All right, good morning, everyone, and welcome. We're thrilled to be here and thrilled to have you here as we talk about dispatches from the concussion field, Carf International's new concussion rehab program standards, and ACRM's revised diagnostic criteria for mild TBI. First I want to state that there are no financial or non-financial disclosures for Dr. Graff, Dr. Whitehair, Dr. Grease, or myself. And now I'd like to take a minute and introduce our panelists and our speakers. Christine Grease is certified in physiatry and brain injury medicine. She completed her residency at Rutgers New Jersey Medical School Kessler Institute for Rehabilitation in 2013 and her fellowship in brain injury medicine at Kessler Institute for Rehabilitation. She started her career at JFK Johnson Rehabilitation Institute after fellowship where she serves as medical director of the concussion program at Hackensack Meridian JFK Johnson Rehab Hospital in Edison, New Jersey. She's also director of the acute inpatient stroke rehab unit. Dr. Grease serves on medical advisory board of New Jersey manufacturers insurance, the concussion committee of the Brain Injury Alliance of New Jersey, and the ABPMR part two examination committee. She also serves as concussion consultant for the New York Rangers since 2019. She is clinical associate professor of both Rutgers Robert Wood Johnson Medical School and Hackensack School of Medicine Department of PM&R. She's heavily involved in research and academics and has authored chapters such as neuropharmacology and acute TBI in critical care TBI, substance abuse and mild TBI, and many others. She also authored publications in the Journal of Trauma, the Journal of Critical Care, and the Journal of Neuromuscular Disorders. She's fluent in three languages, enjoys cooking, playing piano, and the occasional game of hide and seek with her three children. Dr. Graff completed a residency in physical medicine and rehab at Montefiore Medical Center Albert Einstein College of Medicine in the Bronx in 2013. Following her residency, she completed a fellowship in brain injury medicine at the JFK Johnson Rehab Institute in Edison, New Jersey. She is board certified in PM&R as well as brain injury medicine. She's the chair of the Department of PM&R and the medical director of traumatic brain injury outpatient program at Hennepin Healthcare in Minneapolis, Minnesota. She is an assistant professor in the Department of Rehab Medicine at the University of Minnesota. She's been a member of the American Congress of Rehab Medicine Brain Injury Interdisciplinary Special Interest Group since 2015. As a part of the BII sick mild TBI force, she was a co-author and a contributor on the ACRM diagnostic criteria for mild TBI published recently in the archives of PM&R. She also served on the ACRM BII sick disorders of consciousness task force and was a contributor on the case definition and diagnostic criteria for the post-traumatic confusional state. Dr. Victoria Whitehair is board certified in physiatry and brain injury medicine. She completed her physical medicine and rehabilitation residency and brain injury medicine fellowship at Metro Health Rehab Institute Case Western Reserve University. Dr. Whitehair is an associate professor of PM&R at Case Western Reserve University School of Medicine. She practiced inpatient outpatient brain injury medicine at Metro Health Rehab Institute where she serves as the director of brain injury rehab and director of the division of neurological rehab. Dr. Whitehair is a member of the American Congress of Rehab Medicine mild TBI task force. She was also a co-author and contributor on the ACRM diagnostic criteria for mild TBI published recently in the archives of PM&R. My name is Terrence Carlin. I am not a physician. I am a physical therapist. I am a managing director of medical rehabilitation and aging services at CARF International. I have an MBA and a master's in physical therapy and I work to oversee the creation, the edit and modifications, education, business development around CARF accredited organizations and their standards from around the world and I live on the Jersey Shore. And we're thrilled to have you here today. A little bit about the format that we'll have today. We'll have two brief slide decks that will go into details about two unrelated but parallel efforts to support the field of concussion including the revised mild TBI diagnostic criteria that was recently published from ACRM as well as CARF's new concussion rehabilitation program standards. We'll have two slide decks and then we'll have a panel discussion with the three panelists here. So that said, I will hand it off to Dr. Graf and Dr. Whitehead. All right, welcome everybody, we're glad to see you here. So for the first part of it I'm going to walk you through some of the background behind the ACRM diagnostic criteria for mild TBI. Dr. Graf will then take you through how to really apply it and then we'll go through some case examples. So we are presenting on behalf of a number of people, large efforts and many people's inputs have gone into developing the mild TBI diagnostic criteria for ACRM. So working group members are noted here. Our fearless leaders are Grant Iverson and Noah Silverberg without whom there's no way that this would have all happened. We'd like to also acknowledge our expert panel members, many of which are here at this conference and hopefully some of you were able to take advantage of the concussion step course earlier this week and actually be taught directly by some of these experts. By the end of this presentation we're hoping that you'll be able to describe the methodology used to update the ACRM diagnostic criteria for mild TBI, summarize what is new and different about these criteria and apply the diagnostic criteria for mild TBI to new patients. So essentially we're hoping to teach you today the why, the how and the what is it. Going back to the start. So in 1993 the precursor to our current task force developed this definition of mild traumatic brain injury. At that point you know they were the head injury interdisciplinary special interest group but we are the current form of that. This has served us well for 30 years. It's widely used in research, widely used in clinical practice but we did feel it was time for an update. Part of the reason is that since that time we've had a number of definitions and discrepancies come out. Here on this slide you can see seven different diagnoses, definitions, expert case group, definitions that have come out and it's led to some confusion in our field. I think this has led to some of the difficulties in figuring out what is a mild TBI or concussion. We'll get to that in a minute. How do you diagnose one? How do you teach a learner what this would be? So if you look through this list here we have across these many different definitions there is a lot of consensus in the areas of objective symptom or I should say objective signs of disrupted brain function. So loss of consciousness, objective confusion, disorientation, people are in agreement. Where the disagreement happens is what to do with the symptoms, the things that were not seen by somebody else. So as an example I'll point to the difficulty thinking, slowed thinking. This one wasn't even mentioned in the original ACRM criteria in 1993. It's nowhere in there that's why there's a question mark on there. You're about half and half split between no's and yes's for can you include this. So the current state then is diagnostic variability and then inequitable access to treatment. So it matters a lot which doctor you see and which definition they happen to prefer. So the aims of this project were to create an updated diagnostic criteria for mild TBI that integrates the best available research evidence from the past 30 years, addresses limitations of prior definitions, can be used across the lifespan, is appropriate for use in sport, civilian trauma, and military settings, and improve the quality and consistency of mild TBI research and clinical care. Walk you through our process a little bit. This started with an expert survey on the diagnostic importance of signs, symptoms, and test findings. At the same time we were working on some rapid evidence reviews. I mentioned earlier that we did really want to make this scientifically based. So we had a group of people who were looking at what's the research we have out there. Pulling those together we came up with the diagnostic criteria version 1.0. That then went into a Delphi consensus process with an expert panel. Went through three rounds of voting and at essentially version 2.1 in there we did send this out for stakeholder feedback. This went out to it was available for any individual who wanted to give feedback on it as well as went out to some of the major stakeholder groups such as AAPMNR. Coming out of that was our position paper. And I will leave this up here for just a moment. If anybody wants to scan the QR codes they should also be available in the slide decks. One of them is the expert survey. You're able to look through what happened in there, look at those rapid evidence reviews, and then the actual position paper itself is over on the right. I'm watching for when the cameras go down, so you guys are good. All right, and I'm happy to pull those up later too if you need again. So what's new and different here? First of all, signs don't equal symptoms, right? I think a lot of us know this in practice, but this is where one of the challenges has come up with these definitions is some of this has merged. So in this definition, signs are weighted more heavily, they're things that we can see as clinicians or somebody else can document that they saw. And our signs though now are operationally defined. I'll give you an example of that in just a little bit here. So it's not something where you have to figure out is this a sign, is this a symptom? We give you some guidance. We did add observed motor incoordination upon standing as a new sign in this one. This was based on the evidence that was coming out of the sports concussion video reviews. This was something that was repeatedly showing up as pretty consistent, so we included that here. The symptoms must start within 72 hours of injury and symptoms with known poor specificity such as fatigue were omitted. And that again came from the rapid evidence reviews. I will note the 72 hours had a lot of discussion around it. There isn't great evidence to say that's the exact timeframe in there, but on those rounds of Delphi voting, the 72 hours was sort of the best that we could get some agreement on. So it doesn't need to be a hard and fast rule, but that was the one that there was most agreement on. We also have incorporation of balance, cognitive and oculomotor testing with assessing the patient within 72 hours of injury. So the sensitivity of those tests does go down over time. You'll see as Dr. Graf goes through some of this that you can, I think it's in that part, so you can use in this things that were documented early on. So even if you don't see that person within 72 hours of injury, if say the emergency room doctor noted that there were balance problems, you can use that. That we try to make this easy and truly usable. We also incorporated blood-based biomarkers. This is a bit more of a placeholder than a specific guidance in this document just because the evidence is changing so fast and we didn't want to single out any one thing. We want this to be able to remain viable over the years as we learn more about biomarkers. So you'll see how that's written in there, but essentially just the fact that if there is a blood biomarker that has evidence behind it that could help you with diagnosis, then that could be used in making your diagnosis. It does not call out a specific blood-based biomarker because that's gonna change, right? We're hopeful for more as the years come. It also includes forces generated from a blast or explosion as a potential mechanism of injury. And it has more extensive consideration of possible confounding factors. It's actually built into the criteria how you can consider that and how you can use that. We also clarified some terminology. So obviously we're here as something that is labeled concussion, but we're saying mild TBI here. So the diagnostic label concussion may be used interchangeably with mild TBI when neuroimaging is normal or not clinically indicated. This did go through that expert consensus panel. We had 93.8% expert consensus on this. So we didn't have 100%, our goal was 80. So we surpassed that consensus, but we do have that in the statement here. And we as a group did talk about this ahead of time. We have people from a lot of different fields of practice here. And unfortunately, Dr. Epon wasn't able to join us last minute, but he is from the VA world as well. And we all agreed with this, even amongst our panel. So just going forward, we did wanna let you guys know if we're using mild TBI or concussion, we're mostly using that interchangeably here for the purposes of this talk. Also included in this is suspected mild TBI category where there's clinical uncertainty. So at long last, here are the criteria. So mild traumatic brain injury is diagnosed when following a biomechanically plausible mechanism of injury, one or more of the criteria listed below are met. One or more clinical signs attributed to brain injury, at least two acute symptoms, and at least one clinical or laboratory finding attributable to brain injury. Neuroimaging evidence of TBI, such as unambiguous trauma-related intracranial abnormalities on CT or MRI. Confounding factors do not fully account for the clinical signs, acute symptoms, and clinical laboratory findings that are necessary for the diagnosis. And I told you I'd give an example of one of these operational definitions. So here it is, so alteration of mental status immediately following the injury or upon regaining consciousness. Evidenced by reduced responsiveness or inappropriate responses to external stimuli. Slowness to respond to questions or instructions. Agitated behavior, inability to follow two-part commands, or disorientation to time, place, or situation. So that's just one example, but that's the sort of language that we tried to provide for people. We tried to take as much of the question of what does this mean and does this person interpret it this way and this one that way, we tried to take that out as much as possible with that evidence or with that expert level of support. Okay, I'm gonna hand this over to Dr. Graf who will show you how to use this operationally. Yep, so now I'm gonna talk about how we apply this to the, you know, in real practice. So this is good visual representation of the diagnosis criteria. So we'll go over this more closely. So there are three steps. So step one, you have to kind of see if the injury involved any plausible mechanism, TBI. So whether there's any force that was applied to the brain, that whether it is from the like, you know, the brain is struck by some object or the brain is striking some object, hard surface, or brain going through the acceleration, deceleration movement without any direct contact or any force generated by the, you know, the explosion or the blast. So you kind of see that if there was any mechanism injury that can explain a traumatic brain injury. And then step two, you kind of know, you know, if there were any signs or symptoms that were present at the time or within like 72 hours. And if there are any clinical exam finding or neuroimaging findings available at that time. And then step three, if there were any confounding factors that may kind of make it unclear if those symptoms, signs, exam findings are really attributed to the TBI or some other things. So there are three pathways that you can diagnose, you know, somebody with a brain injury. So one of them is based on those clinical signs that shows evidence of disruptive brain function. So one of them is loss of conscience, kind of the same as the previous definition. And then any ultimate status, post-traumatic amnesia, any neurologic signs. But still we have to see the mild qualifier is, we can put the mild qualifier only if the loss of conscience is less than 30 minutes. GCS is, you know, 13 to 15. And the amnesia should not be more than 24 hours. So we kept the same kind of the mild severity qualification the same. And then the second pathway is, this is really new. If the patient having two symptoms and the one clinical finding, exam finding, or the blood lab finding. So symptoms, there are grossly four symptom category. One is also distinct from the original definition. We now separate it from the subjective ultimate status from the objective ultimate status. So clinical signs for the objective signs can be observed, you know, like disorientation, agitation, reduced responsiveness. But as a part of symptom category, we have now subjective ultimate status category, which means that the patient's objective felt that they were disoriented, like, you know, felt dazed or confused. So now this is a part of symptom, not the sign. And then there are other symptoms, physical symptoms, like headache, nausea, dizziness, then sensitive to light or noise, balance problem, visual symptoms. Those are kind of the physical symptom. And there's a chronic symptoms, like, you know, feeling slowed down and difficulty with memory, concentration, and then mood symptoms, like irritability, and then mood lability. So any of the one of symptoms, it doesn't have to be, it's okay to be one in the same category. So two symptoms, and then any clinical exam finding, and there are also three, any cognitive impairment and acute assessment, any balance impairment based on the balance assessment, and any oculomotor dysfunction. So these are the examples that, you know, we didn't really specify what kind of tools to use to examine the cognitive balance oculomotor, but these are kind of, you know, our standards of system concussion, or, you know, balanced error score system, and best oculomotor screening tool, those you can utilize in the acute period. So these symptoms and clinical exam findings are more, the sensitivity goes down if you do this beyond 72 hours. So it's so important that the patient can be seen within 72 hours and then get these history symptoms and doing the exams. And then another one is the left finding. So any of two symptoms and the one of any exam finding or the left finding, you will, you can diagnose TBI as long as there's no confounding factors that, you know, is attributed to the TBI. And then the last one, that last pathway is any, there's a mechanism is there, and then there is a imaging finding of any structural intracranial pathology. So a lot of times mild TBI doesn't require a CT or MRI, but in the trauma center, they come to the ED, and sometimes you cannot assess, you cannot get a good history because they're intoxicated, they're syncopal episode, and then they're intubated. Sometimes it's hard to assess, so you have to utilize the other, the imaging finding. And then if that was performed and that it shows positive and that it meets the mild qualification criteria, you can diagnose it with the mild TBI. As Dr. Whitehair said, we didn't use the term complicated mild TBI when usually people use it when there's a positive imaging finding. Here we wanted, we proposed to use mild TBI with neuroimaging evidence of intracranial pathology or without. And then we also created this criteria for suspected mild TBI. We think that there's a mild TBI, but diagnosis is, you know, not clear, you know, we couldn't get all the information available at the time of the injury, there's more confounding factors, and for those group of patients, you know, if they have just two more, there's a mechanism, is there only two or symptoms, but there's none other signs or the exam finding, or there is only two clinical exam finding or lab finding, and then you can still diagnose them as a suspected mild TBI, or they have the signs or symptoms and find the positive exam findings, but still there are confounding factors there, so it's really unclear if, you know, the patient actually had a mild TBI or not, so you can actually now use the term suspected mild TBI. I think that would really help in the practical, in practice. So why suspected mild TBI category? You know, probably people who are treating patient with brain injury, it's, there are a lot of times it's very, you know, there, you cannot find really, you know, objective signs at the time of the injury, it is unwitnessed, and then, you know, it's really hard to tell if, it's really hard to get the clear history and the exam finding at the acute period, so having this suspected mild TBI category kind of gives the clinical reality, it reflect the clinical reality that the diagnosis is more continuum, and then sometimes you can have limited information in the beginning, and then once you have more exact objective finding, and then you can actually, you know, this diagnosis can evolve throughout the assessment. And also, the previous mild TBI category was restricted in a way that our, it may lead to more false negative, but having more symptoms, suspected mild TBI category kind of like covers that, you know, we may use suspected mild TBI for those who may have TBI without clear signs of those mixed diagnosis criteria, and then also, we don't want to be too specific, so it kind of addresses that dilemma. And also, there is some literature showing that even though there was people without any signs, their, you know, functional and the microstructure in your imaging changes were shown, so it will be nice to have someone with a suspected mild TBI category so that we can treat them as if they have mild TBI. And especially in the sports and military, we want to make sure that if a suspect mild TBI, we want to pull them out of the, you know, the game, you know, play, or that setting, so that, especially in acute care, we don't want to have them, you know, have a re-injury to, may lead to more critical outcomes, so that's the reason behind the suspected mild TBI. So, implication of this suspected mild TBI category, for clinicians, you know, we treat as if they have mild TBI so that, you know, they get all the resources in place, and for researchers, depending on what kind of topic they want to research, you know, if, for example, if they want a natural history study, they may include the suspected mild TBI category, or if they want to do more biomarker discovery, they may choose if they want to include the suspected mild TBI category, or strictly just really mild TBI category, so those are the implication of this new diagnosis. Okay, so Dr. White here will go over to some clinical examples. All right, so how do you then put that to use? Few case studies for you guys. Here's a 42-year-old man, he hit his head. He was picking up his yard, he stood and swung his head quickly, striking it on a metal staircase. He had some acute symptoms, headache, nausea initially, evolved to a horrific migraine, fatigue, somnolent, and difficulty thinking at work the next day. He visited urgent care two days later. He had a CT head, which was negative, and then he was evaluated two weeks after injury. He had spotty recall of the injury event, a gap between his head strike and the bathroom, he was trying not to vomit. He doesn't recall sending multiple incoherent texts, talking to his brother and walking his dog that afternoon. He has persistent headaches, fatigue, and cognitive symptoms. So here if we work down those criteria, plausible mechanism, yes, he banged his head on the staircase. He did have clinical signs, he had post-traumatic amnesia and altered mental status. He had multiple symptoms. We didn't have any exam findings from that acute period, so we can't say for that, and the neuroimaging was normal. It was not better explained, there's no significant confounding factors here, so if we're looking at plausible mechanism and clinical signs alone, you could say yes right there, right? You wouldn't have even had to go further, but from one plus two, and then six not better explained, there you've got it, you have a mild TBI. Here's a 65-year-old woman who fell. She was walking her great Pyrenees dog when she tripped on an elevated part of the sidewalk and fell forward. The EMS note says she had a black eye, a laceration requiring sutures in the right frontal area. She was unable to answer questions about where she was going, and she was babbling about not having an infection. Her GCS was 14. In the ED, she had a headache and facial pain. A CT was negative, and she had impaired tandem gait. So in this one, again, a plausible mechanism, right? She fell and hit her face hard enough to have lacerations. She did have clinical signs, she had altered mental status, so you could just stop right there. You've got those objective signs, so that you could say right there, mild TBI. If you keep looking, so symptoms, she only had one. So you wouldn't get that symptom criteria there, but she did have exam findings, balance impairment, but you can't do those together because you only have one half of it. Neuroimaging was normal, and this was not better explained from something else. She had a facial injury, but that was just present, right? It's not a confounder, it's just part of it. So again, a mild TBI. And here's a 28-year-old woman. She was in a car accident. She was driving in the rain with limited visibility. A deer suddenly appeared on the road. She swerved, lost control of the vehicle, and hit a lamppost head-on at a terminal speed of about 15 miles per hour. She was terrified that her toddler in the back seat might be hurt. Her heart was racing. She tried to exit the vehicle, but she couldn't, and then she realized she's still seat-belted. In the ED, her GCS was 15. She was distressed, tremulous, and repeatedly inquiring if her daughter was okay. She had generalized pressure-like moderate-intensity headache in the ER. Two months after injury, she presents and says she has continuous memory for the events surrounding the crash. She had a momentary confusion in the context of intense fear. She has some brief gaps in memory during the ED visit before she learned of her daughter's condition. So looking at this one, it's a plausible mechanism. Maybe not, right? It was a low-velocity car crash. Clinical signs, yes, she did have clinical signs, but I'm gonna take you back here for a minute. So this really had to do with her, with everything else going on, right? So she said she has some brief gaps in memory, but then she was fine once she learned of her daughter's condition, right? So coming there, so yes, but, right? And then symptoms, yes, but. And then examination, none documented. Neuroimaging wasn't indicated. But this one is better explained by something else, right? The psychological trauma that was going on at the time of her injury. And this is where you don't wanna write them off as something, but this is one where once you're putting the story together, you go, okay, well, does this make sense or not? You know, and this is one where when we're really seeing this person in clinic or wherever we are, maybe she would end up as a suspected mild TBI, right? Just depending on how that story goes. But that's where that can give you, you can put those together to say, well, what is that story? And if she were, if looking back at this year, if this was a little bit less clear, and you're like, gosh, I can't really tell, you know, what was the psychological distress she was having, or was this a mild TBI, but I just don't have enough to make this, you could take that confounder pathway and take that down to a suspected mild TBI. And you could treat her as a mild TBI then, just depending on that story you're getting. But those are some examples of how you can put that to use. And emails are in here for myself, Dr. Graff, as well as Dr. Silverberg, who has acted as a contact for a lot of this. And I will hand it back over. Great, thanks very much, Dr. Whitehair and Dr. Graff. I wanted to make two quick acknowledgements. One, we wanted to acknowledge the contributions of Dr. Blessin-Epen, who was part of this group that worked on this effort. He was not able to make it, but we're very grateful to have his input from the VA and as a co-author of the VA DOD mild TBI guidelines. And I also neglected to mention my clinical experience. I worked at Kessler Institute for Rehabilitation and Select Medical Inpatient Rehab Division for 20 years as a provider, a manager, a director, an educator, an administrator, and I supported the accreditation and program development of the hospitals within that rehab division. So now we'd like to switch gears a little bit and share with you what's been created over the last two years with the support of the field and CARF's new concussion rehab program standards. Just a quick show of hands, just to get an idea of the audience, who either works at a CARF accredited organization or has worked at a CARF accredited organization before? Okay, so sizable group, great, great. So I'll go into a little bit detail about where these standards will live and how they'll relate to some of the other standards in the standards manual, particularly the brain injury specialty program accreditation standards, which exist and are not in conflict with the concussion rehab program standards. So about CARF International, we're a nonprofit, a third-party accreditor of Health and Human Services. We accredit over 4,000 rehab programs around the world across the spectrum of rehab. We utilize peer surveyors to use field-driven, evidence-based, and person-centered standards, and they focus on quality and performance improvement, not just in clinical practices, but in business practices as well. And I just wanna stop and thank the field. There may be people in this room right now who participated in our public field review, and we're incredibly grateful for all of those that participated in it. We conducted 56 interviews over two years with all of our stakeholders. So that included providers, researchers, insurers, and payers, person-served, person with lived experience of concussion, as well as their family members as well. And it'll come as no surprise to you that there was a vigorous response to the field review that was released. We had over 200 responses, and we incorporated that feedback into the work that we did to create these standards. And we also had a small advisory committee that used a modified Delphi process to arrive at consensus on 17 standards, which I'll share with you today. And I'll acknowledge that group of experts as well. Here, everyone in the room is probably very, very well aware of the fact that the concussion field is very active right now. We're here talking about two parallel efforts that serendipitously occurred at the same time. I was also able to participate and support the concussion certification step course over the last few days. I will tell you that it was wildly informative and incredibly educational. And I was really grateful to see all those experts in one room at one time. It would have taken me 25 webinars to find the content that I was able to get in a two-day period. We also have the sixth consensus statement on concussion support that was just released recently. And ACBIS and the Brain Injury Association of America are also working on a provider certification as well, similar to their CBIS certification. So look for that sometime in 2024. And now we're talking about CARF concussion standards today. So who is affected by concussion? You know, we're incredibly grateful to the field of concussion that really worked with sport-related injuries of concussion as well as injuries from the military because those brought concussion to the forefront in the 90s, the 2000s, and the 20-teens. But we know that there are vast other populations that are affected by concussion that have barriers to access, health equity, and social determinants of health that get in the way of them accessing the care that is required for these individuals. The literature is also heavily skewed away from these groups. These are the elderly. These are victims of intimate partner violence. These are victims of trauma. And these are individuals who have experienced a fall. And there are some remarkable stories of individuals who are victims of intimate partner violence. That picture in the upper right-hand corner is from a New York Times article that was published about a year ago, which is in my references, which really speaks to the epidemic that exists, the under-recognized epidemic. And Dr. Bell, Dr. Kathleen Bell, spoke to that incredibly eloquently in the concussion course as well. We know that of those who are affected by intimate partner violence and domestic violence, 92% of them have injuries to the head, the neck, or strangulation. So it's no surprise that concussion is an occurrence in that population. We also know that 10 to 15% of folks have symptoms beyond four weeks. Persisting, not persistent, system, important language to use and to recognize. And we're also recognizing the fact that biomarkers are potentially a way for us to assist in the not so distant future. Can't pin me down on a specific date or time, but we know that we are looking to that for potential guidance from both a diagnostic as well as a prognostic perspective there. So, we know that individuals who experience concussion may require and benefit from the services of more than one discipline. And feedback that we received from the field of stakeholders that we interviewed was that there was great support for the creation of these standards. The experience of the person served that we interviewed had experience of persisting symptoms. And they struggled to get the right care at the right time from the right provider. And that's why these standards and this accreditation are interdisciplinary in nature. So I want to come right out and make that clear, that they are interdisciplinary program accreditation standards. We also know that there are two to three million concussions a year in the US, multiply that by 15%, and you arrive at about 300 to 450,000 persons served with persisting symptoms. Now, these standards and this accreditation are not just for those with persisting symptoms. These could be for individuals who have their symptoms recover and resolve within two, three, four weeks, and may need a few sessions of education and interventions to address them over time. But I think what you'll hear from the panel as well is that there is no shortage of individuals to work with in concussion. That the volume is certainly there to support the care of these individuals over time. But it's also a time in the feedback that we receive where we can expand our perception of how injuries occur. One of our individuals that we interviewed as part of the creation process for the standards was a cheerleader who experienced five concussions over six years as a high school and a college cheerleader. And the public doesn't necessarily recognize cheerleading as a source of concussion in sports related concussions. There's also recognition in the consensus statement on concussion in sport, the most recent one, that para-athletes are at a higher risk for concussion as well. So we are expanding our perception of who is affected by concussion. There are many cooks in the kitchen, and PM&R shares a space with neurology, orthopedics, pediatric, sports medicine in the space of concussion. And it is a rapidly evolving field with multiple disciplines. And one of my hopes is that this process and the creation of these standards will steer programs towards more collaboration, a breaking down of silos, and a more opportunity, greater opportunity to find how each of these disciplines can contribute to this interdisciplinary effort to meet the needs of persons served with concussion. So now the standard itself, what is a concussion rehab program? Like I said before, it's interdisciplinary in nature. It is individualized, it is coordinated, and it is focused on return of persons served to participation in life roles. Including, but not limited to, return to sport, work, and school. It provides integrated evidence-based person-centered care. And here's something I really want to emphasize. The scope of each program is determined by that program. These standards were created so that their breadth can cover all etiologies of concussion. And it is up to the individual program to determine what their scope is. Which specific populations will they serve? And what competencies do members of their interdisciplinary team have to address the needs of those unique populations? We recognize that these programs won't serve all different types of etiologies. That would be a very, very rare situation. But it's important that programs identify their scope of service. These programs will go beyond just providing care. They're going to be a resource to the community, to healthcare providers. They will advocate, they will educate, they will be engaged with research. They will identify research opportunities for persons served to participate in if they choose to. And they will comprehensively address the diverse and potentially complex needs of individuals affected by concussion. I also want to take a quick side note and go a bit into the weeds with CARF standards. Know that these standards do not live alone from an accreditation perspective. They can be used as a standalone resource. But they will be applied in conjunction with our business practice standards in section one, as well as rehab process for the person served standards in section two, which include a section of standards that apply to any program that serve children and adolescents. So just kind of keep that in mind as you consider these standards. The first standard, the program demonstrates application of evidence-based practices to concussion, including prevention, assessment, treatment, and education. Know that these standards will also have intense statements and examples. So under prevention, we go into discussions about education on fall reduction strategies in elders. We talk about education regarding strategies to avoid head first contact in sports. We talk about the recognition and identification of potential concussion and removal from play. So these are the type of practical examples that we will give in the example sections of standards. We certainly recognize that there are diverse and potentially complex needs of individuals with concussion. And that is why all of these domains should be included in the initial and ongoing assessments. If you're familiar with concussion, these will not be a surprise to you. It is an expansive but an important list. And it is the responsibility of the interdisciplinary team to consider these factors during the initial and the ongoing assessments. I also meant to mention that these standards will be published in January as part of the 2024 CARF Medical Rehab Standards Manual. And they'll be available for accreditation in July of next year. The programs will also provide or arrange for resources, services, support, and or interventions in the following areas. These do not need to be directly provided by the interdisciplinary program. They need to be provided or arranged for. So arranged for really just means that they have other identified providers that they can work with to deliver these services for individuals. These programs also will demonstrate a coordination and integration of services both inside and outside of their program as well. There's a requirement for communication and notification of status of the person served at the time of initial assessment, significant changes, and diagnostic, excuse me, discharge condition with a primary care provider. If you know CARF standards, you know that there will be a standard about education. There is no difference here. The education standards requires a systematic education program about concussion to person served regarding what a concussion is. Danger signs, both neurological and mental health. Expectations for recovery. I think that's a real important piece to identify that we want to be sure that our programs are sharing information about the likely prospects for recovery from their concussion. Risk to daily activity, how to reduce the risk of additional concussion. Communication with providers, emergency behavioral health resources, self-advocacy, physical advocacy, physical activity, self-management, and the impact of alcohol and drug use on the recovery from concussion. We also recognize that oftentimes it's not just the patient that's being treated but the entire family. And so the program is required to address the impact of concussion on the family and the support system, return to school and return to sport protocols. As relevant to the population served, the programs need to demonstrate the knowledge of these protocols as well as other protocols of external stakeholders. And I do want to give you a little bit of a look underneath the hood of what one of these standards will look like. So that's an example of an intent statement. And that's an example of some of the examples that we'll share. So the intent statement does exactly what it sounds like. It clearly describes what the intent of that standard is. And the examples give potential ways that an organization can demonstrate conformance to that standard. It is not an absolute. There are many different ways to demonstrate conformance to standards. And that's one of the beauties of CARF accreditation. And the standards is that they are not prescriptive. And that conformance is on a spectrum. But the standards that are used in China are the same that are used in Saudi Arabia, in the United States, as well as South America. A return to work. This is actually feedback from the field. We created this standard in response to the field. They really demanded that there be a standard on return to work, and we heard them loud and clear. And based on the individual needs, the person-centered planning process addresses return to work, including but not limited to functional return to work goals, developing work tolerance and work pace consistent with the requirements of the job, reasonable accommodations, and with the permission of the person served, assisting the employer in understanding the effects of concussion on the person's ability to work. And again, here's some detail that you'll find in your slides. You can go to this whenever you need. I don't want to overwhelm you with words right now. But know that there are specific examples that we gave for conformance to this standard. There is provision for contact between the program and the person served after discharge. Again, if you know CARF standards, you know that there's going to be a requirement for competency. And you'll also note that many of these topics are aligned with the education topics that are delivered to persons served as part of the program. The field and the committee that drafted the standards also wanted to make sure that it wasn't just an orientation and on an ongoing basis, and not on an annual basis. because there was actually consensus that there might be a need to have these competencies addressed more frequently than annually to reflect the changing literature and guidance from the field over time. Engaging with providers in the community. I think these next two standards are two of the most powerful standards in the concussion rehab programs. So our programs will act as, they will be advocates. They will be engaged with providers across the spectrum of care regarding what evidence based practice is. Outreach and support, how to identify concussions in the space where they occur. Their management, their rehab, and then we also have a standard here and also in the next area regarding advocacy for underserved and underdiagnosed populations. There are many underserved and underdiagnosed populations. And there is no doubt, based on the feedback that we receive from the field, that the program will have no shortage of aspects of care that can be chosen to advocate for. It could be race, ethnicity, gender. It could be victims of intimate partner violence. It could be victims of human trafficking. And the list goes on and on and on. There are tremendous disparities. And so we're very excited to see how the rehab programs, the concussion rehab programs, will take this standard and apply it to advocate for these services. Programs are also required to engage with stakeholders in the community, community centers for the elders, coaches, parents, similar topics, how to identify concussion, how to prevent concussion, impact concussion rehab, reasonable accommodations, and advocacy for underserved and underdiagnosed population. I'd mentioned this earlier, that there is a need for these programs to be engaged in research in some way, shape, or form. Also, to notify families and individuals with concussion about available research opportunities and clinical trials. These programs also will need to demonstrate knowledge of their pair mix, referral patterns, and denials. And then finally, it's important that these programs will be able to collect data on no-shows, cancellations, and dropouts. We know that these populations are at high risk with not continuing with the services that will result in the resolution of their symptoms over time. So programs are required to collect data and analyze that data to ensure that they are able to improve their delivery of care to these populations over time. Thanks so much for your attention. That's my QR code for my email address, as well as my email address. Feel free to contact me any time, and I'm happy to share those standards in January when they come out. So now we're going to be able to move on to our panel discussion with Dr. Graff, Dr. Grease, and Dr. Whitehair as well. So we'll go ahead with the questions, and we will start with Dr. Graff, and then we'll move down the table for this first question. Tell us a little bit about your work, the populations that you serve, and the providers that are referring to you right now. So currently, I'm running the Traumatic Brain Injury Outpatient Program in the acute care hospital at the Level 1 Trauma Center. So we serve populations that are admitted to the hospital with a trauma, polytrauma with a mild TBI or moderate to severe TBI, and also patients that came to the ED. We also serve the patient who referred by the primary care at a subspecialty with a possible brain injury, and also from local, like, chiropractor, neurologist. And also we get some, you know, serve the patients from the, you know, referred by the Minnesota Brain Injury Alliance. At this time, we serve the, in our program, we serve patients 13 years and older, and in our system, 12 years and younger are seen by pediatric neurology. So those are kind of the population we serve. Great. Dr. Grease? Hi, everybody. My name is Christine Grease. I'm going to look a little bit louder than I expected. So we are actually part of a very robust inpatient rehab and outpatient rehabilitation institute in central New Jersey. Part of Johnson Rehabilitation Institute in Edison, New Jersey, we are actually affiliated, and we are part of the largest hospital network, Hackensack Meridian Health, in the state of New Jersey. And therefore, our population is comprised of a multitude of different types of individuals with concussion. We see from peewee sports to professional athletes, college and professional. We also see a mixture of population of teens, falls, motor vehicle accidents, plenty of workers come. Our concussion program is a very robust program. Five days a week with myself and three other absolutely amazing physicians who see several patients anywhere between 10 to 16 a day and running five days a week program. Major referrals actually include, besides our local emergency rooms, neurosurgery groups, major neurosurgery groups in the area, as well as neurology groups in the area. Pediatrics, we have a lot of also family medicine and internal medicine that refer to us. And also local and regional high school athletic trainers that will refer to our program. We accept patients from 14 to 99. Sometimes we'll get the occasional 100 year old if they want to come. But pretty much, yes, it's a very robust outpatient concussion program. Thank you. So I'm at Metro Health Rehab Institute in Cleveland. And so we are affiliated with a level one trauma center. We see, so we see a lot of the trauma patients. We have inpatient and outpatient brain injury rehab programs. Our outpatient program, we have kind of two tracks within it. We have our sports physicians who handle most of the sports related concussions and the ACPs. They see adults, you know, whoever it is and in whatever circumstances. And then we also have a robust sort of adult trauma, you know, non-sports related practice. We see a lot of workers comp. A lot of sort of, there were multiple injuries that happened. And we also see a lot of the patients who are just complex and challenging and maybe went through a program somewhere else with their PCP and didn't get better. So we get referrals years, years, years out from injuries. And that's our typical. Let's start the next question with Dr. Greese. What are the greatest challenges that you experience related to concussion diagnosis and management? Actually, that's tagging along what Tori just said. Mainly the challenges is failure to recognize the concussion or almost a delay in the referral by our colleagues who mean well. It's really more so all of them apply the sit it out to 100% of their concussion patients as opposed to being very wise about judging who should sit it out and who should probably seek more of the resources. I think that that is really one of the major challenges. Another challenge that we find is not really knowing who we need in our village and in our team to take care of our patients. Unfortunately, it is one of those things that we can't, we won't know what we need in order to take care of the patients including, but of course, all of the different team members, vestibular vision therapists, neuropsychologists, normal psychologists out in the community, you know, speech therapists, audiologists, really failure to recognize that there is a team approach and everything else that really ACRM and CARF kind of came out with. Unfortunately, these are the biggest barriers. So education for all of our other colleagues that are non-physiatrists, non-brain injury medicine physicians, I think that is really the first step and the key to being able to, you know, get those resources out there to patients and minimize the delay in treatment. How do current physiatrists struggle with identifying the resources that are needed to create or support an interdisciplinary effort? Go for it. A lot of times they struggle mainly, besides just awareness and recognition, being able to have those resources and communication available to them, approval of those resources initially, and not knowing what to do when they get the insurance denials. Some of them, it could be really well meant where a neurologist knows, especially local neurologists, they're very aware, for instance, that their concussed patient needs vision and balance therapy, and let's say Dr. Grease's schedule is a little bit busy and they can't get in for maybe another few weeks, but then they get the denial for vision therapy and they just don't know what to do next. In terms of our own physiatrists, they find a lot of the resources are not available to them locally, and so it is very hard to get visual and vestibular certification among the therapy community, and therefore, those lack of resources, it's very difficult to get those patients treated. Again, balance testing officially and not just the simple examination that the physiatrist can do in the office, such as a Dix-Hallpike or the balance error scoring system. When we need more advanced testing, such as a VNG rotary chair test, that is a lot more objective in nature. That is also a lot more scarce. We may not find those different resources, so, yeah. I'll echo off of that, because I agree that it's hard to find all the things that you need, and I know for us, I would much rather send a PT who really understands concussion and understands the related problems there, and we have PTs who understand that, right? I have the OTs who I go to and the PTs who I go to, but not everybody has that. At the same time, you might not know who that is in the community, so we don't have all of those parts of the puzzle that Terry mentioned, right? We don't have all those people at Metro, but I know who to refer to, and I think that that's where that importance is of do you know your community there, and one of the hardest things I find is how do you build that community wherever you are, and if you don't have something, how do you train team members or encourage them to get trained in something that would help you, and so I do think that's one of the challenges, and we're in a big city, and it's still hard to do, right? So I imagine that in the smaller cities, that's challenging as well. So I think, you know, and this might be getting away from this question a little bit, but I think one of the goals that a lot of these programs that are coming out with are trying to do is to educate everybody on what are the things that might help you with your patients, so it's not just you have to get into a subspecialty clinic, but what are the things that a subspecialty clinic might be having so that we can try to build that in the bigger community as well. May I add just one last thing? One thing that we found very helpful in New Jersey when our institute developed an annual concussion symposium, we gathered all of those team members, and we were in it maybe twice, so it was actually two, it wasn't two consecutive years in a row, because there was one where there was COVID in the middle, but it was very helpful for physiatrists and non-physiatrists alike that do see concussion patients in the community because they got to meet all of the team members in one place for three days and understand the diagnosis and the treatment of concussion. If, you know, if you're out in the field and you have those resources and part of a hospital network where we can do that, then it would be the best option, really, because it does help keep the, you know, treatment and everybody in one mindset, really. So our program is located in the downtown Minneapolis, so being a level of trauma center, not everybody lives close by. Some people live like four hours away, so our program has all the members, team members available, PTOD speech, neuropsychology, clinical psychology, audiology, neuropsychology, everything's available, but it's hard to get, you know, offer those resources for people who live really far. I think thanks to the, you know, positive outcome we got out of the pandemic, now the telemedicine is available, so we are trying to utilize more for the rehab side of things. For example, cognitive rehab, like those things can be done virtually, clinical psychology support can be done by virtually, and then even like neuro vision rehab, like they may be able to, you know, travel a couple times, but, you know, once they kind of know the, you know, the exercise, also they can check in with a therapist, like virtually, so that has been really, you know, valuable, you know, like with the continual care for the people who don't have resources close by. So I think that a lot of concussion programs are really built around the big academics or a big system, which I feel like still there's some access, like barriers for people who don't, you know, get those resources, so. Great points. Thanks, everybody. Regarding payers, what have you seen are the greatest barriers to individuals with concussion accessing the right services at the right time, and how have you overcome those barriers? You know, I'm thinking Medicare, I'm thinking workman's comp, commercial insurance. Tell me your thoughts. I find worker's comp is the bane of our existence. I hear this different in other states, but in Ohio, it is horrible. I find that for a lot of the other insurers, it actually goes pretty well. You know, there's, I don't know, we don't get too much pushback about the basic treatments. You know, I think it's more about finding the right person than it is about not being able to get access to it, so most patients are going to be able to get PT if needed, or can get neuropsych testing if needed, it's just do you have the right person on board, but worker's comp in Ohio is like pulling teeth, right? That's a challenge. It's a lot, a lot, a lot of time of trying to educate and fight back on denials, right, and you can't, you can't let it go, you know, for those of you who are out there, you can't let it go. You got to fight, got to advocate for the patients, obviously, but some of us were even talking last night about in the state of Ohio, how can we advocate at a bigger level to try to change the Ohio worker's comp program to get access to some programs like this, so you know, I think picking those big things is the next step for our field. On our end, I agree, worker's comp is definitely a very motor vehicle, insurances tend to be a barrier when they've exhausted most of their benefits, they've already gotten PT for their neck and the whiplash injury, they've been diagnosed with a cervicogenic headache, but then maybe the neurogenic headaches and the migraines have been missed, and then they just kind of are categorized under one umbrella, so getting those approved is definitely very difficult. It was helpful in the last maybe three or four years with one particular worker's comp agency, and again, in terms of educating them, offering to discuss with them what concussion is, offering to do free education to anyone who would be willing to listen, so that it would be affected at a larger level, and not just for, you know, helping one individual patient. I found that very helpful. Other barriers from the patient themselves is, again, delayed recognition, and so if they're not aware of what they're suffering from, many of the patients as well, to answer your question, Terry, they don't know that they've had a concussion and they assume that their migraines just got worse, now they have balance issues as well, and they're assuming, oh, maybe I'm just getting a little bit older, that fall really maybe took a toll on me, and then they just continue to move forward without knowing and being aware and identifying that this is, you know, really a serious issue. How do your programs screen for victims of intimate partner violence in human trafficking who have had a concussion, and kind of what precautions in the screening and pre-screening process need to be in place to ensure their confidentiality? First, there are two types of either intimate partner violence, which we've seen more since quarantine has been lifted, and then there are also the group that comes, the human trafficking group we generally know about from local judges. They're generally referred by local judges, but the intimate partner violence are the ones that we actually don't, or may not be aware of it, so first thing for screening is having that index of suspicion is always there. Second is really looking at their nutritional, their overall nutrition, their health, whether they're malnourished, asking simple questions, the approaches, everything. Sometimes in terms of asking questions, we like to ask the question more than one way in order to see if their answer is scripted, and then also looking at the nonverbal cues, the body language, whether or not they're looking at another individual that's in the room for validation or for the right answer. In that case, when those flags have been raised in the examination room, we generally ask the other individual to step out, just like we would in any other case, and ask again these questions, and of course looking for signs of abuse that may not be reported and really mismatched in its presentation. One thing that we also look for is to see if they are going to follow through with some of their treatments, and one thing I've also noticed is, and this was something brought up by a medical student that was very observant in the room, and they noticed that those who were victims of intimate partner violence really did not know where their identification documents were, even something as simple as a driver's license was held by somebody else in the room, for instance, and so it's good to look at these small little details in order to screen for intimate partner violence. Before we open it up to questions, does the panel have any other thoughts or comments that they'd like to share? One other thing, and maybe we're thinking along the same lines for this, one thing that we talked about a lot as a group as we were planning this was where is the field of concussion and mild TBI going, and kind of some interesting discussions that we had, and I'd like to share a little bit about some of what we were thinking. Terry had that nice slide up there about all the different groups that are working on things and all the new things that are happening, and I'd say I think we think it's all very exciting time right now, but a lot of unknowns, and so I think that as we look at some of these programs that are developed right now, are they going to hold into the future is going to be very important. How can we work together is important, so I know that for the mild TBI task force with ACRM, they've been talking with the concussion and support group, right, and also Noah Silverberg is also in the group that is going to be at the NIH TBI classification and nomenclature group in January of 2024, right, are we going to go away from mild, moderate, severe traumatic brain injury, what is that going to look like for the field? So I think that the more that our groups can talk and actually get on the same page about where we're going with this, it's going to be really important as some potentially really major changes come down the line, so, you know, as physiatrists in the room, I would encourage you to talk with the neurologists. If you're not a sports concussion doc, you know, make sure you're talking with the sports concussion folks. Make sure everybody's on the same page as we try to make these big changes. Yeah, just one comment I want to make is with this updated mild TBI diagnosis criteria, we are really trying to provide a lot of, like, education for our trauma, like, resident trauma surgery team, because especially the identified symptoms and doing the exams within that acute period is so important in the diagnosis, so we're trying to work with the trauma surgery team in the trauma center, and then the resident always rotates, so they, you know, we always have, like, how do we help them to be able to identify, and I know that there's usually more critical, severe injuries that is happening, but still recognizing TBI at that moment is so important in terms of what the outcome will look like once they're back to the community, so we are trying to, how do you identify, how do we look at the mechanism, how do we, you know, like, you know, get the OT or PT who are seeing most of the trauma patients in the acute care setting, in our system, OT does all the cognitive screening with any mechanism of the brain injury as a part of the system, and so we're trying to incorporate neural, you know, ocular motor screening, so it seems like it's a lot of multi-resources to be even able to diagnose somebody or evaluate somebody in the acute care setting, and then once they're identified, how we can bring them to the outpatient for those who still have a persistent and difficult getting back to work, so I think that, yeah, wherever system you are in, you know, how we can partner with other, you know, other specialists to be able to identify and then continue the care of those people, you know, so. And the ACRM group is working on implementation products to utilize these criteria that we've been doing, and the idea is to have them usable in different environments, so one tool that would be a quicker screen for somebody in the emergency department, something for a more comprehensive clinic where you're two years down the line, something that's a research tool, so that is the next step that's being worked on, so we're hopeful that those will roll out well into these environments to get that in there. Fantastic. We have a few minutes left. I want to open it up to questions, and also want to mention one other thing. If you are with a program that is also brain injury specialty accreditation in an outpatient setting, it is possible to maintain your brain injury specialty accreditation. You may also seek CARF rehab program accreditation as well. It's really about defining your scope of service within that program and identify the criteria for inclusion in both of those populations. However, you are not required to seek concussion rehab program accreditation if you have a brain injury specialty and you serve individuals with concussions, so I know I got a little in the weeds there, and I apologize for that, but I'm sure at least one person in the audience had a question. Questions for the group? We have about five or ten minutes for questions. Why is CARF not following the same standard as SCAD and SCALP for the support injuries? For example, one of the criteria that recently changed was the GCS 15 and under, but in your slide it's 13 to 15. So is it anything that you can align yourself with that updates that come more internationally? So for the ACRM criteria, we really chose to go with, at the time that we were working on this, we chose to align with what was the current standard at that point, which was still the 13 to 15 for GCS, and really that mild, so the criteria themselves, I mean they're diagnosing a traumatic brain injury, right? It's really the qualifier at the end that's saying these are the criteria we're using to say it's mild, so it's not mild if you have one of these, and that was somewhat purposeful, right? That was that, that's, we didn't want to redefine what the greater society was using at that point for what mild TBI was, things like this are going to change, and that's where I think everybody needs to be talking and aligning, because when we have one group that's choosing to redefine in one area, and another one using it, that's where we're getting confusion, you know, and that's why there are also efforts to move away from some of these traditional mild, moderate, severe types of classifications, but we were using the historical qualifiers for this. Will you speak more about the new suspected mild TBI category for, and how you're utilizing it clinically, particularly for patients who clearly, who do not have any of the clinical signs, but have a variety of clinical symptoms that develop within 72 hours? Yeah, I find it's really helpful, you know, it's, it's that patient population where you, you had the feel that maybe they had a concussion, and they have some of it, but you're just not sure. You can utilize it in a lot of different ways, though, and that's where, you know, we don't, we don't tell anybody this is how you have to use that. It's more about the giving the option. A lot of what you're talking about was you don't want to exclude, right, so we didn't want to exclude people who maybe had a TBI, but didn't meet everything, so that's where we find the most utility in it. If you suspect it, you pull them out of play, right, it's that same idea, so if you suspect it, you pull them out of work, right, you give them the resources that they need. If you think they, they had a mild TBI, maybe, and you think that they need X therapy service, you can still order that therapy service then based on your suspected mild TBI, but that's all your clinical decision making, right, so if you see this patient, you're like, well, maybe they had a mild TBI, but you weren't planning to do anything other than, you know, pull them out of work for two days, and then get them on a progressive return to activity, you could do that, too, right, so your clinical decision making is still your clinical decision making, it just gives that category where you can, you can give the resources to these patients even if you can't get that firm diagnosis, you're not having to exclude that group. So, two questions, the first was on that 72-hour onset, is that for clinical signs, or symptoms, or all-inclusive? It actually applies for both of those, and that's why I mentioned, you know, the evidence is very sparse, we had a whole evidence review on these timelines, it just hasn't been done to say, okay, well, you know, if we, if somebody out here could please do a study, you know, that looked at each of those hours, and what does this end up with, that would be great, but yeah, that applies for both, but the language in there is that it should be, you know, it's a little bit soft, so that was the guidance timeframe, but you know, we also talked about the fact that for a patient who, let's say, is out of work or school for those first 72 hours, and then returns to that environment that has a higher cognitive load for them, that you could count that, right, like, that's, that's, that's this new thing that they're having to deal with, and so you don't exclude that patient because of that, you know, that's, that's not their fault that we told them not to do something. I have one other question, and I apologize for being the devil's advocate here, but, you could easily, us old people here, could easily argue that our outcomes are worse now than they were a generation ago for mild TBI, and again, I don't think we were all that stupid to miss, you know, to miss persisting symptoms after concussion, the prognosis was felt to be excellent, and, and so how do we balance this validating the patient and their symptoms or with facilitating illness behavior, or, and that type of thing, and as we create all of these programs, and we're putting people into this, and we're aggressive about education, how do we avoid being part of the problem rather than part of the solution? That's a great question. I remember when I first started seeing concussion patients, I met with Stephen Royce, who developed SCAT 5 criteria, and one advice I remember he gave me was, stay away from the post-concussion syndrome scale. The more that they write down their numbers, 0 through 5, 0 through 10, this is how bad my symptoms are, the more they will feed into it, and so recognizing it is one thing, treating it and moving on, and I believe that the biggest factor is understanding that they do need a short amount of time for vision therapy, setting the expectations, because expectation is the mother of all disappointment, and so I feel that if we set the expectation properly, and say, we're going to put you in a vision therapy program, and this is what you're going to do for vestibular therapy, if it doesn't get better, then we may or may not use the need for medicine, which we don't have to, but the return to work is this is what's expected, and for you to perform for you, for your family, for your loved ones, for your own mental health, and therefore we set a precedence in our clinic where permanent disability is maybe filled out once every two years, and that's about it, but otherwise they get the temporary disability, they give that maybe for some patients when we work very closely with neuropsych, but you need also, and again, the help of the village, you need a good vocational rehabilitation team that's going to get them back so that they go back to work, they go back to learning, they go back to play, and we always tell them, look, we have professional athletes who concuss really, really badly on the field, and so if my high school basketball player doesn't want to go back because of X, Y, and Z, then we have to delve further into why that is, and so education is very important. Well, unfortunately, we're out of time, but I want to thank the panel of experts. It's been a pleasure collaborating with you, as well as Dr. Blesin-Epin. I want to thank all of you for your questions and your attention and just being here today. Feel free to approach us afterwards and enjoy the rest of the assembly. Thanks so much.

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