I wanna take a moment to introduce Dr. Tara Sharma, who graduated from New York College of Osteopathic Medicine, went on to do residency training with Cleveland Clinic and is board certified in neurology. She's a clinical assistant professor in the Department of Neurology at UW School of Medicine. She has clinical interests to include sports-related concussion, post-traumatic headache, and trauma and brain injury. Without any further ado, ma'am. So I'm gonna talk about concussions and traumatic brain injury. And so goals of this presentation, first is to define a concussion. So we're gonna go over the definition of concussion. And so then we're also gonna talk about knowing the difference between concussion and TBI and the difference between those two. Concussion is basically just a mild TBI. And then to describe the role of neuropsychological testing and follow up with evaluation of concussion. And then we're gonna go into some red flags of emergency referral for a concussed patient. And then we're gonna describe some of the symptoms and complaints of a person that's concussed, and then describe the general concussion injury recovery process and some of the treatments for it. Okay, some concussion statistics. So basically the recent data from Concussion Assessment Research Consortium showed that actually 50% of the athletes recover at 14 days, so only 50%. And 85% recover within 20 days. And so now that we're thinking that even it's best to educate your patients and best to educate these athletes and have coaches, parents, everyone not really kind of pushing them to recover if they're not recovering within 14 days. So 28 days is usually the time that we see most athletes recover now. So basically definitions of concussion. So we're gonna go over some of this terminology. Mild traumatic brain injury. And we'll kind of go over complicated, uncomplicated mild traumatic brain injury. Post-concussive symptoms. And so basically we'll discuss different types of symptoms that concussed patients present with. Post-concussive syndrome. I really don't really care for that terminology too much. And so I usually say resistant symptoms after concussion. So these are the people that kind of suffer from prolonged symptoms after their injury. And chronic traumatic encephalopathy. And so this is basically just a repetitive injury to the brain from repetitive concussions or traumatic brain injuries that eventually lead to neurodegenerative condition. It's basically mainly a neuropathological diagnosis. And so there's a lot of media coverage on a fairly complicated issue. So first we're gonna define concussion. And so there's a various amount of definitions of concussion. But some of the ones that I like is, one is that it's kind of the result of a biomechanical force resulting in a neurological dysfunction. So basically it's characterized by a hit to the head. And it doesn't have to be the hit to the head. It could be hit to the body that causes a jostling of the brain and the skull. And this causes a constellation of symptoms such as cognitive impairment, self-limiting, and resolve spontaneously. And so I like to tell my patients that you had an injury and the injury involved either a hit to the head or the body causing a jostling of the brain and the skull. And this leads to a functional disruption. So basically this leads to headache, dizziness, cognitive impairment. And so I usually like to tell people, you can think of it as traffic on the freeway. You're stopped, you can't go anywhere, can't go from one place to the other really quickly. Your brain is functioning kind of in a similar way. Your information from your brain can't travel from one place to the other very quickly. It's kind of slowing the process. And so the severity of TBI we define actually in clinical practice by the Glasgow Coma Scale, not really the presence or absence of any known symptoms or symptoms at random times following a trauma. Confusion and amnesia are hallmark complaints of a concussion, but they're not the only complaints as we'll kind of discuss in a little bit too. And so I just want to go through the Glasgow's Coma Scale in a little bit. So basically it's three things, eye opening, verbal response, and motor response. The higher the score that you get, the better your cognitive function is. So basically kind of like where we're at right now, spontaneous eye opening, oriented, obeys commands. So that's where we usually see a lot of our mild TBI concussion patients at. The lower the score, the worse off they are neurologically in terms of function. So concussion versus TBI. So what's the difference between a concussion and a TBI? So concussion is basically a mild uncomplicated TBI. So basically there's no structural damage on the CT scan or no overt structural damage. So no big bleed or anything like that. Complicated mild TBI, basically 13 to 15 in the Glasgow Coma Scale, but they have evidence of a bleed on the CT. So either an intracranial bleed or contusions or subdural bleed or kind of a hematoma outside the skull. I just want to kind of clarify too. So the Glasgow Coma Scale for the mild TBI is 13 to 15, approximately at 30 minutes of injury, not within 30 minutes of injury. Moderate TBI, the GCS will be nine to 12. So a little bit lower on the scale and severe will be less than nine. And so the WHO definition of concussion, basically they don't really go by the GCS, but they go by loss of consciousness. So loss of consciousness of less than 30 minutes, post-traumatic amnesia of less than 24 hours, and then transient neurological deficits, which we'll kind of go in again, to go into in a little bit. So this is another definition of concussion. So concussion is a brain injury defined by a complex pathophysiological process affecting the brain induced by biomechanical forces. So let's kind of pick this apart a bit. So what does it mean by brain injury and complex pathophysiological processes and biomechanical forces? And so brain injury, basically we describe it as a brain movement injury. And kind of what I was discussing before, your brain, your head gets hit, or it doesn't even have to be the head. It's just basically the movement of the brain and the skull. And you don't have to be directly hit. You don't have to be knocked out. And there's no gross structural abnormality on the imaging. It's also a complex pathophysiological process. So basically complex pathophysiological process is basically everything that occurs after a concussion. So basically the energy of crisis that occurs. So basically there's a rapid, rapid consumption of glucose, increase in extracellular potassium, influx of calcium initially. And then there's also, because there's an influx of calcium, there's a release of glutamate, which is an excitatory neurotransmitter. And so this leads to an increase in cerebral blood flow, followed by a decrease. And it usually lasts around seven to 10 days. And some studies even further than that, like I said, up to a month sometimes. Biomechanical forces. So biomechanical forces is not just the forward and backward motion of what happens when you get hit. It's also the rotational forces as well. So basically if you're getting hit to the lateral side of the head, or impact to the side of the head, you could also have rotation of the skull. And this could cause a diffuse axonal injury, and as well as microbleeds and things like that inside the brain, in certain areas of the brain. And so this is basically a nice little slide kind of showing an overview of pathophysiological process of concussion. And so this is kind of at UCLA, what our neuropsychologists, the way that they used to describe concussions. So basically it's like kicking the leaves up in the air. So that's the initial injury. And that's when your cells are kind of taking a lot of energy to kind of restore function. And then after that, it reaches a peak, and then those leaves fall around three to four weeks. And that's when the brain continues to heal. After three to four weeks, so about like a month period, some people could get prolonged symptoms. And when they get prolonged symptoms, and we think of other things that kind of are playing a role in kind of keeping those symptoms up in the air, kind of like mood, depression, anxiety, stress. Sometimes people have PTSD from the initial accident, deconditioning, neck pain, medication overuse, such as overusing over-the-counter medications to treat headaches, pre-morbid history of headaches or migraines too. So next we're gonna go into some of the symptoms of concussion. So what are some of the common symptoms that people with concussion experience? So first we're gonna start with these physical complaints. And so the physical complaints are the complaints that I usually mostly treat and deal with. Headaches is one of the most common concussion complaints. Dizziness, also pretty relatively common too. People could have autonomic dysfunction as well with concussions. Balanced difficulties. So postural difficulty with maintaining balance, kind of feeling woozy. Light and noise sensitivity, kind of some migraines features there. Vision problems. Vision problems could mainly be usually blurry vision or double vision. A lot of times people complain of double vision with looking at screens. Like convergence insufficiency. Nausea or vomiting or with or without vomiting. Tiredness, drowsiness. So, and then we divide it into cognitive complaints. So what are some cognitive complaints of concussion? Well, a lot of people will say that their attention is pretty bad. So they have difficulty paying attention, difficulty processing information. Impaired reduced memory. So their short-term memory is off. They can't remember things as well. They're mentally slow. So slow, they're fatigued. They can't think, they're stuck in the mud. Bogginess and concentration difficulty. Kind of go hand in hand with not being able to pay attention and reduce memory. How long do those usually last? So a lot of these, like again, like I said, about four weeks, give or take. That being said, people could have prolonged symptoms. Like 15% of the people could have prolonged symptoms after that. But a lot of times it's because of, you have to pick apart other things that might be playing a role in causing their cognitive difficulties. I see a lot of the times that ADHD people sometimes have a predisposition or predisposing history of like learning disabilities or ADHD, or if they have like anxiety or depression or something like that. And you could tell from cognitive testing, if they score pretty low on the attention portion, so the immediate recall, then that's likely also influencing their memory too. So a lot of times my patients complain of memory complaints, but a lot of times it's attention. It's causing them to have short, bad short-term memory or problems with short-term memory. Behavioral emotional complaints as well. So sometimes people could say that I get more nervous, anxious, depressed, jittery, hyperactive, especially in people that have PTSD from an injury too. We see that a lot with a car accidents or other traumas. Irritable, short-tempered and jittery are the main ones. So the most common complaints. So like I mentioned, headache is one of the most common complaints and the most common thing that I treat in clinic. Dizziness and slow indentation is another common complaint too for patients. Fatigue, light and noise sensitivity. Again, light and noise sensitivity goes hand in hand with headaches, also too with PTSD. So diagnosis of concussion. Well, there's a lot of different things to consider. And right now we know that concussion is mainly a clinical diagnosis. So there's not a hundred percent test that kind of leads us to the presence of a concussion of injury or kind of leads us to the diagnosis. And there's a lot of research going into functional imaging and blood tests to determine concussion. Yet there's right now, as of right now, there's no kind of clinical blood tests that you could do or kind of blood tests that you could do to help you determine if the person suffered a concussion or not. So some things to consider with a concussion is the mechanism of injury, symptoms, cognition, balance, visual evaluation. Basically kind of with the visual evaluation that I kind of mentioned with the convergence insufficiency. And that's another thing too that could cause a lot of cognitive complaints in people too. They can't converge to the target accurately or if they can't see the screen correctly, the blurred vision or double vision. Coordination difficulties, medical history and medications that they're using too. So this is a diagnosis of concussion, the likelihood of concussion. This is kind of how we diagnose concussions in the clinical setting currently. This is kind of the diagnostic protocol that we use at UCLA. So basically witness mechanism. So they have to have a witness mechanism that's pretty definitive, whether it's a hit to the head or whiplash injury or anything like that. Typical symptoms. So typical symptoms basically are either 1A symptoms, going down here, basically loss of consciousness or amnesia are the 1A symptoms or three of the B symptoms. So fogginess, confusion, headache, dizziness or loss of balance, nausea, vomiting, drowsiness, vision changes, photophobia. So those are kind of lumped together there. Tinnitus and mood change. And then improving onset within 24 hours. So I usually say within 24 to 48 hours when it's usually when symptoms develop most of the time. And improving time course. So altogether the time course, initially usually right after the injury, pretty bad, but then it slowly gradually improves with time. And so we say that four out of four, so if they have all four of those criteria, no real alternative diagnosis, then we say that's a definite concussion. It's three out of the four. So maybe they have three of these, but they don't have one, like their symptoms are not improving with time and no alternative diagnosis. Or in some cases people might have a history of migraine or a history of episodic migraine or something like that, but still their headache characteristics after injury are a little bit different. They have more neck pain, things like that. Possible is if it's one or two of the likelihood of concussion, these four things. And there's a possible alternative diagnosis. So like when I mentioned a history of migraine headaches or dehydration, it was really hot that day, they're mentally and physically exerting themselves, things like that. I think it's kind of cut off back here at the bottom. And zero to two, so if they don't have any of these symptoms or if they have some, but not all, and there is definitely an alternative diagnosis, then we call it not a concussion or unlikely a concussion. So diagnosis of concussion, going into complications of concussion. So basically complications of untreated symptoms or poorly treated symptoms could be poor cognition, depression, anxiety, migraine headaches, poor sleep too is another one too that could lead to poor cognition as well. And that needs to be addressed. A lot of times deconditioning, so taking a prolonged period of rest as well could cause a lot of these physical symptoms as well as cognitive symptoms. And then multiple injuries. So second impact syndrome, it's very, very rare. It usually happens more likely in the young adults and in the children because of their developing brains. Basically that means that they have a concussion and then they have a second concussion shortly after, usually within a month or a couple of weeks or even a couple of days. And those rapid swelling or massive swelling of the brain leading to coma. So kind of like people that have a noxious brain injury where they're kind of down and out and it's at high mortality rate. And then CTE too is kind of what we mentioned is the neuropathological diagnosis of when people have multiple hits to the brain. So neurocognitive testing. So neurocognitive testing or neuropsychological testing is super, super important. It's one of our main objective measures to determine objectively if somebody has suffered a concussion or not. So kind of what I mentioned before, a lot of the other features that I was talking about like headache, dizziness, things like that are more subjective measures. Well, this is one of them, cognitive or objective measures that we could determine if somebody has suffered an injury. So some of the testing that we use is the impact testing. So immediate post-concussional assessment, cognitive testing, I believe it stands for. And we do use that a lot with our athletes. It's like basically a computerized test. And the SAC. So it's a standardized assessment of concussion too. And that's the one that I commonly use in clinic. This could aid in determining if, like I mentioned, if athlete has suffered a concussion or if they're ready to return to unrestricted play too. So usually we do one of these testing, usually the SAC, right before they return to unrestricted play to see if it compares to their baseline or pre-injury SAC scores. There are studies have shown, study by Iverson has shown that when you administer these tests within 72 hours of the injury, it can predict recovery within 10 days. So if they score pretty poorly on the test, so they score below the 10th percentile on multiple measures of the test, that usually means that they might take more than 10 days to recover. And so that kind of, it kind of predicts that in that way. And so it's great because then it could kind of lead teachers to kind of give the athletes kind of restrictions or kind of accommodations, testing accommodations or classic room accommodations before they even experience symptoms. Formal neuropsych testing is useful in those with prolonged symptoms after concussion. So it basically identifies factors that could be contributing to prolonged recovery. It also could provide reassurance to people like, hey, you're not having a neurodegenerative or dementia or anything like that. But it also helps us, it helps guide us in recovery too, or guides us in our treatment plan too. Like I mentioned, it's a valid and objective measure to evaluate cognitive and behavioral function. So impact testing, I'm just gonna go through this really briefly. So it's divided into word or verbal memory. Verbal memory is basically you're presented with 10 target words or 12 target words, sorry, for a couple of seconds on the screen. And then after that, you're asked to recall as many words as you can. And so basically this is an example, was this one of the words that was displayed initially on the screen? So that gives you several different words and you have to pick out the ones that were initially displayed on the initial screen. Design memory, basically it's a measure of visual memory. So they give you several unique designs, different designs and different orientations. And then they give you test designs. So they want you to recall the designs out of the initial 10, 12 designs that you had. And you have to click to see if actually this design was in the initial 10 designs that, or 12 designs that you were given. Visual motor speed and processing. This occurs along with visual working memory. And basically what this tests is you have several designs on the top row and then you have numbers on the bottom row. And you're supposed to click as quickly as you can. A design shows up, you're supposed to click the number, corresponding number as quickly as you can and as accurately as you can. So basically tests your speed of processing and your accuracy as well. Then impulse control tasks. The way this works is there's a word displayed on the screen, same color as the word or a different color as the word. And the test taker has to click the box in which the same colors of the red and the red, let's say the red word is red. So the same color and the name of the word is the same. And that's the box that they click. And the reaction time is basically average speed of responses to the Bob tasks. So standardized assessment of concussion. So this is the one that I usually do in clinic because it's pretty quick. Impact is mainly just a computerized test. So basically I just ask the patient month, they know the month, the date, the day, the day of the week, the year and the time. So the time is approximately an hour to the nearest hour. Immediate memory, you're given five words and you're asked to repeat them three times. So basically it tests immediate memory or your attention. Then concentration, digits backwards. So usually I start with three digits backwards and you progressively increase. And the max that you do is six digits backwards. And you give them two tries for each digit backwards. And months in reverse order is you ask them to recite the months of the year on the reverse order. Then after that, you do the neurological exam, which kind of just poses cranial nerves, converge for current emergence insufficiency, balance testing, things like that. And after that, you tell them to, they could recall any of the five words that you've mentioned previously in the immediate memory section. So validity tests, these are kind of interesting. So they kind of show us if the individual is responding honestly or accurately to their symptoms. So it kind of evaluates if they're exaggerating their symptoms a little bit or if their effort is poor when they take the neurocognitive testing. So this is particularly true a lot of times in athletes during their baseline testing. So a lot of times athletes, they wanna botch their baseline testing or not do well just so when they get a concussion during the season, it won't be detected. And so these kind of validity tests kind of test for that. Also to people with persistent symptoms after concussion, a lot of times if they have financial incentive to still have symptoms or if they have a disability or something like that, or if there is some type of gain that they're getting for having persistent symptoms, that could be detected using some of these tests as well. Other reasons for these tests or other causes of failing these tests is fatigue, ADHD, ADD, reading disability, these kind of people to kind of sometimes score poorly on the validity test too. So you'd be cautious about that as well. There's a variety of different validity tests out there. A lot of them evaluate memory. So word memory or visual memory. Visual memory, a lot of times it's intact or close to intact. And even a lot of people that have really, really bad neurological conditions. And so you could kind of determine if somebody's malingering based on a lot of visual memory, how good their visual memory is. So for example, the test of memory malingering, they give you several designs. And then after they give you the designs, you see those designs for like six seconds or so. They give you one design that was on the screen initially and one that was not on the screen initially. And you have to kind of determine which one was on the screen and click the right one. Word memory test is basically kind of similar, but with words. So kind of presents two words that are very similar. So for example, pig and bacon at the same time. And then after that, after a couple of seconds, you're asked to, they give you another associations like pig and apple, and you're asked to click the right word or the word that you saw previously. And a lot of times people are actually able to do it pretty well, even people that have severe neurocognitive impairment. And so people that score very poorly, then that kind of means that, hey, you know, maybe they're exaggerating their problems a little bit. So it's kind of interesting. The IMPACT-4 also has a validity measure as well. So basically there's various scores that you get for various different composite scores for each section of the IMPACT. So the impulse control word memory task, kind of what we mentioned in the previous slide, design memory, and three letters total correct. So three letters total correct is kind of evaluation of visual motor skills. And so if they score below the fifth percentile of test takers according to their age, gender, and other factors, then it's likely that the test is invalid. They could be not making a lot of effort or not putting a lot of effort into getting good scores. And so these are kind of the cutoffs for each age group. So red flags for emergency referral. So when do you refer patients to the emergency department that has suffered a head injury? So a lot of times if there's fluctuating level of consciousness, so they're kind of in and out, kind of dazed, a slurred speech, or their speech is kind of inability to speak, or they have aphasia, it's definitely a reason to refer. It could indicate there's a more serious injury going on. Seizures, if they have a lot of seizures or a seizure that's concerning. Also too, if they have focal neurological symptoms, so if they have weakness or numbness on one side of the body, which is usually not typical for concussion, then they should be referred. Pupils that are unequal size. So again, if they're fluctuating level of consciousness and if they have pupils of unequal size, that could mean that there is impending herniation of the brain. Impending herniation of the brain. And poor recognition. So when they reach the emergency room, usually the emergency room doctor tries to determine if they should get a CT head or not. And so for mild TBIs, there is this Canadian CT head injury rule. And it basically determines whether you should get a CT head, whether you should observe the patient, or whether they're safe to go home. Again, this only applies to patients that have a GCS of 13 to 15. So the mild TBI spectrum, and they have to have at least one of the following. Loss of consciousness, amnesia, witness disorientation to the event. Exclusion criteria is if they're young, if they're less than 16 years old, they're on blood thinners, or if they have seizure during the injury. So high risk criteria is if GCS is less than 12, or sorry, less than 15 at two hours post-injury. So again, 15 is completely intact, and less than that, it means that there is some decompensation in their mental status. If they're suspected open or depressed skull fracture. Any signs of basilar skull fracture, so that being raccoon eyes, so they're bruising near their nose, or if they have CSF rhinorrhea, dripping from their nose, things like that. Greater than two episodes of vomiting, or greater than 65 years of age. So these type of people, anyone that has any of these criteria, should get a CT head. Medium risk is, well, you could consider a CT head, or you could observe in the emergency revocable RSC how they do. So retrograde amnesia for greater, that are equal to 30 minutes, so that means basically they can't remember anything in the past or the distant past. Dangerous mechanism. So dangerous mechanism being fall, greater than three feet. So you fall off a ladder, fall off stairs, or something like that, greater than five stairs. Or if you're getting, if a pedestrian gets hit by a motor vehicle, if a biker gets hit by a motor vehicle, stuff like that too. You could consider a CT scan. Well, but the scary stuff aside, so that's kind of the scarier end of the spectrum. A lot of times after concussion, your patients will recover if they're managed appropriately and correctly. The majority will recover within two to four weeks. And again, these are the risks of protracted recovery. So people that are kind of having those symptoms persist beyond the four-week period. Females, as females sometimes, a lot of people that have menstrual cycles and that have migraines or headaches during their menstrual cycles or before their menstrual cycles could get more symptoms. Also concussion as well kind of leads to more disruption in the female hormonal cycles. Be conditioning. This is one of the common things that I see people telling their patients to rest and not do anything till their symptoms resolve. That kind of gets them into this phase where they're not doing anything and it's hard to get them back out there and doing stuff. Past history of migraines. So that's kind of like a lot of the patients that I see, they have migraines, they have chronic migraines before, and then they get a concussion and then they have more chronic headaches. Mood stress, PTSD, and depression. Pre-morbid history of ADHD or ADD. And so that's a lot of times the neuropsychologists could kind of tease out. Sleep disturbances, especially like sleep apnea, things like that. Psychiatric history or previous concussion. And especially if the previous concussion was within a month of the concussion that they just had. So concussion injury recovery. So there have been several studies done that have shown that actually concussions have a favorable course. So a favorable course meaning there is neuropsychological recovery and there is recovery of their neurological symptoms. And this recovery usually is a period from days to weeks and rarely beyond the three-month mark. And even the WHO kind of took in a lot of these studies and that those studies also showed that recovery was pretty good in people that have suffered a concussion. And yet, however, 15% still have disabling symptoms. And kind of like what I mentioned before, teasing out and picking out the things that are kind of lifting those symptoms up in the air, kind of making them have those persistent symptoms like I discussed on the previous slide. So it's good to advise your patients or your concussion patients. Actually, they have pretty good outcome to their somatic, behavioral, and cognitive effects. So a lot of them resolve for the three-month mark. And so that's reassuring to people. And it's good that they know or are reassured by that because that's positive thinking. It's also very helpful for the patient suffering from a concussion. So what's the best step to have your patients successfully recover from a concussion? So first is a stepwise effort to minimize symptoms, to allow the brain to recover without over-isolating them. So we don't want to prolong over-isolation or sensory deprivation. So we want to minimize the symptoms and allow the brain to recover without over-isolating them. So that's a good step to have for those sensory deprivation patients. Early intervention. So usually I start about the month timeframe for early intervention for neck pain. So basically neck physical therapy if they still have symptoms of neck pain from a whiplash injury, let's say. Mood disruption. So seeing a psychologist if they still have mood issues beyond the one-month period. And then vision therapy if they have symptoms of vestibular therapy and things like that for balance issues, especially if they have peripheral vertigo as well. Frequent follow-up too is super important because you kind of want to monitor them and see how they're progressing through the course of their injury. What's the question? Yeah, can you describe the very first thing you have on there? Can you describe what that looks like? I realize you're not putting them, like locking them into the stairs, but do you let the person go home? Do you let them come to work? Do you tell them to stay home in their bedroom? What does the first one look like? So basically, and I'll kind of go over a little bit in the next coming slides, but two days of rest. So yeah, two days of kind of trying to limit the computer screens, minimize that, minimize looking at your phone a lot, minimize exercise other than just walking back and forth in your home, things like that. So basically two days of complete cognitive rest, brain rest, and then after the two days, then you could gradually return to activities. So first starting with the cognitive activities, so gradually trying to adapt to screen time. So bigger font for screens, larger screens, things like that for a couple minutes a day, I say starting with like an hour maybe or something like that. Exercise as well, so walking. So after the two-day mark, try to see if they could walk for 30 minutes or so. And if they can't, if they still have symptoms, then obviously they stop, rest the next day, and go back the day after doing a little bit less, maybe 20 minutes of walking. So kind of like a back and forth like that, kind of seeing how they're doing and seeing how they're progressing. We'll go into a little bit to the protocols that we have for athletes and for physical activity as well as cognitive activity in some of the coming slides too to make it a little bit more clear. So basically this is kind of what I mentioned, physical, cognitive rest, then return to learn, return to play, and then re-process. So cognitive and physical rest, so okay to sleep. So that's one factor that I wanna stress. You don't need to wake them up several hours in the middle of the night. That's gonna actually prolong their recovery and inhibit their recovery. So they could sleep, they could rest, sleep during the day too at the start, and kind of minimizing screen time, minimizing exercise and reading and stuff like that. First two days, they would do that. So anything that increases their brain rate. And then after one to two days or one to three days, depending, I usually like to do one to two days, then you start partial work. So one to three hours. So let's say one hour of screen time or one hour of doing some emails or answering some emails or doing some work on the computer, things like that. And also too, maybe doing a little bit of walk, a walk outside too, with that or the day after. And so stage one, I usually give them if they're able to tolerate, it depends on the person, usually a week or so, give or take. Again, if they can follow up to see how they're doing. And stage two is full school, full workday with maximal supports. So basically, they're able to do a full workday, but you want them to take rest breaks during the day, short time to do work, if they're in school, extend time on tests, if they're in school, stuff like that, modifications like that. And depending on how they do about on that, so again, you know, another week, maybe even less than that, if they feel like they're capable, they could move to stage three, which is full day with moderate supports, full school, full work with moderate supports. So basically, just maybe an hour break between meetings or something like that, or walking around every couple minutes to kind of get their eyes off the computer screen. And then stage four is full workday. Usually at this point, I usually just if they're good with moderate supports, I usually just return them to full school, full work, see how they do. If they still need some supports, like, you know, they're like, I feel so sometimes I'm slow with my work, feel like I need to take more breaks during the day, then I'll give them more breaks until they feel comfortable that they could do a full workday on their own without supports. And so yeah, stage five is just basically, basically returning to full school and work. However, you know, stepwise return to work is ideal. However, some employers are all or nothing, which is very unfortunate. I have some patients, especially in patients in the manual labor kind of fields, like housekeepers and things like that, or construction workers where it's just, you know, you have to do it or it's nothing at all. And so that's when we, I usually refer them to vocational counseling rehab. And then I also tell them if they're, I think I had one lady that was a statistician that it was just too hard. Her employer was like, you have to either go back to full time or nothing at all. And so I just told her to try to gradually adapt to screen time, doing emails on your own, maybe using the computer one to three hours in the day, using bigger font for screens, blue filter glasses for your work, reading too as well, just doing things that are, that help you stay cognitively active, gardening, doing some walking, things like that to kind of getting you on the regular schedule to kind of normalize things. But these people tend to also take a long time to recover because it's hard when you can't get back to work and when you're just not in your regular routine of things. So kind of like what I mentioned with physical activity, light housework, walking, biking too. Sometimes we push a little bit more, I push a little bit more of the physical exercise if they're not able to return to work just to get them on a good routine and a good schedule when they, so when they do return to work, they're less symptomatic. Yeah. Okay. Okay. So this is basically just a study that showed how important employer support is in returning to work. So employer support, meaning modifications to work schedule, shorter hours in the day, rest breaks during the day, transfer to a easier position or another position, things like that. It's super important within three months of injury because those people tend to return to work fully and recover a lot more easily. Those who have persistent symptoms at three months also tend to not be able to return to work within the year period. And also the study showed that about 17% one year didn't return to work and about one-fifth had a decrease in their annual income. And so that also causes a lot of stress on people if they can't earn a living, they can't return to work, and that leads also to prolonged symptoms, which is very unfortunate in a lot of cases. But it just shows, it's good, it shows that employer assistance is super important to helping these people out. So injury recovery. So this is basically the return to play protocol or return to activity protocol. This return to work, but it's mainly returned to activities. And so again, like I mentioned, 24 to 48 hours of complete rest. Then after complete resting for two days, trying some light aerobic activity, not using the vestibular system. So basically bike riding, recumbent bike for some people, especially if they have other injuries, let's say ankle injuries or something like that. Walking too. Walking is the easiest thing that a lot of people could do because they could just go outside and do it for 20 to 30 minutes and seeing how they tolerate. They have no symptoms after two days and they could go to moderate activity. And moderate activity is basically jogging, swimming, hard swimming, things that kind of use a little bit more of the vestibular system. Like stage four is heavy non-contact practice and work. So basically running, hardcore running, doing complex drills and soccer players, basically adding the cognitive component as well as the endurance component to the activity. So that's basically stage four is mainly for people that are like athletes. So usually for regular people, usually stage three is what they make it up to. Then stage five is full context practice work. Usually before they jump from stage four to stage five, they've had to have tolerated heavy non-contact practice without symptoms for two days before they're cleared to stage five. Sometimes you do like a cognitive test assessment to see if they're close to their baseline too, if they're athletes. Then if they're able to tolerate full context practice and work, so five and six come hand in hand, then they're able to kind of return to competition work. Usually after a day of being able to do full contact practice without symptoms, you could do competition. So these are just some concussion myths. So it doesn't have to be a loss of consciousness to suffer a concussion. You don't have to have a concussion every time you hit your head. Don't have to be waking up every hour after a concussion. Avoid NSAIDs after suffering a concussion. Not necessarily. Usually I say after 24 hours, you could do take NSAIDs. It's totally fine. Just because Tylenol sometimes doesn't do the trick for headaches, it's okay to play through it or tough it out. That's the olden days when you get your bell rung. But now, nowadays, we have clear concussion protocols to prevent that from happening. Helmets, headgear, helmet add-ons protect you from concussion. That's not true, too. In fact, a lot of people probably get the same amount of concussions, even if they have helmets, just because they're doing more aggressive things, just because they think that they're protected. Medications, there's no real study to determine if medications are useful on acute concussion symptoms or for treating acute concussion symptoms. There's probably only one that's been done, and this is basically in the pediatric age population, youths 8 to 18, show that alternating between Tylenol and Ibuprofen for 72 hours or Ibuprofen alone kind of helps reducing the frequency of headaches and reduces also the amount of headache days that they have in a month. But there's no clinical studies that have been done on OTC use or over-the-counter analgesics in concussion in athletes. We're trying to actually here at UW look into that topic. But as of right now, for clinical management, for my acutely concussed patients, I usually do decadron taper sometimes if they're two days out of their injury and they're still having some symptoms, just to help them along a little bit to return to work or return to athletic or return to doing some sort of activity. Yeah? Five minutes. Okay. Five minutes. Okay. That was a hand raise. Also to do actually a short course to have steroids, or sorry, NSAIDs as well. Steroids too, sometimes it's tricky with athletes. They might have to get approval from certain people for that. Like I said, steroids are preferred just because they're less likely to cause rebound headaches or worsening headaches. And because I feel like they're more effective than NSAIDs. But if they have a lot of anxiety, if they have PDSD, they have insomnia already, it's probably not the best choice. Educate your patients that even if you were to give them medications in the acute recovery phase, they will only help relieve the symptoms, but will not alter the overall pathophysiology or course of recovery from the concussion. So it won't help with the pathophysiology, but it will help them kind of have those symptoms be a little bit more manageable so they can return to school. So they're able to like basically focus on screens a little bit longer or do a little bit more of a run, kind of help them recondition a little bit better. If returning to sport, they will have, however, need to be off all medications. So they can't be on any NSAIDs or steroids or anything like that, unless they have a pre-morbid history of migraine, they're already taking like Imatrix or something like that before they suffer the concussion, or if they're already on preventative therapies for migraines. Other treatment modalities, acupuncture, I actually recommend it to a lot of my patients. A lot of people don't want medications. That's fine. Well, some of the alternative therapies tend to be beneficial too. Acupuncture tends to help relaxation, helps relax the muscles, the mind. Chiropractor too, a lot of people are really into that. All I say for that is just not, no neck, neck cracking, because that could lead to dissections and things like that. Neck physical therapy, I really like neck physical therapy for a lot of my patients, even my migraine patients that don't have a concussion, just because it kind of helps increase the mobility of their neck, which also helps manage the pain. It also helps with the stiffness in the neck. Some people get facet, inflammation of those facet joints after injury and neck physical therapy just helps with reducing that inflammation in those facets. OMT, kind of the same thing. It really, there's actually one study that shows that it really has helped athletes that have suffered acute concussion. We actually have a provider at University of Washington that does it for our concussion patients and she does cranial sacral therapy, which has proven to be actually pretty beneficial for a lot of my patients. Like I said, especially my patients that don't want to take medications or are sensitive to medications. So concussion specialists, so they're health care providers who know about concussion management and have experience with the guidelines for concussion. Basically what we do is basically we do a subjective score evaluation, and this is usually more for the acute cases. For the chronic cases, it's usually just taking a history of their injury and things that are kind of like making their injury or the symptoms worse. Balance testing, we do the balance error scoring system. I usually in clinic actually do like walking the tightrope or tandem or basically walking with heel to toe. I actually also kind of does balance. Balance error scoring system, I don't know if you guys know what that exactly is, but you're asked to stand on one foot for 20 seconds and count how many errors they have. Errors being if they take their hands off their hips, if they kind of move around a little bit or shift positions during that, or if they put their foot down. And also tandem, so one foot in front of the other, 20 seconds holding tandem, tandem gait for 20 seconds and seeing if error again is if they take their hands off their hips or if they kind of fall over or move. Vestibular screening, I don't do this as much, but basically it's evaluating for nystagmus or saccades during the eye movement testing. And neurocognitive testing, I kind of mentioned that already. We do either the computerized impact score or the sacc. Vision screen, the only visual screen that I really do is evaluating for their visual fields, making sure their visual fields are intact and evaluating for convergence and sufficiency. So for convergence and sufficiency, the way that you do that is you ask the patient to look at the tip of their thumb and put close to their nose. And you see when the eyes diverge out, that's their objective convergence. The subjective convergence is when they kind of feel like there's getting double vision or blurry vision when they're looking at the tip of their thumb. And it's super important for people that are complaining double vision or injury. And then just a regular neurological exam. These are some people in the concussion care network. Do we have time for, okay. So the case will be in the handout. Okay. So the cases are in the handout. You can look at them. You could email. I don't know if you have my email address, if you have any questions about them. Any questions? In the non-responder, that 15% who's like a couple of three months out who had a documented head injury, like subdural contracoup, I mean, was sick. At what point in time when they're not getting better, does advanced imaging like MRI and EEG need to be done to rule out other stuff? Okay. Or if ever. So, yeah. So I always, if somebody has a subdural or, so that's actually more than a concussion, it'll be either, do you know what their GCS was at the beginning? Was it a head injury? I don't know. I mean, she was getting a mammogram. They squeezed too hard. She had a single episode. Okay. So probably. After surgery, signed off and said it's a neurology problem. It's probably more complicated than TBI. So yeah. If there is a bleed, evidence of a bleed, yes. I always usually do do an MRI on them just to make sure too. And I do it with contrast too, just to make sure that there's no leak too, because sometimes people with subdurals could have a spinal leak and that could like drag the brain down even further and cause more bleeds to, or like worsening of the subdural. EEG, not necessarily unless, unless they've had a seizure. So if they have an event that kind of sounds like a seizure, then I would do an EEG. And I'd always do neuropsych testing too on those kinds of folks that have bleeds because a lot of times if the bleed is still there, they could have some deficits in the neurocognitive testing even a year out. So kind of like what I meant, what I'm going to mention in my next presentation on Friday, there's usually no difference between doing neurocognitive testing at a year and five years, but usually the year time point for those types of people kind of is the most accurate in seeing where they're at in terms of recovery. So if the subdural is still there, potentially could be affecting some, some cognitive frontal lobe function. I don't know where it's at. It's in the frontal. Okay. Thank you. The last couple of questions. Okay. What dosing? Okay. So for the decadron taper, I usually do eight for, so I usually gradually go down eight, eight for two days, eight milligrams for two days and six for two days. Then four for one, one to two days and two for one day and then off. So it's probably about two, three, four, six, seven, seven days. Also too, one thing that's easier to do than the decadron taper actually, so I've actually started doing now since it's quicker as mineral dose pack. So you just type in mineral dose pack and it pops up and it has all the dosing schedule. Just tell them to take it with food, take it in the morning. And it's just as effective as the decadron taper. So for PT, for vestibular imbalance symptoms, it depends on what the vestibular symptoms are. So if there is, if it's BPPV, yes, then vestibular therapy is very beneficial. If it's, let's say that there, some people get this thing called persistent partial perceptual dizziness, where it's a constant sensation of dizziness. It could commonly occur in people that have had a history of concussion. I do actually still think balance therapy is super beneficial, but they also need to do with cognitive behavioral therapy as well. So the balance therapy just basically helps with their strengthening and kind of eye movements and things like that to help with their position sense. But the cognitive behavioral therapy really helps kind of with the processing of their symptoms. Some vestibular therapists that are specialized in concussion and specialized in vestibular therapy actually do do some cognitive behavioral therapy in some cases with balance testing or balance therapy. Any other questions? Thank you very much.

concussions

traumatic brain injuries

Glasgow Coma Scale

neuropsychological testing

emergency referrals

cognitive impairments

recovery process

personalized management

alternative treatments