Okay, so we're going to start our session. If you didn't do this, sign up for the live polling. It will come up when the actual slides for the polling takes place. That's going to take towards the end of the presentation when we start talking about cases. So we're going to talk about recovery and concussion, what works, who gets better, and why. I just want to acknowledge that my speakers are my former fellows from my Brain Injury Fellowship Program. So I want to first invite Dr. Patel up, who will start speaking about concussion. Thank you, Dr. Sabini, and it's a privilege to be here. So today's talk, and I thank you guys for joining us to talk about recovery and concussion, what works, who gets better, and why. Obviously it's an important talk in today's kind of environment, especially I'm sure many of you have seen the news with the sports world as well. So the objectives of today's talk are going to be to understand some of the concussion guidelines that are out there and how we use these guidelines to modify and achieve recovery. And then lastly, we'll go in through some of the cases that we have in this presentation for you guys to talk about how we dealt with those concussion cases and how we went on to treat those patients. There's no financial disclosures with this talk. So back in 2016, there was a consensus statement that came out, the fifth one, and so it really helped to identify or redefine what a concussion was and set standards on treatments. And so one of the big takeaways, if you read through this article or this statement, is the R's. So it goes through redefining concussions, recognizing concussions. And then also an important part of it is the return to sport, return to play, and return to school kind of protocols that they had in there. And so as they look to redefine concussions, so what we look as a concussion is not only just a direct blow to the head itself, but also any indirect forces that may be transmitted to the head. So this causes transient symptoms that usually follow a sequential pattern. And for the most part, patients tend to get better within 10 to 14 days. And I'm sure many of you have experienced patient populations that may take a little bit longer than that as well. The important part about understanding what a concussion is is that we can recognize it. One of the important parts that we look to develop is recognizing the concussion. And that way we can start and initiate treatments earlier on. And so understanding the nature of the injury. Was there loss of consciousness? Was there any post-traumatic amnesia? Were there any other frank neurological signs involved in the injury itself? And that way we can rule out any other more severe injuries or any other cervical spine injuries, things of that nature. So the goal really is to screen quickly and then diagnose. In addition to that, we want to monitor symptoms after someone has an injury, just so they don't develop more significant findings after. So some of the tools that are used on the sideline, one of them is the Sport Concussion Assessment Tool, or the Child SCAT-5 as well. So it's performed by healthcare professionals and it helps to accurately identify any deficits. So it looks like things like orientation, symptom severity, also looks like cognitive effects as well, kind of more in that acute phase right after the injury. And so this should be performed by a licensed healthcare provider and it helps to determine what kind of disposition that individual needs. Do they need to go to the ED? Do they need to be monitored more closely on the sideline? But no matter what, what came out of that consensus statement was that someone who's suspected to have a concussion should not return to play that same day of injury. And so after that, the determination of whether or not or when a person should be ready to go back to play is really kind of a medical decision that's best made, I think, by an interdisciplinary team at that point. And so when you're evaluating patients, it's good to evaluate not only those immediate symptoms that people are facing right after the injury, but also the delayed symptoms that come on the day after or a week after. And so there's different symptom scales that are out there. This one kind of goes from zero to six and kind of gives you a grade of what percentage a person's feeling in terms of impact on their day-to-day functions and their usual activities as well. And so it's important to know what patient's previous level of function was, their medical history, and when we look at what other issues they may have dealt with prior to the injury. Did they have migraines? Did they have sleep issues? When we look at concussion symptoms, it's really a constellation of symptoms that can be affected by other things as well. And so we look at headaches. We look at things like dizziness, vertigo, cognitive issues, psychological issues, and then sleep is, of course, a big part of that as well. And so like I was mentioning, seeing if people had any previous sleep disorders, any previous headache disorders, looking at any psychological aspects that may be affecting their treatment and their care moving forward. Things like learning disabilities, attention deficit disorders, pain disorders as well is important. And then when we look to evaluate folks in clinic or after their injury, it's important to do a full kind of thorough neurological exam looking from cranial nerves, motor strength, sensory coordination, ocular motions, and things like vestibular ocular reflex, psychotic eye movements, and then gait assessments are important as well. This way we can kind of look to see what other treatment options may be beneficial for folks. Do they need to see specialist therapists with vestibular therapy? Do they need more formal treatment later down the road with neuropsychology or speech therapy? And then also, like I mentioned, ruling out other more serious injuries. Do they need a head CT or an MRI? Now for the most part, imaging is not ordered routinely unless there's suspected higher level of injury initially. There may be x-rays or CAT scans if someone gets sent to the emergency room initially. But by the time folks see us kind of in the clinics, it's not as routinely ordered because we don't find as much on those imaging studies. And so one of the big things that the consensus statements did mention, and that was kind of a shift in the paradigm, was the period of rest. So now we recommend a rest period of really 24, 48 hours, and then getting back into some sort of activity. Now there's a kind of defining moment of what we call rest. Now defining complete rest, and I think it's hard for any individual, if we ask them to do complete rest, to go through that, right? Life still goes on, so we still have to deal with our stressors outside of work, outside of school, outside of our relationships, and it's hard to just completely shut down. And so there's no real studies or evidence that show that complete rest causes people to achieve recovery after a concussion any sooner. In actuality, the complete rest may intensify or worsen symptoms in the long term. People may go down the road of developing poor sleep patterns, developing things like anxiety or depression just from dwelling on their symptoms and not having social interactions going out into the community, especially if you're seeing folks that are high-functioning, high-level people at work or in sports. For them to go from doing things every day to not trying to do nothing is quite difficult. And so for that reason, a brief period of rest sure is warranted, but I think after that, getting back into activity gradually in more of a symptom kind of fashion is important. And so one of the key things I think we do as brain injury physiatrists is education and reassurance. And that's why it's important for folks to come in to see us in the clinics, right? To provide that education that symptoms are going to get better and this is how we can help to manage some of the symptoms. A lot of the folks that are dealing with vertigo or migraines or sleep issues don't know how to get back into regular routine, day-to-day things. And so it's almost like we're a life coach in that sense of providing that education piece and that reassurance piece to them. And then reintegration into more physical activities as their symptoms start to get better. And so the consensus statement did come out with these return to school and return to sport protocols. It's always good to have return to school before we think about return to sport. But this is not a protocol that is for everyone, right? It's individualized. And so everyone's activities are different. Everyone's school is different. Everyone's work is different. And so they have to be somewhat individualized when we're talking about what a patient has to accomplish on their day-to-day basis. Some people might not necessarily need to start at the bottom stage of stage one. They may be able to start at a higher level if they're starting to recover. And so like I mentioned, the typical recovery for most individuals is that 10-14 day period. Typically around two weeks for adults and then for children it's a little bit longer. And then there isn't a universal guideline like I mentioned for every individual. It's really an individual protocol that we look at creating and how do we get them back to being asymptomatic. And so there are some special populations, some complex presentations that people have repeated concussions or exposures to other traumas in their life that may be causing some of the prolonged symptoms as well. And then, like I was mentioning, individualized treatments for work, school, activity, exercise, and then determining if there's a need for any type of pharmacotherapy or other additional interventions, whether that's a physical therapy program or vision therapy, things of that nature. A lot of success has been shown with multidisciplinary approaches as well as that education piece with concussion. And so I'm going to pass it off to Dr. Sabini to talk a little bit about persistent concussion symptoms. Okay. Okay. Thank you, Dr. Patel. So as Dr. Patel mentioned, there is an expected progression for what we expect after these injuries, right? So you have this initial setting of acute symptoms. There's a progressive improvement. They're expected to be self-limiting and it should follow a predicted recovery course of progressive improvement. According to the consensus statement, we expect that to be four weeks in children up to two weeks in adults. And it's considered to be relatively uncommon that you sustain permanent problems after these head injuries. And that even if microstructural damage has happened, it's probably insufficient to cause and have persistent symptoms. So these persistent symptoms are not a reflection of a single pathophysiologic entity. They describe simply a constellation of nonspecific post-traumatic symptoms that could just be linked to either coexisting factors, confounding factors, preexisting conditions. And it just does not reflect something that's ongoing as in terms of an injury to the brain. So I use this quote in all my presentations because it's... When you're seeing these complex cases that are seeing you months and months after their initial injury, you start thinking about the symptom picture is not so much about the injury itself, but the person that sustained the injury. So my fellows love these patients, right? This is the perfect case. You're like, Dr. Sabini, this is easy. Let's go in. Let's clear them, right? It's their first concussion. They're young. They're healthy. They're motivated. They have no preexisting conditions. They don't do any drugs. They're good kids, high-functioning, aged students. They have no incentive to be sick. They want to get better and their coping styles are very high. So when we talk about what the risk factor is for developing persistent symptoms, you look at the surrounding actual injury that occurred. So you look at presence of loss of consciousness, although that could be debated in terms of the length, post-traumatic amnesia. And if there's some sort of positive neuroimaging, there is some association with a worsened outcome. But that relevance and the correlation remains understood. And certainly injury mechanisms, right? Your sports folks are probably going to do a lot better than someone who was in a motor vehicle accident, right? Your sports athlete, they're going to be younger, relatively in good health. They have incentives for recovery, where someone who gets into a car accident may have bodily injuries, MSK problems, psychological trauma, and certainly there's some potential for access for compensation. Post-injury, there are certain symptoms that seem to be linked to more prolonged recovery. Migraines, fogginess, dizziness, emotional symptoms. But the one thing that has shown to be consistent across some of the studies that have come out is the more symptoms you have, the more severe the symptoms you have at the initial visit is most likely the strongest predictor for how you're going to turn out, right? The more stuff you got, the more time it's going to take to recover. And the longer durations of symptoms is thought to be associated with a lot of emotional behavioral disorders. So other symptoms. So physical factors. So you're in a car accident, you may have persistent pain issues, cervicalgia, musculoskeletal injuries. And then there's also those physiological changes that happen after concussion, that exaggerated sympathetic response, such as increased heart rate and change in auto-regulation where you start seeing the symptoms every time their heart rate goes up. Psychosocial issues. So what is their support, right? So a lot of the times people just manage to get through things because they have the support, whether it's family, friends, et cetera, whether they find that in school, at work. But occupational support is a big one. So you have those that come in from a work-related injury and you're trying to get them back and for some reason their job is not being accommodating, so it just comes into this very antagonistic relationship and then they have no incentive to want to go back to work. And societal anxiety. I mean, like Dr. Patel said, the news is pretty excessive in how much we, you know, they love to give a lot of anxiety about everything, right? There's a lot of things happening in this world that just induce a lot of anxiety. And then people will show up to a party and say, oh, I had a concussion. And then someone will say, oh, you know, my kid had one and he's never been the same since. And so these are things that actually impact people's perception of what to expect and certainly how they're going to recover. And that leads into the cognitive attributions and expectations, right? Some people just expect to have these symptoms and then they erroneously attribute these symptoms to be directly related to the initial injury and they might have some unrelated symptoms that then now all of a sudden just become part of, nope, this was from my injury. Then you have the nocebo effect. People just become sick just because they have the expectation that I was told that this is what I'm supposed to feel and I'm feeling this. And then the good old days bias. I've had people tell me that I've never been sick. I've never had a headache in my life. My memory is like a filing cabinet. I could pull things out and just remember like that. And the reality is, is that we've all had some challenge with our memory at some point. And so, and that certainly gets influenced by the amount of stress that you're in, certainly how much sleep you've had, et cetera. So waiting for that asymptomatic because they think that everything was perfect before and now they're symptomatic leads to preclusion of that ongoing return. So pre-injury risk factors. So certainly having a neurological history of a previous injury that leads to disintegrity of the brain, whether it's from previous damage or some significant substance abuse. Learning disability, having psychiatric history. Certainly the stability at that time of the injury plays a role. And then just who the personality is, the characteristics, the resiliency, the coping styles, right? So how does someone adapt to an acute stressor, a trauma, and be able to have the adversity to get through it? Because they can either face their fear and cope with it, have a sense of optimism, or just be completely pessimistic. Do they associate the emotions that they have with this potential for improving with recovery or they're always saying, this is not looking good, I'm never going to recover. And certainly prior life experiences certainly shape how we get through that trauma. And there have been studies that show that pre-injury resilience can be predictive of how someone is expected to recover later. And the big elephant in the room, malingering and litigation. I've had patients literally tell me that, my lawyer tells me, I shouldn't tell you I feel better. And a good neuropsychologist that I worked with used to tell me that this is what they were feeling and that they actually persisted in having these ongoing symptoms simply because the lawyer told them, don't feel better. So what to do when this is lasting way beyond this expected recovery time, right? So usually I get these complicated cases within my own health system because some folks are just a little bit more nervous about dealing with these cases that are significantly more of a challenge and take a lot of effort and you're counseling significantly. So at the very least you do a significantly detailed assessment. You're looking at primary, secondary pathologies that could be contributing to the current symptoms and at a minimum you do your comprehensive history, your physical exam, any special tests. You want to obtain a better differential. We can't just say this is a concussion, right? Especially if it's like years down the road. We can't just come and say that, okay? We have to come up with a better differential as to why these symptoms are still persistent. I think we're doing, we're not being very good clinicians if that's all we're going to tell people because they're going to stay in this empty void and not have any ability to move forward. So you want to acknowledge and reduce the patient's suffering and overall just being physiatrist, improve their overall functional outcomes and get them to where they need to be. So there is, and I am working with my fellows, they know how much I hate the term cognitive deficits. So I see this more of there's a psychological distress on cognition, right? I just talked about how just any distress can suppress your ability to remember things, pay attention, be able to store that information and retrieve it. And so these cognitive symptoms seem to be above and beyond those accounted for by these initial injury, which leads to frustration, stress, anxiety, and it shakes that sense of identity. And that distress can often intensify to the point that it now becomes more disabling than the initial injury. And certainly like I mentioned, personality can certainly affect how that's interpreted. And as it relates to sports, some of you do specifically sports related head injuries. So psychological distress can influence how someone performs on these computerized neurocognitive tests, which I do not condone. I do not think that those are accurate tests that really assess how someone performs cognitively. It's just a test to measure efficiency at taking the test. I have proof of it. Results can determine sports participation. So now you may potentially be keeping athletes out for more prolonged periods of time. You delay their sports participation, their school demands go up, they miss school time if that's what happens. And then there's pressure from teammates and coaches to want to come back. They're perceived as weak. Then they are afraid that they're going to lose the position and potentially advance to a more desired position. They have isolation. They lose affiliation with the team. They could potentially have scholarships on the line. And then you have the social pressures of all that potentially returning them too early. And then now they're playing through the pain. So there's a lot of messages, explicit, implicit, that then adds to the added complexity of how these athletes get through it. So these pressures influence the very vulnerable. And so we need to understand that potentially having proactive psychological treatments to the overall care is very important because you help reform the attributions and misconceptions. This is actually a screenshot I took out of Zasler, the former edition. And all the circles are pretty much the behavioral non-organic causes of what we see as post-concussion like symptoms. So just to give you a visual. So education, right? That's really where it starts. So how do you minimize the risk of it lasting any longer, whether it's the first time you're seeing these patients or it's months later? So again, a single psycho-educational session can be effective in preventing these persistent symptoms. So you educate about what the expected symptoms are, the expected recovery course, emphasizing appropriate attributions of the symptoms to benign ideologies, not that they've had this severe brain injury. And then starting with the understanding that a couple of days, we need to start moving. So this is a really good resource, the Ontario Guidelines, where whether you're in, again, a few days out, months out, you're addressing the symptoms in a very hierarchical manner. You begin with the things that you can treat very easy and that will ultimately lead to the most beneficial response. So treating headaches, treating pain. And then the treatment is guided by extrapolation by the best evidence supported by that, right? So you're trying to figure out, well, what kind of headache is it? Is it a cervicogenic headache? Is it a tension headache, migranous headache? And then directing the treatments for that specific type of diagnosis. And the aim is to maximize functional improvement. And the way I try to teach it to my fellows in practice is that we look at things in domains. So you saw these gears and they're all interrelated with each other, right? So you focus on the pain, you try to improve their pain, because ultimately pain, headaches can have influence on their daytime fatigue, their ability to participate, how they sleep at night. And so if you can optimize that, then you're starting to move the gears in that direction of recovery, right? And then again, with sleep, you get them to be more active. They be, even though they may be fatigued in the day, you start in between some aerobic activity. They get themselves moving. They're more likely to feel more tired at night, right? And then if they sleep better, we can get them to participate there in more cognitive related activities, demanding activities such as school. And then dizziness and balance, if it's present, certainly treat it because that can go undiagnosed. And certainly psychological behavioral treatments to help improve and reduce psychological distress can also affect all the above. So some of the psychotherapeutic intervention is to break up this feedback loop that happens where you have pain, changes in mood, fatigue. It disrupts your cognition. It causes further reactive anxiety and depression, and then further cognitive disruption. So you start with validating their symptoms. You identify the factors contributing to the dysfunction, and the goal is to reestablish this new sense of self, focusing on gaining control, compensatory strategy, and the emotional responses. So cognitive behavioral therapy is one of the things that we always recommend, and certainly biofeedback to help aid through those. And we are physiatrists. Exercise should be part of every recommendation. Even in my most symptomatic patients, I tell them, you got to start moving. There's evidence to support that it's a foundation for the treatment, right? We know that it facilitates, right? So why do I take my minimally conscious patients, my severe TBIs, my severe strokes, and I'm getting them into three hours of rehab every day? So we need to move them and get them active, because we know of the neuroplasticity and the neurogenesis involved. It's certainly adjuvantive in the treatment for depression and anxiety. It's associated with improved cognitive functioning and self-esteem, and certainly with sleep. We want to reduce symptom reporting in those that are slow to recover. And if you feel that you can't get them to exercise on their own, then send them to a supervised rehab program. So that way they can be desensitized from the anxiety of developing the symptoms. The therapist, the athletic trainer, is there to help identify what the heart rate maximum could be, and therefore allow them to safely perform the exercises without overt symptom exacerbation. So what do you prescribe for those? You start with the usual day-to-day exercise. Go out, take a walk, stretch, and identifying, again, if you're working with some physical therapist or athletic trainer, to identify what that sub-maximum heart rate is. And my motto is, if you feel good doing something, keep doing it. Because that's the benefit more than anything, just to get them moving. And if you don't feel so great, just take a step back and try again later. Right? And this is what we should be doing for everybody, right? These are healthy habits. Anything that I'm saying right now is what we should all be doing, right? We should be getting good sleep. We should all be exercising. Okay. So we're going to move into our case presentation. So Dr. Patel is going to start us off. And this is where you're going to see some slides that are going to ask for some polling. All right. So I'm going to be presenting the first patient here. So this is a patient that I saw about two and a half, three years ago. So she was a young 31-year-old female of Caucasian descent. She did not have any previous head injuries or diagnosed concussions. And the only real medical history that she had was an astigmatism as a kid. And she does currently wear glasses. But besides that, she had no real other medical history. So when I see patients with concussion or a head injury, I like to focus a lot on their social status, what they do for a living, getting their prior functional status, seeing what their home environment, social supports are like. And so she was currently undergoing her master's degree in language studies. She was married, didn't have any kids, didn't use any tobacco, rarely used alcohol, and no other illicit drug use. And so her injury happened in 2019. She was involved in a low-speed, low-impact motor vehicle accident where she was rear-ended. She reported that her head kind of whipped back and forth, and she hit the back of her head on her headrest. There was no airbags that went off, and she was using her seatbelt. Did not lose any consciousness, and she was able to exit the vehicle on her own. And because of this, she did not seek any medical attention because she didn't have any real symptoms initially. And so she came in to see her primary care physician about two to four weeks after the incident, complaining of cervicalgia, some blurry vision, double vision, difficulty reading. She had some headaches associated with some light and noise sensitivity as well. And so her primary care physician saw her, told her she should go see a sports medicine doctor, she should start some physical therapy, and then gave her a letter to keep her out of her master's program. And so, like I mentioned, she was in her master's programs for language studies. So when I saw her, she had mentioned that a lot of this involved reading on the computer, reading different textbooks in different languages. And so it was a lot of higher-level reading, things of that nature. And her reading days were pretty much all day. So it was very tasking for her. And so she went to go see one of the sports medicine docs that I worked with about a month and a half after her injury. She continued to limit some of her physical activity. She remained out of her master's program. She had told him that she was trying to get back into it, but every time she was going to read something, she would notice that her headaches would get worse. And so the sports medicine doc addressed the cervicalgia and ordered some x-rays to take a closer look at that pain, gave her some trigger-point injections, and then referred her to the concussion clinic. And so what would you—so this is our first polling question. And so what may we expect on clinical exam for this patient? I'll give you guys some time to answer that here. So again, a few answers in, so poor balance, normal exam, normal, maybe some trigger points in the neck, abnormal saccades, balance impairment, good, awesome, depression, good. And so, by the time she got to me, it was about two and a half, three months later, and so like many of you mentioned, it was a fairly normal exam. Her cranial nerves were grossly intact. She had five out of five strength in all of her extremity, normal sensation. Looking at her eyes and doing a more thorough kind of visual exam, so her extraocular movements were intact. Her smooth pursuits were fine. She didn't have any nystagmus or saccadic eye movements, but I did notice that her convergence was abnormal at 18 centimeters. And then when we did her vestibular ocular reflex and her head impulse test, those came back without any symptoms. And like you guys mentioned, she also had some tenderness in her paraspinals as well as her cervical musculature. And then she did have a flat affect when I first saw her as well. And so what would we recommend for treatment for her? Awesome. So, SNRIs, cognitive behavioral therapy, vestibular therapy, psychology. Good. Counseling, that's all. Okay, good. So, first and foremost, education was a big piece of this. And so, this was now about three months out from her injury and kind of talking to her about her initial injury, what happened, the symptoms she felt, and just educating her about concussion symptoms, the expected recovery time frame, what we can do to help her get back into her activities and her schooling were important at that point. And so, with that, we talked about a kind of more detailed activity profile. She wasn't a high-level athlete. She didn't go to the gym extensively, but getting her into routine walks on a daily basis just to get her some aerobic exercise was kind of the initial period for her. Improving sleep hygiene was also important. And then, continuing physical therapy for her for her neck. And then, we had also referred her to occupational therapy for some vision therapy and neuro-optometry because she wanted some additional vision evaluation as well. And so, we had diagnosed her with convergence disorder. And so, that was leading her to have some of those difficulties with her reading, especially with her master's studies. And so, I asked her to follow up in about four weeks, giving her some time to get her therapy sessions and start some of that, start her aerobic exercise programs, get her better sleeping patterns in place. Unfortunately, she did not follow up initially that four-month period and eventually ended up following up about seven, eight months after the injury when she was kind of at a worse point at that stage. And so, initially, her husband had reached out to me, not even her, saying that she was not doing so well. And so, at that point, she wasn't even able to leave her house to attend any activities or appointments. And at this point, COVID had hit. So, thankfully, virtual appointments were becoming a thing. And so, she was able to do some of that via phone call. She wasn't even able to sit in the car without having symptoms, even though the car was not moving. She continued to have the light sensitivity and difficulty with reading. The headaches were still present. Her sleep was getting worse because she wasn't having much cognitive activity during the day or physical activity to make her tired at night to sleep. And then, she had increased stress because now it had been six, seven, eight months before she had even touched anything from her master's program. So, she was worried that she was now going to get kicked out of her program. And so, is this still a concussion or is this something else? And as we can overwhelmingly see that most of you guys are agreeing that it was likely something else. And so when she came back to see me, we were seeing each other virtually, but we spent a lot of time diving into the stress levels that she was having and the current stressors in her life. At this point, I had been, I think I had saw her for the fourth time. And outside of her master's program, which we talked about being a stressor in her life, what else was going on in her life to to kind of cause some of these symptoms to be exacerbated and to be persistent? And so she told me that her and her husband were dealing with some issues regarding fertility and how that was causing a stress in her life and how she had some relationships that were also impacted because she wasn't able to go to as many social events, things of that nature, and that had also impacted her life. And so we talked about how those stressors may have impacted her concussion symptoms that she had initially had. And so we talked about how that accident that she had, that traumatic event, even though it was a small fender-bender, may have been the straw that broke the camel's back and triggered a lot of these symptoms that persisted and continued on. And so because she was limited to treatment within her environment that was local to her, we sought to kind of find treatment that she would be able to either walk to or providers would be able to possibly do a home visit for her. And so we looked at more adjunctive therapies, things like acupuncture, massage, osteopathic manipulative medicine. She got to the point that she and her husband actually ended up moving from the location that they were in. And this was in the DC area. And so they initially lived in a apartment that was close to a fire station. So the noises from the fire trucks would hurt her ears and cause her to have headaches. And so they ended up moving to a more suburban area. And so thankfully there she was able to get some of these adjunctive treatments. And then we also started her on esotelopram as well as getting her in to see a psychotherapist as well to do some cognitive behavioral therapy. And so because she only had a few sessions of her vision therapy and her physical therapy regarding her neck, we asked her to continue doing some of those exercises at home to help with that improvement. And so about 12 months after the injury, she had been on the medication for about two months. She had started seeing a psychotherapist and she had tried to do some of the exercises at home. We started to see some improvements in her headaches, in her visions. She started doing small periods of time where she was able to get back in the car just to sit in the car and kind of avoid some of those symptoms. So we started with brief moments of just a minute, just her being in the car and then getting out of the car. And slowly we were building up to higher periods of time that she was able to be in the car, outside in the sunlight, looking at screens. And so we really did a very short period and then slowly built up for her. And then last I had talked to her, she was restarting her master's program because she felt that her symptoms were improving at a reduced workload. And then eventually we were providing accommodations for her, not only at that reduced workload, but also when she was planning to go back into full-time. And so out of the treatments, what do you guys think benefited the patient the most? And this is what I was hoping to see, kind of a mix of everything, because really, likely, it was probably a mix of all the treatments that helped her. It's hard to say which one exactly. I think a lot of what we had seen was related to her psychosocial aspects of her life and how psychotherapy, cognitive behavioral therapy, how the medication really helped her deal with some of that stress in her life was important. But I think all of them really probably played a part in her recovery. And so I'll hand it off now to Lindsay, who's going to go through the next case. Hi, good afternoon, everybody. My name is Lindsay Tharathil. The next case we're going to talk about is the case of the altered quarterback. A quick summary on what the case is about. This is a 14-year-old male. He presented to the ER after a football injury. There was a fumble and he was tackled by multiple teammates. He presented via ambulance. EMS had reported that he appeared to be altered in the locker room. He was unsure if there was any loss of consciousness and the patient couldn't recall the actual injury. ER physician evaluated the patient as well, determined him to be altered and disoriented. He had positive C-spine tenderness, therefore he was placed in a cervical collar and the patient was uncooperative with the neuro exam. As time passed in the ED, the patient's sister reported that he was in and out of consciousness. She stated as he received IV fluids and as the pain got better, he became more responsive and reactive. The ER attending decided to upgrade this patient to a level two trauma as he appeared to be altered. This is the pediatric trauma assessment. So we're going to call this patient M.A. He's a 14-year-old male, status post blunt force trauma during a football game. He was a quarterback who was tackled by multiple players. He was wearing a helmet. There was a positive head strike, but unknown loss of consciousness. He was able to get up and walk off the field. However, he progressively started to develop severe headache, photosensitivity, and cervical spine pain. He was taken to the athletic trainer's office where an evaluation was done, but he appeared to be altered, confused, and had limited verbal output. Therefore a decision was made to call EMS. He presented to the hospital, evaluated by the pediatric attending, and decided to upgrade to a level two trauma for being altered mental status. Patient did admit to having nausea, but no emesis. He also had severe headache. He denied any dizziness or blurry vision, no chest pain, nor shortness of breath. Trauma assessment. So GCS was 15 on arrival. He was lethargic, but tachycardic, 110s to 120s. Neuro exam intact. Motor exam also intact, except it took them multiple attempts to get him to participate in that. Exam was consistent with positive tenderness to touch throughout the head. He also complained and had tenderness to spine palpation throughout the spine, as well as photosensitivity and abdominal tenderness. Trauma did an extensive workup, including CT of the head and complete spine, which everything came back to be negative. History. History was mostly non-contributory in this patient, except for some findings on the review of systems. He was positive for photophobia, nausea, back pain, neck pain, dizziness, headaches, and weakness. Would you admit this patient? If so, and why? Take a few minutes. Right, so just as expected. This patient was admitted to the trauma service. Reason for admission by trauma. Had persistent worsening nausea, headache. He failed outpatient monitoring, not really sure what kind of outpatient monitoring was done because he was transferred from the field to the ER and they determined he need continued neurological status checks and abdominal checks, which required inpatient level of care. He was placed on bed rest by trauma. Pain control with Tylenol, neurochecks, IV fluids started. Trauma attempted to clear the C-spine, but was unable to do so due to ongoing midline C-spine tenderness. Therefore, MRI C-spine was ordered, which was negative, no acute findings. What next? Would you discharge this patient? Trauma decided to call for a pediatric evaluation. Pediatric team came down and assessed this patient. Agreed with trauma's assessment. Only other findings that were listed as in regards to his social history. He lives at home with both his parents. He's got five siblings. He's a straight A student. No history of alcohol, drug, or smoking. Development was appropriate for age and positive findings on the pediatric assessment was patient was sleepy, but able to be aroused with repeated commands. He was able to respond to his name, but stopped participating in much of the rest of the exam. He did follow most commands, but required several attempts. What was their assessment and plan? They agreed with the trauma assessment. Continued bed rest for this patient. Continued neurochecks, pain management. Recommended NPO for serial abdominal exams. Trauma's follow-up. Abdomen was benign, so therefore was taken off of NPO and started on a diet. They said, oh, suspect head injury or concussion. Let's call PM&R for consultation to assist with neurocognitive rehabilitation. Just to note in all of this, patient did get up in the room which was witnessed by the nurse, did ambulate with two-person assist with his eyes closed, but was seen opening his eyes many of times. So PM&R was called for head injury evaluation. So when entering the room, he was seen with the lights off, blinds closed, TV off, multiple family members in the room doting on this patient, including two family members who were physicians who were requesting pain medication, muscle relaxers, and on and on. Multiple family members talking at a low voice. They didn't want multiple people to come in and examine the patient at the same time. On exam, he refused to open his eyes, limited participation, limited answering questions, but he did on multiple requests get up and able to take a few steps at bedside, but was seen squinting. There was some questionable impairments with his balance, but overall motor exam was intact. The neuro exam was intact, except he refused to open his eyes. We did request PTOT evaluation at bedside and it said if he can ambulate safely, then can DC home without patient follow-up. So PT evaluation, they did... He did ambulate with contact guard level assistance, but was noted to have some unsteadiness and they recommended patient to go home with a rolling walker. Patient never received the walker to go home, but was eventually discharged. So first office visit. This was five days post-discharge from the hospital. He presented with both of his parents. He presented with his eyes open and he walked into the office handheld assist. He continued to complain of daily headaches, which were intermittent throughout the day. His headaches were mostly located in the occipital region. No changes with or complaints to his vision. He did continue to have intermittent nausea, but no vomiting. He also complained of right-sided neck pain, which he describes as tightness. He no longer had any photosensitivity, but he did complain of noise sensitivity. Parents reported that he was sleeping throughout the night, but seemed to be more lethargic and sleeping during the day. The patient itself admitted he was more irritable, more anxious, more nervous. He thought he had some difficulty with concentrating and some concerns about his memory regarding what happened around the incident. Parents were concerned that he had trouble articulating his words or finding the right words to say. And they were also concerned that his balance remained slightly impaired. To note in all of this, in the last one week, the mother did admit she was helping him with all of his ADLs, including bathing. And the day of the visit was the first time the patient himself decided to bathe himself. To this point, he has not yet returned back to school. So this was the first concussion symptom evaluation that was done. If you see here, he had a total of positive 15 symptoms out of the 22 with a symptom severity score of 51 out of 132. We didn't really ask about physical activity or mental activity because he was so-called on bed rest for the last one week. So it was not pertinent. On the standardized assessment of concussion, he scored a 26 out of 30. And there was positive findings on the modified balance error scoring system, which was consistent with the imbalance episodes he was having. Physical exam. Real only positive findings where a patient was taking a decent amount of time between questions that were asked. It took him a prolonged period of time to formulate his responses. Static balance was intact, but his dynamic balance was impaired. And he continued to have C-spine tenderness of the cervical paraspinals. What would you do now? Would you send him back to school? Sports? School? No sports? So, overall, plan of recommendation was for him to start physical therapy for the neck pain and for the balance complaints, Tylenol for headaches. Concussion protocol was discussed extensively with the patient and the parents. Sleep hygiene including well-balanced diet, hydration was discussed. I strongly advised the parents to encourage patient to return to his daily activities as much as possible with limited help from the parents because they were providing a lot of assistance for him at home. At this time, I said no contact sports or gym until the next evaluation, but plan to return to school with appropriate accommodations as needed including extended time to complete homework assignments, etc. He was to return in one week for follow-up. Second visit was one week later. At this point, he walked into the room without any difficulty, no complaints on his balance. Headaches improved. He had, I think, one headache that morning which he attributed to poor sleep the night before. He had improvement in his neck pain after starting outpatient PT. He continued to feel more tired and lethargic compared to his baseline and was sleeping less than his usual, and he also said he had trouble falling asleep at night. He was concerned about concentration, therefore hesitated to want to go back to school. There was no more concerns about his mood or photosensitivity or phonosensitivity, and the mother still remained highly concerned about his recovery. At this point, he still has not returned to school even though in the first office visit it was recommended for him to transition back. The second concussion evaluation, symptom... number of symptoms that were positive has improved. His symptoms were down to 6 out of 22 with a symptom severity score of 11 out of 132. He has been a little bit more active at home, so symptoms did not get worse with physical or mental activity, and the modified balance error scoring system was negative at this point. What now? So some limiting factors for his recovery. What do you guys think? Is it his ongoing symptoms? Is it the patient? Is it the parent, the school, or all of the above? Agreed, all of the above. So big limiting factor was the parents. The mother didn't think the patient was ready to go back to school. She wanted additional time, additional accommodations. She wanted him to have a pass to use the elevator, wanted extra time for him to transition between his classes. The father was the complete opposite. There's nothing wrong with my son. He should go back to school in sports right away. The patient, on the other hand, he was one of five siblings. He was getting a lot of attention at home, and he was loving it. A lot of social concerns. He had a lot of fear of returning back to school. What will my friends say? What will my team say? As well as he had academic concerns. He's a straight-A student, so now he's fallen behind in school two, three weeks. So he's worried about that. So ongoing symptoms. That, at least, it's headed in the right direction. So the headaches have improved. The neck pain has improved. But he's feeling slowed down, fatigue, and difficulty concentrating. Well, what do we expect? This is a 14-year-old kid who's active, multiple extracurricular activity, who's a football player. And you put this guy on bed rest for two, three weeks. It's kind of expected. He said he had trouble falling asleep, but he's at home doing nothing. He's sleeping during the day. He's up at night playing video games. That's also expected. So what was the plan? Extended conversation with the patient and the parents and encouraged them to help him transition back to school to normalize his recovery as much as possible. Explained there's going to be some difficulties in the first few days. That's expected, but we'll address them as they come up. In this conversation, there were other things that came up too. Patient said this was his first concussion, first incident for something like this to happen. He was shocked of what happened at the scene and all of the attention he received around it. He felt embarrassed and kind of pretty much shut down. So if you look back, then it pretty much skewed a lot of his exam in the hospital, if that's the case. Third office visit was another week later. He did return to school. He said the first two days was difficult, but he did just fine. Caught up with his homework, assignments, no concerns with ambulation, no concerns with his balance, sleeping well, eating well, no mood issues. Headache frequency also improved and improvement in the neck pain. He continued with physical therapy. This was his third concussion evaluation. Total number of positive symptoms were down to three with a symptom severity score of three out of 132. So big difference from the first visit. Overall plan, at this point we initiated the return to play protocol. It was a new letter that was given to the patient for school so that accommodations are lifted. He followed up with me two weeks later and at this point he successfully completed the return to play, back to school with no limitations and no new concerns or symptoms. Okay. Okay. So I have a couple more cases, but we're going to go quickly through them. Thank you, Dr. Thaddeville. Fascinating. So this is a 14-year-old that presented day four to a concussion physician from a basketball injury. They were unclear what happened. They might have been hit in the front or the back of the head. Overall doesn't remember the events, but was having headaches, nausea, photophobia, dizziness, and fatigue. The exam at that day was fairly benign except for smooth pursuits was abnormal and there were some symptoms upon the testing. This was the assessment and plan. Discuss findings of today's exam and possible causes. Educated patient on their most probable diagnosis of concussion. Decided best course of treatment will include conservative management and continued rest. Patient is not cleared at this time to enter return to sports strategy and advised to continue physical and cognitive rest. Follow up one to two weeks. There's a couple of you I have to convince. Come up here later. So in the following months, mind you, I'm getting to when I get involved. So day 17, returns to the same physician, continues to have headaches, limited improvement with Tylenol. She got a Meddral dose pack, had ongoing cervical thoracic back pain. She had this ongoing abnormal vestibular ocular exam. She was referred to vestibular therapy. She continued school with modifications and assists, but she had continued physical and cognitive rest. So by day 30, she finally gets a vestibular eval. Her dizziness handicap inventory was very high. Her vestibular exam from the vestibular therapist was within normal limits. On day 47, follow-up for the third time with this concussion physician says, well, you're still having headaches, go to pediatric neurology. She happened to have the appointment the following day. She was trialed, and this is now looking back, trialed amitriptyline, venlafaxine, melatonin, and clonidine. Does anyone have a problem with any of this? Yes, this is a nightmare. No, seems perfectly reasonable. Eh, I'm so used to these complex cases, I just roll with it. Did I convince those two? Okay. All right, hopefully I converted two people today. Okay. So I see this girl at the five-months time. I'm still having headaches. They're frontal temporal headaches, tension throughout the day. There's no nausea, no sound, light sensitivities, but there's a little bit of some cervicalgia. And the dizziness aspect still reported some feeling off balance, lightheadedness, there was no spinning. Sleep-wise was waking up often. The melatonin and clonidine didn't help. And mood-wise, she felt anxious, she felt depressed, and she reported significant cognitive inefficiencies. Her activity level was very limited. She pretty much didn't do anything, but her goals to me were, I'd really like to get back to school full-time and return to sports. I said, coming right up. So I did the exam completely normal, no vestibular, ocular balance issues. Somatic-wise, I recommended that she just take Tylenol as needed. The dizziness aspect domain wasn't applicable. And sleep, I said, we need to just get you physically more active so we can get you tired and sleep. And I pretty much ignored her mood and her cognitive inefficiencies because I said, if we fix this, maybe we can fix that. So I reassured her of the current symptoms. I reattributed the origination of the symptoms and why she's still having them. I DC'd vestibular therapy because she was still going, not sure why. We were going to attempt to return to sports and encourage walking daily and progressing the speed and the time which she should do that. I recommended return to school full-time with phys ed, but no contact. And I did recommend, you know what, stop the clonidine. But let's just keep the venlafaxine for the moment. So she failed the return to sports stage three. And what I usually do is I have them try it twice. And then that's when the athletic trainer or the therapist, they alert me and tell me, look, they failed twice. They need to come back to see you. But she said she was using the treadmill every day, at least in phys ed, and she was going around the track. So I started her on the Buffalo concussion treadmill. So the therapist calls me and says, we can't continue it. I said, why? Well, she's having too many symptoms. I said, okay, can you send me your eval? So does anything up here seem a little glaring? And if you don't catch it, I'm going to show you. So this girl was on this treadmill. And I don't know how many of you are familiar with the Buffalo concussion treadmill test. They try to figure out what your tolerance is by constantly advancing the speed and the incline. So she was on this for 13 minutes. Yes, she reached a maximal heart rate of 206, so her threshold was 191. Meanwhile, she had her resting headache beforehand was a seven, and her headache didn't get worse. And I said, okay, we got to move this along. Her headaches are tension. They're not related to the exercise. They're there, and they're not significantly worsening with exercise. So we went back to the return to sports, and somehow she completed it a week later. And she was cleared. So final case, this brings up a little bit of the autonomic piece that I mentioned earlier. This is another female who was hit in the back of the head of the volleyball game. She had no loss of consciousness, no PTA. She felt dizzy, unsteady, some blurriness of vision. She walked off the court. But the next day, they didn't take her out. She went to practice 90 minutes with a few rest breaks, but the loud music caused the dizziness to return. So she ended up going to urgent care that day. The head CT was done. There were no acute changes, and she was referred to the concussion program. And the physician who saw her said, well, you didn't sleep well. So she didn't sleep well that night before, because she was afraid that she was going to be told she had a concussion. She was noted to have hypertension, so 150 systolic, and a heart rate of 130. She had persistent dizziness, worse with any position change, sit to supine, supine to sit, you name it. She couldn't stand any position changes, but laying down, she was good. So they took her out of sports and recommended physical rest. So over the next course of the month, and the beauty of being in a large system, I get to peek in all these notes. So she was sent to vestibular, but the exam was completely normal. But due to the persistent symptoms, she was then transitioned to homeschooling. So she was taken out of school. And she also was sent to psychotherapy, because she had this ongoing anxiety. She was actually referred to cardiology, because she had constantly orthostatic-related dizziness. Her blood pressure was always elevated, and so was her heart rate. But they did a halter monitor, they did a complete workup, and they said, look, you just got to hydrate, you got to exercise and lose weight. And she was highly offended by that. Because the girl's like 6'8", and she was highly offended by that comment. So then she returns to the initial physician who referred her there and said, you have autonomic dysfunction. So somehow she makes her way to month four, because the mom was pretty aggressive in trying to get her to feel better and get her back to school and get her back into sports. So I see her at month four. I'm still having symptoms from my concussion. She was having headaches just one time a day, lasted about an hour, and resolved by Tylenol. There were no associated symptoms, right? So she had, again, these tension-type headaches. But she still had this feeling of dizziness, off-balance, associated with this position sense. She was definitely more tired, took too long to fall asleep. She was definitely anxious and reported that she had cognitive inefficiencies. So her activity level was, she spends most of her time sitting at home. She'll do yoga maybe one to two times a week. But because of all the position changes, she had to modify them, does them all on the floor. And really, it's not much that she can do. But she did walk her dog 15 minutes a day. And again, I always get the people that are like, can you send me back to school? Can you get me back to sports? So on my exam, this was crazy. She shows up wearing a pulse ox to show me her tachycardia. So clearly, slightly anxious. But her exam was completely normal, right? Neurologically, she was clean. Her even when we do vestibular assessments for balance, we do the standing, eyes closed, change in position. And then we have them walk up and down the hallway with head position changes. And she just did perfectly fine. So I said, look, your headaches are only once a day. They last an hour. Do you really need Tylenol every time you take it? You know, why don't you try tapering it? The lightheadedness, I said, you know, we just realized that just because you have that doesn't mean that you have to stop, right? You just have to desensitize yourself. And if we don't, even the vestibular therapist will tell you with vertigo, you have to feel dizzy to get better, right? It doesn't feel great, but that's what you have to end up doing. And so I also recommended increased physical activity. And then I said, let's just see how things roll. So again, reassurance of the current symptoms, reattribution. I recommended the Buffalo concussion treadmill test for her, continue walking, and then counseling for biofeedback and the anxiety. Unfortunately, she failed the Buffalo concussion treadmill test because she felt lightheaded, diaphoretic, but she felt that she could keep going. Some of the therapists, it depends who you have. Some can be very aggressive, some are very conservative, so it's just a matter of conversations. She was walking. She was definitely doing activities. She was telling me how now I'm able to go to the beach and I can walk a half hour with my dad and just had minimal reports of these dizziness. She had no headaches and was just sleeping much better and her overall mood was improved. So I said, okay, let's return to school full time with modifications. Maybe leave a few minutes before the bell so you're not overcrowded. Go to the nurse's office just in case something triggers your headache and return to phys-ed with no contact. So I wanted to present her and she actually didn't follow up with me, but I called her. So it turns out she went back to school full time, no restrictions. She was back in sports. She went for a second opinion with cardiology who agreed with what I had recommended, did not agree with autonomic dysfunction or any of that, and she's currently in counseling. She's making progress and she's living a great life. The parents were extremely thankful for that. So I want to extend my thank you to everyone for lasting out this long day. I want to thank my speakers, my former fellows. You did fantastic, but we're more than happy to take questions. You can put them into the polling and we can answer them up here. And then there's some live questions you can do through the AAPMNR app. Oh, I figured it out. Usually that's done by the therapists. We're gonna have to go back to these questions because they're getting lost in the, so go ahead. What else can you do for sleep? I will put to your consideration. So the one question is beyond sleep hygiene and exercise, what else can you do for sleep? At what point do you consider meds? So I usually initially always start with sleep hygiene as the initial go-to. Some folks are, it depends also on if they have previous sleep ailments or any issues regarding their sleep patterns. Sometimes we do turn to meds. Usually I'll start with melatonin as the first kind of substance. It also depends. I've had a lot of patients that tell me that they don't wanna be on any meds, whether that's even melatonin. And so then we talk about things, alternative type of things, lavender, chamomile, many type of teas that they may try as well. But I think the most important thing that I tell folks is that you gotta physically and mentally get your body prepared to sleep. And so that's daily activity, getting your brain tired, getting your body tired, and then also dealing with any stressors that you may have prior to going to bed. So some folks I may even tell to journal or even do some activity before bed, meditation, things like that to help them get to bed as well. So there was a question that was asked, is there any guidance regarding limiting screen time post-concussion? There are no limitations. There was actually, back when I was in training, there was a physician who told patients that after a concussion, no laptops, no computers, no screen time, no phones, nothing. We don't follow those recommendations anymore. It's as tolerated. So I usually tell my patients, screen time is completely fine. So obviously, if you're using the computer for an hour or two, and the second hour or third hour of using it, it brings on symptoms like nausea, headache. That's your body telling you it's a little too much, too fast. So you just stop, you rest, and you go back to it at a later time. So there's no hardcore rule in terms of length of time in terms of what you can use for screen time. The person that wrote the question, do you use the SSS in adults? Is that the symptom severity scale? Just clarifying. Maybe. Yes. I mean, right. So you still want to assess... Or is that the return to sports? Yes. Okay. So go ahead. Yeah. So yeah, I think it's still important to use that in adults as well. So it helps to quantify symptoms and grade them. Also, I think it depends on the patient. So with the scales, I think there's some caution you have to use as well, right? Because so the scales list out a bunch of symptoms. So if patients see, okay, nausea is the next thing. Oh yeah, I get reminded I did have nausea last week or yesterday. And so that kind of prompts them somewhat. So you do have to use it with caution. But I think it does help to quantify symptoms as well as seeing some improvement or worsening of symptoms along the way. So I guess this question is for me. How did you get her through return to play if she's still reporting symptoms such as tension? So that's the thing. You have to differentiate what are the symptoms that are related to physical activity and whether they're getting worse. You're not going to know, right? People have baseline symptoms as it is, right? People come with preexisting challenges as it is, whether it's pain, neck, headaches, even before their injury. And so you can't preclude them for and wait for this asymptomatic status because you'll never get them to trial. So it's important to identify the kind of headache that they have, right? Because people can have tension headaches just related to poor sleep, stress, et cetera. So the question is, is it exacerbated by putting them through the treatment? So one of the questions is how long do you schedule for initial eval for concussion, for follow-up, and then do you bill based on time or complexity? So my situation's a little bit different. So I just switched from the private sector to the VA. So in the private sector, I would schedule my initial evals for 40 minutes and my follow-ups for 30. And so at that point, I was billing based off of complexity. Now my schedule's where I get initials for 60 and follow-ups for 30, but I'm billing it based off of time. So I think it depends on what level you're at or what realm you're in and how you're billing for that. So I'm still in that private sector. But typically, it's based on time more than anything, especially for my follow-ups, because we end up having significant, lengthy conversations. It turns into a therapeutic session. My goal is to have them walk away with the right expectation. And unfortunately, a lot of what I see, I have to undo what everyone else has told them. And then they say, everyone else told me something completely opposite. And I said, I know. So... Who do you use for feedback? Is it you or is it me? Do you want to answer that or not? Rincey doesn't want to answer that. Okay, who do you use for biofeedback here? So usually it's a psychologist that I have on staff that does this biofeedback with the patients. For the most part, they're the ones that are providing that biofeedback as well as any type of coping strategies counts. Sure. So I've had to send a few folks for a functional capacity evaluation and I don't think there's a definitive point to say, okay, at six months, a year, you're now going to go to do a functional capacity evaluation. I think from what you've heard from all of us, I think it's, we like to get people back into activity, back into their routine, daily lives, back into work, school, play, things of that nature. And so sometimes when you have patients come in and your gut tells you that there's something else going on, whether it's litigation, avoidance behavior, secondary gains, especially if folks, I have disability forms I have to fill out and then a month later folks come in and it's just a continued kind of repetition of my symptoms aren't changing. I'm doing everything you asked me. I still need to be out of work. Then I'll ask them to go get a functional capacity evaluation and that'll just help me kind of guide some of that paperwork that I'm doing with disability as well. So we're five minutes over. So if there's anyone else who wants to ask questions, please come up here and we'll try to answer them for you. Thank you so much.

recovery

concussion

early recognition

treatment

assessment tools

individualized treatment plans

rest

gradual return to activity

persistent symptoms

comprehensive assessment

therapeutic interventions