following their concussion, either because of their symptoms that they're having, causing trouble falling asleep, or because they become what we call sleep zombies. So again, they're told to stay home, so, but they have nothing else to do, so they sleep all day and then they get very, very fatigued, and they get in this bad pattern of sleep. They may have a previous migraine disorder that's been undiagnosed. OK, actually, when you look at the literature, and you look at, there's a study that looked at uh patients that came into a clinic to evaluate headaches with pre-diagnosed or preconceived sinus headaches. And when the headache specialist actually uh looked and got through their history and actually got came with an ultimate diagnosis, only 3% of the patients that actually came in with a preconceived. Uh, pre-diagnosis of a sinus headache actually truly had sinus-related headaches as oftentimes as migraines or other headache disorders. So, so again, maybe they had migraines and they were attributing their previous headaches to just sinus problems all the time. And malingering, and this is not usually typically a thing that we see too often with our athletes, but if a concussion happened from something else outside of a concussion, so they had a bullying event, so, so there was an assault as an example. There was a car accident, a kid, new driver, they just crashed parents' car, and they're super, super distraught about the fact that they, they trashed their parents' car. You know, again, that, that could be something that can cause some issues, and they just don't want to get back to their normal situations because of the fact that they have issues. So, the crux of the talk is this, we're gonna go through these individual things here in very depths, uh, looking at stuff related to treatment for a concussion. So we'll start off just the, the, the bottom line. So if someone gets an acute concussion in, in sports, and so someone like me, I'm oftentimes on sidelines of events, so we're gonna do that acutely, but you may have a patient that calls in. You know, through, uh, an exchange or what have you, and is asking questions about my kid, probably has a concussion. What are the red flags that warrant a referral to the ER? So these are red flags that we talk about in the world of concussions. Some of these to me are more concerning than others, and I'll kinda highlight each of those. So, so if we have weakness or tingling, burning in the arms or legs, that's definitely a, uh, more of a concern for me. severe, progressively increasing headaches, so like worst headache of their life. Uh, if they've had loss of consciousness, although loss of consciousness is kind of a tricky one. Because the literature suggests 30 seconds of loss of consciousness is the concern. But I don't know anybody that's sitting at an event with a stopwatch waiting for someone to go down. I know I'm not doing this when I'm at a sporting event, and waiting for someone to go down and I hit my stopwatch in 30 seconds. And if you're in a situation where, you know, I work with the MLS team and so we have, you know, 22,000 people at a, a full game. And if I go out on the field and 30 seconds has gone by, and someone's been unconscious, honestly. Feels like 3 to 5 minutes. So, so again, in the big picture things, your time is actually a little bit distorted there a little bit. So, and is there anything different with a concussion that took 29 seconds for their loss of consciousness versus 31? Probably not. So, so prolonged loss of consciousness would be our, our biggest concern here. If it was a brief losses of consciousness, that's not something that we would get worried about. That happens very infrequently with concussions anyhow, so 5 to 10% of concussions result in a loss of consciousness. If they have a deteriorating consciousness state, so again, they're having much harder time staying awake, uh, and keeping them conscious, uh, vomiting, uh, I have what's called the two puke rule, so if they've thrown up more than twice, they need to go in. They give them 2 pukes free, and then after that, then they probably need to get assessed. And increasingly restless, agitated, or combative. So those are concerns as well. So there are a couple other ones that aren't highlighted on there. So, neck pain and tenderness is pretty common. Obviously, if someone's had a neck injury and you're more worried about their neck, uh, and then, again, that may be something we need to worry about in terms of the neck, but I wouldn't worry about it so much in terms of the concussion. Double vision, like I mentioned, visual symptoms and visual problems are very common after a concussion, so I don't get too excited about that one. And seizures or convulsions. Actually, the literature that's looked at seizures, post-traumatic seizures for head injuries, doesn't show a correlate with actually intracranial abnormalities if you scan people. So, they freak everybody out cause seizures are always a concern, uh, when you see one happen, especially if it's post-traumatic, but the correlation of the brain, any severity of the injury is not there. So, so yeah, it's there cause most people freak out about it, but if we're looking, it doesn't really actually uh lead to something else that we're more concerned about or something more intracranial going on, then the concussion probably not. So who needs imaging? Um, so I love pediatrics because we have things like PCARN, which is the, the ER, uh, multi-syste or multi-center group that actually looks at some of these questions as far as making our ER assessments, uh, much more efficient. So they've actually looked at who needs neuroimaging and, uh, in the pediatric age group. So this has actually been validated multiple times, uh, on various studies. So it's, it's a good protocol or a good, uh, uh, algorithm to follow. So, so someone comes in if they have a Glasgow Coma scale of 14, so anything less than than full normal, uh, or other signs of altered mental status or signs of a basal or skull fracture, if those are present. Then yes, you need to look at a CT scan that accounted in this group that they did this study on 14% of the population. And out of that group that had a scan, 4.3% of them had something that was considered clinically important on their scan. So still a small percentage of patients when they even have those criteria that actually had something on it, but in those situations, the CT scan is recommended. If they don't have, if they have a normal Glasgow Coma scale, they don't have altered mental status. They don't have signs of a basal or skull fracture. Then we have another tier. So if they've had a history of loss of consciousness, history of vomiting. Severe mechanism injury or severe headache. So if those were present, which accounted for another 3, almost, of the population here, and those that had scans, 0.8% of them had something that was clinically um important on their um uh on their scans. So that triage group, this is where, where I think we do things very well here at Children's is um you can observe them for 4 hours and if nothing worsens, then you can send them home without a scan. Um, or you can consider a CT scan, and there's other clinical factors in here. So physician experience. Uh, that's obviously always one. I know, certainly when I started my sports medicine career, just in general, uh, I certainly got a lot more imaging of certain things than I do now, uh, just having seen more and had more exposure to things. Um, multiple versus isolated findings, worsening symptoms or signs of emergency departments after emergency department observation. And then the final one is parental preference, which that one, as I usually tell people, please try and talk people out of it. You know, again, CT scans are not benign. Uh, we do know that obviously the radiation that's there, um, it, it is relevant and we don't wanna do unnecessary radiation to our pediatric population if we don't have to, uh, especially when we're talking about in terms of CT. Now, again, we do things for low dose radiation to make it as less as possible, but it's still significant. So if we can avoid it, uh, that's great. I mean, I had one kid I saw in my practice that had had, um, 7 CT scans over the course of 2 months, uh, because the, the, uh, clinician who was following them was just kept concerned they weren't getting better. So let's keep getting a new CT scan. That's probably not what we want to really be doing in those situations. So, so again, that's where just having sometimes that conversation of how useful is the CT scan for somebody. And that's always a question we get in the office is when do we need imaging? I tell them if they don't have any of these things on here, then the odds are they don't really need intervention. So, and then if they follow that category of no, which is a little over half of the population in this study, they have less than a 0.05% risk of anything clinically relevant and CT is not recommended. And even those, the ones that had relevance, uh, clinically important TBI stuff found on their CT imaging, which was 0.9% of this whole population. Neurosurgical intervention was even more rare, accounting for only 0.1% of those. So, so again, the lot, the odds are pretty low that you're gonna need something done, uh, interventionally from our neurosurgery colleagues, um, after a, a concussion. Yeah. Um, no, uh, but again, that would be like, again, worst hit of life is kind of the way I would kind of describe that to someone. Now again, that's gonna be very difficult to assess in someone who's 2 or 3, cause this does go down to that age group. Um, but, but in the big picture of things again, that's, that's gonna be still a subjective thing there. So again, could you watch them and see if something changes with their headache? Sure, of course you could. So, cause that falls into this category, that's second tier symptoms. So, yeah. Yeah, yeah. Over them and and for them to uh. Yeah, but basically just tell them, hey, you know what, we, we have really good criteria that are out there. There's been lots of research that's been done on this that actually shows these are the things that actually we really need to scan for. And in those situations, Jack and Bill. OK. That we need to get a CT scan for. So in those situations there, that would be reasons why I would do it. But again, I usually use the, the radiation part of things there. I don't wanna do any unnecessary radiation to your kid if I don't have to. And there's nothing that's on their exam. There's nothing on their history that warrants them getting imaging, and we can just watch them and, and odds are we're gonna be good. So that's kind of how I explained. Doctor Halstead, could you repeat the questions that people ask in the room? Sure, yeah, I'm sorry. But. I And your lifetime of cancer is actually very. Excellent. So the comment was made as far as uh an ER attending had made that your lifetime risk of having something more from the radiation from your CT scan is higher than what we would find on uh the imaging that we would do uh in the ER evaluating someone. So again, you can certainly use that as another way of talking about that, so. Um, so sleep, um, so numerous studies out there in the world of concussions demonstrate the negative influence of too much. And too little sleep on concussion recovery and their symptoms. So if you're getting too much, that will have a negative effect on your concussion recovery and your symptoms, and too little. So, we want that sweet spot. So our typical, um, you know, recommended sleep duration for whatever age we're talking about. So there's numerous studies out there. Um, these are only just a, a, a smattering of just a few of them, uh, that have been published over the years on concussion and sleep. So, again, we really wanna kind of target sleep and, and talk about it a lot, but also talk about it in terms of we don't wanna do too much. And this is, again, where sometimes the recommendations are, it's just stay home and rest and sleep, get as much rest as possible. Again, I don't mind for the first couple of days getting a little additional sleep, but we really don't want to make it a prolonged, uh, course where we're doing lots and lots of napping, cause a lot of that sleep dysfunction really causes some troubles with the kids that we see and actually can be contributing a lot to some of their symptoms. So, we already know that our kids and teens have poor sleep habits, so that's problem number one. So we usually will discuss in our office consistency with sleep schedules. So a consistent bedtime, wake up time, just good sleep hygiene in general for all of us, having no distractions in the room, having their phone away, not having the TV on. And, and then really stressing that their bed should be for sleep. It's not for lounging in, for doing homework in, for scrolling through social media, and we really want the bed in your body to be recognizing that environment as an environment for sleep, and not all these other things that may be more stimulating that they may have you have a harder time falling asleep. And for most of our pre-teens, uh, and teens, the adequate sleep is 8 to 9 hours per night. So we talk about that a lot. Um, I mean, I, I, again, I had a kid this week with concussions who normally on a regular basis is getting 6 or 7 hours of sleep, and that's cause they Swim 2 hours a day, and they have another, they do extra running for another 30 minutes before that. Um, so, so they're just, they're not finding time to sleep and do their schoolwork and all that, and that's certainly a challenge that we see with a lot of our athletes. Certainly some sports lend themselves to that as well. Hockey is one of those that's a problem, because there's limited ice time availability. So, we have kids that are 9 and 10 that are doing practices at 1011 at night sometimes, um, because that's the only time they can get on the ice, just because of the, the lack of ice rinks to do practices on a regular basis. So medications and supplements, it is OK to use acetaminophen or ibuprofen after you've done an initial evaluation for concussion if there's no concerning findings on the exam. I usually caution using ibuprofen in someone who has underlying nausea. We don't wanna add fuel to the volcano. Um, so, so again, I, I usually try and avoid that. I don't usually recommend scheduling medications, so the Q6, Q8, alternate back and forth. And honestly, when we ask our patients when they come into our office who have been doing those things on a consistent basis, I ask them, do those things make any difference with your headaches? And the vast majority of them say no. And so I don't wanna just Keep using those medicines just for the sake of medicines. Again, we always want to try and do something in medicine to kinda help, but if it's not working, stop. And so, I usually will have them stop using those medications. And we do know that medication overuse headaches are very prevalent with those. And I do have some patients that have been using those medicines for a month or longer when they come in to see us, um, and they really haven't made any benefit. So I'm gonna certainly stop it in those situations there. And all the other medicines that are out there, there's no medicine that's specifically designed to treat concussion or MTBI. So anything we're using is meant uh to try and treat symptoms and the literature that's been looked at, at, at, at the few uh medicines that we tend to use have not really shown much improvement with things. And it's always hard when you're talking about looking at medication. And the benefit of it, because we don't have a standard like course that this is going to go away in somebody. So if I'm comparing two groups and just isolating how the medicine has been effective, it gets very challenging with concussions cause we don't know that that person's going to naturally improve in 2 weeks, or did it really actually go through their natural course of recovery, or is it because of the medicine? So it gets a little bit more challenging when we're looking at medicines. Um, and there's really, again, no research to date that shows any consistent benefit and symptom improvement or time to recovery with any supplement or medication. However, there was a recent pilot study that was just published this past year that suggests that branch chain amino acids may help with recovery. Again, it's a small pilot study, so it needs to be looked at a little bit more. Um, but that may be something, who knows? Uh, we'll see, uh, as more research comes out about that. I do tend to use a lot of melatonin with kids to help assist in sleep initiation, uh, if it does become an issue. Uh, so I don't, I don't shy away from melatonin for some of these kids just to kind of get them on a good sleep schedule, if they're having difficulty falling asleep at night. Cervical strains, super common. OK. Got to look for it. OK. So when I go through histories with patients and we're talking about going through their symptom checklist, when they endorse headaches, there's several things I ask them as additional questions. I ask them, where is your headache? So is it front, top, back, sides, all over. Um, and so if they're telling me that their headaches are typically here, and maybe they have an endorsed neck pain.s are pretty high. They've got a neck component of that. So you better be evaluating their neck. You should look at it anyways if someone's had a, a history of a concussion. Uh, and just do simple neck range of motion and see if that, and I asked him, does that produce any head or neck pain? So, so it may, they may just say their head hurts when they move it, but it shouldn't cause any headaches, um, from a concussion, uh, getting exacerbated just by moving up your neck unless your neck is contributing to it. We do know that cervicogenic headaches are super common. Uh, they actually do produce headaches. They produce pain behind the eyes. So when you see. Those things historically, that better be looking for them. And I am very aggressive with treating the neck if I see them, um, just because if we let them go, those tend to stick around for a long time. So my pearls are constant headaches. So it's pretty unusual for most concussions that we see. If someone endorses, I have headaches all day long, rarely is the headache all day long because of the concussion itself. OK. Usually, I see associated neck problems with So if they've had a history, my headaches are there all day long. I can almost guarantee you every single one of those patients has some sort of neck component to their, their symptom profile. Again, towards the posterior head, that's definitely a concern. And again, if they have any pain with neck movements, those are ones that you definitely need to be um considering the neck, in addition to the concussions. So, so again, don't, those are two separate problems, but we want to be treating the concussion and the cervical strain. Uh, ocular motor dysfunction. I'm not gonna go into all these in detail. You can certainly, if you look at VOs, uh, if you go to YouTube and type in VO's concussion, uh, you'll find various videos that show you how to do each of these assessments. But these are different eye assessments that we'll do in the office, smooth pursuits, saccades, convergence, visual, uh, motion sensitivity, and the vestibular ocular. Reflex, looking for things that may provoke symptoms and watching how their eyes work. Um, and there is ocular motor therapy that we can do for kids that actually can help them with their recovery if they're having some of these challenges. Fortunately, a lot of these things will resolve on their own, so not everybody do we have to send for therapy for these types of things. Um, but these are things that can be contributing to their symptoms. Profile. So if they're having lots of dizziness, uh, uh, uh, certainly, obviously with the headaches, we wanna look at that. If they're having any eye symptoms, blurry vision, uh, dizziness, things, or blurry vision, uh, double vision, things like that. Uh, I'm definitely gonna be digging into their eyes a lot more, uh, as far as a possible source of their symptoms, and then treat that appropriately, uh, or give them some other suggestions to do. Yeah. Yeah, so Right. So, so we do have specific therapists through children's. Uh, the Young Athlete Center has a couple that do these types of things. Um, there are a couple centers in town, uh, um, Lisa Diler, and then there's, um, uh, on my blank on her name right now, uh, um, Cheryl Davidson, um, who is the Center for Vision and I. Uh, they, uh, also have an interest in this type of stuff. Um, and then certainly there are other, uh, physical therapists around town. Usually what we do, uh, if the physical therapist, uh, if we're sending them for that. A lot of the therapy places will have vestibular therapy. If they have vestibular therapy, usually that means they have someone that does concussion therapy there too. And usually they have training and doing ocular motor rehab. So, so that there's different places around town and sometimes it switches this therapy place, therapists move different locations. So there's not like one consistent place outside of, again, we know our children's therapists do. So, so that would be a, a tried and true resource for, for if you're gonna send someone for that. Mhm. Yeah. So the question was, where do we send people? So, sorry about that. Right, driving. OK. This, I think it's overlooked a lot as far as counseling about driving in teenage patients. So there are several studies that show that actually drivers are, um, uh, uh, after a concussion, people are impaired with navigating road hazards. So they've actually taken, uh, people and put them in driving simulators, um, after a concussion compared to the people who've had orthopedic injuries or, or. Something else that's non-concussion related and their driving performance is definitely um less. And so if we have someone that's a newer driver, which is most of our teenagers, uh, I usually don't want them behind the wheel. Uh, I have a 11 example I use all the time. I had a patient, uh, this is probably a decade ago now, who came in and, and told me their post-concussive story. They had a concussion from football. Um, they, um, came out of the game, went home, uh, drove themselves. Um, they puked in their car once, um, after they, uh, were driving home, went to his girlfriend's house, got his girlfriend, and he does not remember anything that happened after he, uh, picked up his girlfriend. He doesn't remember anything the rest of the night, doesn't remember how he got home, what he did with his girlfriend, where they went, how he got his girlfriend back, how he got back home. Um, so again, we have to remember that these are impaired drivers after concussions. So we really don't wanna have our kids be doing the driving. I usually will suggest at least for the first week after their concussion of not driving. Um, uh, but it depends on what their symptom profile's like, as do we want to extend that. So we just have to remember that when we're thinking about our, our driving age, uh, adolescence, uh, that driving is probably not the most safe thing for them to do immediately after their concussion. Flying, that's a different story. They can fly. We get that question all the time, is can someone go on an airplane after a concussion? Yes, you can. It's safe to be in uh probably not being the pilot themselves, um, but, but certainly, um, them actually being a passenger in a plane is fine. It doesn't worsen your concussion. All right, so screen time. OK, this is one we're gonna spend a little time on here because this is a question we get all the time. This causes lots of consternation for my teenagers and younger in our office. So, so for a long time, we've talked about how screens are this evil thing. And yes, in the world of pediatrics, screens are not the best thing in the world, just in general. But are they harmful for your recovery after a concussion? Um, so, yeah, and again, I'm part of the problem here because I wrote the first concussion statement that the PAP put out in 20 2010, and we did put on there reducing screen time and talking about that you should be minimizing this as much as possible. The second one we put in 2018 talked about that that's probably not what we should be doing. So for the last seven years, we've actually had recommendations to not have that as the recommendation. Uh, but I know that still exists. So these are two studies that were just done in the last 3 years that looked at what does springtime do for our effect on recovery from a concussion. So I'll talk about these. We'll do about the first one, which is the JAMA Pediatrics that got a lot of press. To begin with, the second one, not so much, but I think the second one's actually a better study. So, I'm not gonna go through all the individual details here, but, but there were two study groups here in this. They were ages 12 to 25 who presented to the ED. They put them into a screen time abstinate group. We'll talk about that in screen time permitted groups. So about 60 in each group. They were advised no work or school for the 1st 48 hours. The abstinate group was asked to abstain from screens, so again, abstain from screens, so not use them for 48 hours. That's an important point here when we talk about the actual results here. Half are male, mean age 17. Interestingly enough, the study was only over, uh, over a period of 10 days. They followed them. Um, and 25% were lost, lost to follow-up. They were not included in the follow-up in the final analysis. That's pretty hard to lose that many or that number of patients in just a matter of 10 days. I mean, there's studies that look at people over years that have 90% follow-up, and this one lost a quarter of their patients, uh, in their final analysis. And so what they did is they did a post-concussion symptom score at the time of enrollment, and they followed them for 10 days. And then they did 3 calendar days post discharge from ED consistently they did those, and then they had a screen time survey, uh, and then after 4 to 10, the participants complete completed an activity survey and then symptom scores. So, when we look at this, it still was probably about an equal number when we looked at uh screen permitted and screen abstinence. Half of the patients here were relevant to my population, which is in sports. And what did they find? So those that were allowed to use screens had an 8-day median recovery time. Those were, that were in the screen abstinate group were 3.5 days recovery time. So this got a lot of press because it looked like in the 1st 48 hours, if you reduce your screen time, that it actually will help facilitate your recovery. There's a couple interesting things though, when you really dig into the weeds of this study that were kind of confusing to me and don't make a lot of sense. So this first one here is the time to return to school and work or. Exercise. So in the screen permitted group, it was 7 days. The screen abstinence group, it was 6. So you get 1 day less for school or work and which was a little confusing to me if they were actually recoverable, why are they still spending time out of school or work? That didn't make a lot of sense to me when we look at that. And same thing for exercise. So they were still out of exercise over that period of time. And we do, this was already a point where we're talking about encouraging exercise for patients to help facilitate a recovery. But when we look at the nitty gritty here, as far as screen use, the median group. The permitted group, who's 660 minutes a day of screen time. 11 hours, 11 hours. I don't, I, even when I get my little update on my phone every week and tells me how many hours, and I'm like, really? Um, I don't even come close to that. And the 75th percentile was at 990 minutes. So, I mean, an astonishing amount of time spent on screens for the screen permitted group. So that already tells me something there. And the screen abstinence group, we're truly not screen abstinence. So that's why when we talk about when we're, we're translating the results to the general public, we have to actually be really clear. Abstinent means you're not using it at all. These people that were on screen abstin, we're still using screens for 2 hours a day. So, so again, reducing, you don't have to eliminate can help facilitate your recovery. So again, in the big picture of things, and even when you look at the range here, the 25th to 75th percentile was anywhere between 1 hour and 4 hours plus of using a screen per day on the screen abstinate group. So, Again, we have to dig into the weeds this with this, because when you take these interpretations and they go out to the general media and everybody says, oh well, screens are really, really, uh, uh, bad. Well, this study actually doesn't show that that's the case. And it may help shorten your recovery in the if you abstain from screens or reduce screen use technically in the 1st 48 hours, but you don't have to eliminate it, OK? So, and this one here, I'm just gonna skip over this one here. Um, so this, uh, when we looked at the second study, this one actually had this longitudinal cord. They have a huge cohort with this group, and they have 633 kids that have acute concussion, and they follow them over a long period of time. And they also compared them to those that just had an orthopedic injury. So they looked at them within 7 to 10 days of their injury, weekly for 3 months, then biweekly for months 3 to 6. And so they measured screen time a little differently. They use this healthy lifestyle behavioral questionnaire. They used both parent and patient reported screen time. And what they found in the 1st 30 days, the ones that had the lowest amount of screen time, and the highest amount of screen time, were associated with more severe symptoms. Ones that were in the middle. Get the best and have the less amount of symptoms. This will, you'll see as we go through the talk and keep going through this. That's the common denominator here is and, and one of the things I like to use as an example is Goldilocks and the three bears. And they actually refer to this in their study a little bit as the Goldilocks phenomenon. We, we don't want the too hot, we don't want the two cold pors, we want the just right. And that's what I talked about with my patients. So again, if you're Extreams of stuff, whether it's physical activity, whether it's your screen time, whether it's your sleep. Probably the odds of you doing worse with your concussion recovery is higher, OK? So, we want to find that sweet spot in the middle, and that's again, that's the hard part is kind of guiding patients towards that. But, but again, we don't have to stop everything, but we also don't want everything unrestricted either, when we're talking about concussion management. And they found that screen time was not uh a linear moderator in in uh post-concussion severity, so it wasn't like the more he used it was actually linear as far as what their recovery and severity was like. So, so again, the ones that had the worst prognosis actually had similar recovery trajectories, regardless of what their early screen time use was. The better predictor for worse symptoms were a higher pre-injury, uh, cognitive or somatic symptoms that they had. Adolescents, females, we know these things already, more post-acute napping, less sleep, again, talked about those before, and then higher pre-injury screen time. So those that were already using them a lot, um, those tend to have worse symptoms. So where do these studies fall short? We don't know the timing of screen use concentrated or dispersed, if it's active or passive. Again, you got a TV on and it's in the corner, and you're not really paying attention to it and watching it, but it's on, um, versus you're actively engaged in something, you're scrolling through social media for hours. The nature of the screen use, again, is it for social connection or television watching? Types of screens, LEDs versus CRTs versus plasma. There is some suggestion that LCD screens actually have more troubles symptomatically than non-LCD screens. The size of the screen, does a bigger screen better than this little small thing that we all carry. And, and does day or night modes on the screens make a difference too? Uh, and again, those are things we need to look into. I put this up here really quickly because I know a lot of patients are recommended these things. So blue light blockers, there are a number of studies that are out there that show that blue light blocking does not reduce eye strain after extended screen time. So, uh, patients wear them if they really want, but I also stress with them that they're probably not really gonna make any significant improvement in their recovery. So, so again, She'll be recommending blue light blockers for patients? Probably not. Let's talk a little bit about school and learn. So, one thing, if we're giving notes back to schools, make sure you're not putting overly restricted notes. They don't benefit the students. When you start putting nos and nos and nos, schools have to follow that, OK? And there's nothing wrong with letting them read or take a test, or doing homework, OK? Um, as I tell all patients in my office, I've never seen a kid come into my office with a concussion from doing too much school work. It's always because they hit their head with something, OK? So, now, your brain is not functioning at 100% after a concussion, you're gonna struggle, but that doesn't mean that that's actually gonna make the concussion, the actual brain injury worse, OK? Your symptoms may be increasing because your body's telling you it's reached the limit, but in the big picture of things, it's not harmful for you to use your brain after a concussion. So, I do encourage also patients to check back in before they start returning to play to make sure they're truly recovered. My big question I ask patients is, is your child or, or if I'm asking them directly, do they feel 100% back to normal, both in and out of school? If not, what's not back to normal. And that gets rid of all the, the symptom checklist because some kids have baseline symptoms that they experience and they're not gonna get to all zeros if we use a symptom checklist. So that accounts for that. Now, again, is this question perfect? Probably not. And again, I'm still relying on their self-report, but we don't have anything better with concussions. We don't have a blood test that can tell you fully recovered. So, so again, that's the, that's the question I tend to use for my patients before I start them on the return to play process. And again, using your brain does not worsen the brain injury. That's a big thing we need to remember. It may increase your symptoms, but it can't damage the brain further. I really encourage and stress with kids to communicate with their teachers. There's a reason why we call it concussions the invisible injury cause you can't see any of the things that they're experiencing, so their teachers can't see it either. I can't see what they're having troubles with just by talking to them in the office. Uh, someone who's dealt with concussions for, for two decades now. So, so again, they have to give me those things, um, uh, and communicate. So the more they communicate, the teachers are much more willing to help, and then people know what they are, are struggling with. And then moderation again seems best uh best with breaks, the symptoms worsen. And really, we should be avoiding requests for 504 IEP plans. So, um, you can use them if they're more prolonged, but in the acute setting, I would definitely not ask for those types of things, because as soon as you ask for that as a healthcare professional, the school is obligated to go through the whole assessment process. And that takes time. I had to do that personally with one of my own kids, not for concussion, but for anxiety that they had when they were in middle school and it was really affecting their learning. And it took us two months to go through. Process. It requires lots of resources. So, so again, and most of those kids are gonna be recovered by the time they finally get through the full 504 plan. A lot of, uh, schools will do an informal 504 where they're actually, they just put stuff formalized in writing without going through the whole process for kids just in general when they recover from concussions. But again, I would just avoid that request unless it's someone who's been really prolonged in their recovery. In those situations, hunt them over to us, um, and we're happy to, to look at them further and see if that's really necessary. So a couple uh quick studies here on cognitive activity. So this was a study that was done a while by one of my colleagues out at COP, uh, Naomi Brown. Um, that looked at, uh, the effects of cognitive activity and the, the, uh, and duration of post-concussion symptoms. I'm not gonna go through all the nitty gritty details for the sake of time, but I just wanna draw your attention to the, the orangeish bar here. So this is a Kappa-Myro survivor curve. So this shows you, um, when the curve gets extended out through here, basically, what that's telling us is this is longer recovery. So, they basically put uh patients into quartiles as far. As kind of the, a level of cognitive activity that they were doing. This group here is the one that restricted nothing cognitively at all. So they basically went about business as normal, but this was everybody else. So even if you reduce things a little bit, their recovery curves were just as much as if you restricted everything entirely. OK? So again, we don't have to restrict them to the extreme in order to get the same, uh, duration or the same kind of speed of recovery. So, so again, we just need to remember that when we're giving recommendations for our patients. This was another one that looked at strict rest. Does it help in the acute setting after a concussion? Um, so this one here, the white bars here are what was considered usual care. So that was a kid going back to school with appropriate adjustments during the school day, uh, as needed. And then strict risks were the ones that were told to stay home for 5 days, don't do anything, and, and then you can resume stuff after 5 days it's kind of getting back to usual care. So. What we saw here in the white bars here is that at various points here, there are statistically significant differences as far as the level of symptoms. So these are the smaller, uh, uh, heights of the bars mean that they had lower levels of symptoms. So, so it actually, they felt better, actually being back in school with proper adjustments rather than staying at home. And when we look at their recovery, Um, the same thing, another Kaplin survival curve here. So the ones that were back in school with proper adjustments on the bottom here, they recovered quicker than the ones that were put on strict rest. So, again, we just, we don't want to eliminate everything when we're talking about concussions with kids. So it is OK for them to be in a school environment and do that soon. This is, again, within the 1st 7 days after someone's concussion. So, I, I steal this analogy here from one of my colleagues, Karen McEvoy, who I've done a lot with, and she's taught me a lot and really helped me with the whole concept of return to learn. Um, so, she likes to use with patients, kind of thinking about their brain after a concussion and thinking about processing and schoolwork, is thinking of your brain as being like an iPhone. And so, when you're not concussed, you're the iPhone 16 Pro. So you have the, you know, the fastest processor, the best screen, um, you have the best camera, you have the best battery life, all the updated apps, but when you're a concussion, you're like the iPhone 12. So it still works. Apple still supports it. It gets your stuff. You may have to have a little bit more patience. You may need to recharge the battery a little bit more often, but it can still get stuff done. So we have to remember that again, it's not that the brain can't function at all after a concussion. It's just not working at the, the highest level, OK? So we just have to account for that. The biggest ones you have to be concerned about as patients in your office are the super high achieving students, ones like all of us in this room, is the ones who don't know how to ask for help, ones who don't know how to say no when they are given more assignments, the ones that don't want to do less work if they're given the opportunity to do less work. So, so the big picture things, those are the ones that are The ones that tend to be the most challenges because they don't like that approach to it because they just feel like they have to do it all. So, so those are the ones that we really stress us even more so, uh, as far as you can get through and you can learn doing 15 problems as opposed to 30. So, so again, think, just think about framing things in those kind of perspectives. So exercise, there have been, this is only a smattering of articles just from this past year of of things that show that aerobic exercise after concussion helps facilitate recovery. So sitting around doing nothing, the complete physical rest, those days are long gone. Now, where does it go wrong? Um, so this is the problems that I tend to see as kids when they're told exercises, they're not giving any parameters about this. So it should be what it's called sub symptom threshold training. That means that they're, when they're doing their cardio exercise, it is not exacerbating their symptoms. If their symptoms are worsening, we stop. And then we'll try again the next day, OK? But we don't want to push through symptoms that are increasing. It's not going back to normal sports skills or their sports practices. I generally start with 20 minutes. We increase it to 30 minutes if they're tolerating it after a week. Um, but again, with the same parameters that if their symptoms increase, then they back off for that day. Um, there are what are called, uh, treadmill tests, a buffalo treadmill test. I know we do that through our physical therapist at Children's, that actually can get a better, more detail where exactly should they be going heart rate wise and things like that. But most patients don't have access to that. So I just give them guidance of either light work on an exercise bike, so just not winning a Tour de France kind of speed. Uh, just getting their legs moving, a brisk walk or a light jog is kind of the intensity of activity. I encourage you to do it daily, but again, we need to be clear with our instructions because this causes a lot of confusion when patients are trying to do activity and they're giving this recommendation in the, in the, uh, pediatrician's office. So we do want to do exercise. We just need to have some parameters around what does that mean. And this is not starting the return to play progression thing, like we're going through the full 5 steps. What needs to happen before they go back to athletics, they need to be asymptomatic or rest or back to their normal level. Um, so that's where symptom checklists help. We gradually increase exertion, no return of symptoms with exertion. They're performing at their pre-injury level in school. It doesn't mean they have to be all caught up if they're behind and stuff. They just are performing at the pre-injury level. They're off of any medications that we were using to control their acute symptoms. And again, we just have to account for pre-existing problems. So kids that had ADHD or depression, anxiety as, as things that may be still having some of their symptoms be where they are. This is a very complicated chart. This is the most recent iteration of the return to sport progression. We have not yet adopted this in Missouri, um, because it, it, they made it a lot more complicated with this 2A and 2B aerobic exercise now, which I don't know why they'd start dividing up stages and they don't just make a new step, but, but these are, these are some of the experts internationally who created this. This is super helpful if you are in a professional or collegiate sports setting where you have lots of resources and lots of people to help monitor this. This is not as practical when we're talking about we're giving a recommendation from a primary care physician's office, and this is how we go through this. So if you have someone that can help you with this, you can certainly do this. We haven't changed our return to play protocol yet in Missouri. We're trying to figure out a way to make this simpler and more understandable. Um, so. That we can translate that. But basically, what this has on it is the 1st 3 steps can be done while you're still symptomatic with caveats on there. But we don't move to 45 and 6, which are non-contact training drills, full contact practice if your sport is a contact sport and returning to sport until they're symptom-free and back to their baseline. So, so again, there are some levels of exercise that we can be doing and increase that. But again, uh, the way that this is set up, this is a lot more challenging to navigate on a daily basis with patients. Uh, protective gear. So, uh, some of my colleagues in Wisconsin came up with this one, which is super helpful this last year. They looked at guarding caps, those lovely giant helmet extensions in football that they put on their helmets that make them look like they had giant marshmallows on the top of their head. Um, and they actually looked in high school football players and the risk of practice of using the guarding caps to get concussions. No difference between the group that used guardian caps versus not. Now, there's one caveat with high school as opposed to college and the pros. The guardian cap is different. In the pros and collegiate level. It's thicker, it's got a different density of the material. So we can't extrapolate this to college and prose, uh, as far as do the guardian caps make a difference in your concussion risk, um, but it does not at the high school level. You cannot buy the type of guardian cap that is used at the NFL level, or, um, at the, uh, collegiate level. So there is only one mass marketed one. And it doesn't show like it, it doesn't show that it helps. Same thing for when we talk about headgear, uh, related to, for like rugby or soccer, or people that just decide to wear headgear in sports that don't require a helmet, um, headgear has not been shown to reduce the likelihood of concussion in multiple studies. Um, so again, and it's simple physics, if We're thinking about this jello mold inside your skull, and we move it back and forth, and I just put more stuff outside of the jello mold, and I still shake what's inside there, it's probably not gonna reduce your likelihood of getting concussion. Great for reducing your likelihood of getting a skull fracture or brain bleed or things like that, but not so much as far as concussion risk. So what are some management don'ts? Don't recommend cocooning, so that's where you recommend staying in a dark room. Don't do anything until you've fully recovered. Uh, we don't recommend prolonged absences from school. 1 or 2 days is adequate for most. You do not need to wake patients at night. So if you're asking a layperson who is not medically trained to basically do a neurocheck at night, and you're worried about that you're gonna make that recommendation, better be observing them in the hospital if you're that worried about it. Get everybody gets you, get a good night's sleep. We're not seeing kids die in the middle of the night. Just spontaneously from getting a, a brain injury. So, so again, in the big picture of things, if you're that worried about it, then you probably need to be taking it up a notch. Don't overlook the driving recommendations, do not forget about a plan for follow-up. And I just don't recommend just giving a hand about return to play without getting some clear instructions on what exactly does that mean, and I'm not sure why something's popping up here. out. All right, there we go. Uh, and then this is one thing to just remember is iatrogenic worsening of concussions. So a colleague in uh clinical pediatrics published this almost a decade ago now. So we have our concussion. We prescribe rest and activity restrictions. We get deconditioning or we get mood changes, stress, anxiety related activity withdrawal. So guess what? We recommend additional rest. Symptoms worsen, we just Repeat this cycle, OK? So we actually in the world of concussions and how we recommended things two decades ago, we created problems. OK. Unfortunately, we have people who were bold enough to do some research to suggest that that was not the way to do it and we've made changes, but there are still people who are making these recommendations. So again, we don't want to be doing this prolonged rest and activity restrictions. And I'll just briefly touch on retirement. So, so going back to lovely days of, of Sesame Street, so 3 is not the magic number. Um, so, so that is not what we recommend. Uh, there is no magic number for concussions as far as number, as far as recommending retirement from a sport or an activity. Um, it's, it's really individual. You can put 10 concussion specialists in a room and you get 10 different answers as far as comfort level for somebody. Um, so, so I don't use an absolute number as a criteria. Uh, we look at all sorts of factors like what happened with the concussion, what sports they play, what positions they play. So this is where you have to have some knowledge of sports and what's involved and what is their ultimate risk. Um, but certainly, um, if someone's having repeated injuries, we need to start having at least some discussion. But it's not like 3, you're done. That number has been out there for a long time. I think the reason why it's out there in the general public and even in the medical community is there were some guidelines years ago that suggest if you, if you had 3 concussions in a season, you need to be out for an additional a year after that 3rd concussion in a sports season. But I, there's no other published guideline that suggests 3 is this magic number, but it's become this dogma in the world of, of, of sports medicine, uh, or outside of sports medicine, I should say, because we don't use that recommendation. And I put these things up here because there's some relevance here in my world now, uh, that's affecting what we do with concussions. So, unfortunately, with, uh, the changes recently, um, there, there, the CDC fired the five individuals who do the heads-up program at the CDC for concussion. So it was a small group. They did mighty, mighty work. I actually collaborated with them. Uh, over a decade ago, they're fabulous people and unfortunately now they've been laid off, uh, as many other federal workers have, so we don't have actually a concussion TBI team, uh, more through the CDC. So I, I'm hopeful that the resources from Heads Up stay out there. They were actually just about to embark on doing a revision of that, um, with a lot of professionals around the, the country, um, but now that's on pause and so updating and revising these recommendations are kind of on hold for now. So, so again, it, it, it is affecting uh all the cuts that are being happening. And then this just came out just the other day, um, where now, in addition to it, they're also looking at cutting funding for brain injury research in addition to axing this group. So, so again, we have to be aware that it's not, again, it's not just little things, it's affecting all of the world of medicine now, um, and certainly getting into my sports medicine world too. So take on Pearl, again, is we wanna um think about things as far as relax and the three bears. We want the just right approach. We don't want the too hot, too cold, so moderation is best, uh, as far as thinking about how we make recommendations to our patients after concussions. Um, I'll put my shameless plug in here, um, for Oops. For my podcast. So if you like, want to learn more about pediatric sports medicine topics, I have a podcast I've done for 6 years. Uh, we have all sorts of topics that we cover both in the medical world of sports medicine and the orthopedic world of sports medicine, and everything in between. Uh, we just actually recorded an episode yesterday about mono and the athletes. Uh, so, uh, that would come out in another week or two. So, so again, if you're interested and you like listening to podcasts and need something on the drive, you wanna learn about more uh pediatrics topics, feel free to, to join in. So. We got some questions or time for questions, and those are my social media handles there for the podcast and for me. Created by Presenters Mark E. Halstead, MD Sports Medicine, Orthopedics View full profile
