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Melanie Cole, MS: Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole, and I invite you to join us as we discuss concussion with Dr. Jonathan Aubry. He's a sports medicine physician at Carle BroMenn in Bloomington, Illinois, Dr. Aubry, thank you so much for joining us today. So can you start by discussing the current state, the volume attributed to concussions right now? What are doctors seeing? Do you have any trends to address?

Dr. Jonathan Aubry: Hey Melanie. Thanks for having me today. You know, from that standpoint, we see a good amount of concussion and I don't say there's a specific trend necessarily. As a sports medicine specialist, we see a lot of athletes from youth athletes up to weekend warriors, all of these patients come to see us. But I think that we're just becoming more aware of concussions in general. And as I've been training in medicine, I'm only six months in the practice here with Carle. But over the course of residency and fellowship, I think we're seeing more and more just because the general population is becoming more aware that this is a real issue and that there's just generally more awareness to what's going on and that there can be subsequent issues long-term if we don't treat these things correctly. And if athletes and other folks are going back to sport too soon or going back and having a potential another injury, that could cause more damage downstream.

So I think that we're treating more of these things, but I do think that there's a lot of concussions out there that are being undertreated or just not treated at all as well.

Melanie Cole, MS: Dr. Aubry, one of the things that I've noticed in the field is that there's a question about whether the equipment adequately protects an athlete from concussion. It's discussed in the media and schools wonder that and certainly parents do as well. Tell us a little bit about the equipment that we've got out there today, helmets and such, and are they working for us or are they really not intended to prevent concussion.

Dr. Jonathan Aubry: So that's a great question. There's been a lot of advancements in the equipment, but essentially the equipment is a tool to help prevent concussion. It's not going to be the end all be all of prevention though. And so as helmets have gotten better, we look back at NFL players 50 years ago, they were wearing leather helmets, or there's been no helmets in hockey before, things like this. Technology has gotten much better as far as better fit, the ability to take some of the blow potentially if there's a helmet to helmet contact. But essentially, it's just a tool to help prevent kind of partially as well.

So, there's been a lot of help with coaches training athletes, all these things to make the game safer and as far as officiating as well. The only way that we're really going to prevent the concussion in some of these high level sports and high impact sports is by not having those collisions and teaching people to be better tacklers. You know, don't go after the head, no spear tackles, things like that.

So, I agree the technology has gotten improved. It's much, much better, even when back in the day, when I was, you know, doing some youth tackle football, things like this, where your head would maybe be swimming in the helmet. You know, the tighter fit, the better technology, the ability to take some of the blow is essential. And I think it's just going to get better and better. But it's always just going to be a tool and there's always going to be a risk factor for concussion if you do take a blow to the head in those high-risk environments.

And I do think they've gotten a little bit better as far as some sports. Some softball players are wearing helmets, some of the things where in previous sports we weren't doing. And so I think that know we're becoming more aware that, you know, helmet protection is essential in some other sports as well and can provide some decrease risk, but essentially there is going to be some risk, whether athletes are running together or there's a ball coming at high speed. There's no true prevention, but it's definitely a tool to help prevent.

Melanie Cole, MS: Well, Dr. Aubry, as we're talking about some emerging areas in concussion management, can you tell us about the importance of having a thorough concussion evaluation, even if patients just suspect they may have one? And what are your thoughts on impact tests, baseline screening? Tell us a little bit about what's going on in the field now as far as evaluation.

Dr. Jonathan Aubry: Yes, I think it's essential to be evaluated by someone in the medical profession that can handle concussion starting with athletic training. I can't say enough about athletic trainers that are often at events and can do the initial screens and really help to manage a lot of these. But as a sports medicine specialist, we kind of step in and have a lot of tools in order to really help diagnose. And at this point, we use a lot of different things to make that diagnosis. There's subjective measures and then there's objective measures as well.

And so we're looking for, right away, a lot of things, the confusion, you know, altered mental status, loss of consciousness, anything like that, that we can see right away. Those are objective things that we're looking for, the trainers are seeing as well. But again, like you said, there are some things, you know, days later or subacute concussions as well that needs to be evaluated from this standpoint too.

So we're looking at a lot of symptom-based scales. One that we often use is called the sport concussion assessment tool. It's a pretty standardized test called the SCAT where we look at 22 specific symptoms and that can give us a really good idea of whether you're leaning towards that diagnosis or not at this point. And then we also do some other standardized testing. So, you know, physical exam type things that helps you either exacerbate some of the symptoms or maybe you're not as exacerbated, things like this where we can really kind of tease it out.

You mentioned impact testing. We're not using that as much anymore. The impact testing was a computer-based and still is a computer-based system where you can get a baseline generalized concussion evaluation. And so a lot of people would get these things early in the season or at the beginning of a season, and then subsequently tests later post-concussion. I've done the test myself. It's actually quite challenging. I do think I passed in general. I wasn't concussed at the time. But from that standpoint, that is a subscription-based testing. We need computer set up and things. So, here Bloomington, we're not using those very often or at all, essentially, because there's some free testing that we can do with PDF. You know, you just print off a PDF and our trainers can have copies. We have copies, things like that, where there's other standardized testing that has been shown to be quite helpful. And so we're not using the impact, but we are using standardized testing to help diagnose these things.

Melanie Cole, MS: So let's talk about some of the current standard of care for concussion treatment, because one of the things I've found interesting is in new revisions against complete removal of electronic devices, that was one. Speak about return to play and management of concussion, both from the coach and trainer perspective, and even for the parents.

Dr. Jonathan Aubry: So big question is, yeah, what do we need to do? And when can this person get back to play, or even if they're not an athlete, when can this person go back to work or do whatever they need to do? And so for treatment, you know, the standard for a long time was complete brain rest, where you really shouldn't be doing, seeing a lot of lights, a lot of noise, you shouldn't be very active. Things have changed a little bit. We're allowing people to do a little bit more, but in today's world where we see -- I'm currently in front of two computer screens. You know, we have tons of screens in front of us. It's really impossible to keep that completely away. But in general, the standard of care is to allow the brain to rest. So we treat symptomatically. We'll give some Tylenol in the first 24 hours, NSAIDs afterwards, things like that to try to treat headaches. We treat nausea, vomiting. We can treat some dizziness, all of those things. But essentially, most of these things get better with supportive care, mental rest, good sleep, good nutrition, you know, and with the help of us, we can provide some supplemental support, vitamins, nutrition, things like that. And most folks do get better. We kind of think within the timeframe of a child, should be better in about two weeks and an adult, three to four weeks. And if we're extending past that, we kind of consider it to be a potentially extended or prolonged concussion.

And when the big question of return to play or return to work, I like to have most of my athletes nearly asymptomatic or completely asymptomatic at this point. So we're really following symptoms scales. We're making sure that they're not symptomatic with specific movements. And when we think about athletics, there's so much physical movement, there's eye movements, there's all of these things that can contribute to dizziness, nausea. And if you're having any of those symptoms, you're not going to be able to, one, compete at high level, but then, two, you're also going to be putting yourself at risk of other injuries. There's studies out there that show that people that are post-concussive can have increased risk of knee injuries and other types of things. And so we're really kind of a look out for the athlete, making sure that they're not putting themselves into a negative situation going back to the field or the court too soon.

Melanie Cole, MS: Well, that's really important information. As we get ready to wrap up, Dr. Aubry, how can effective management of the injury shorten recovery time? We've learned a lot about that and potentially reduce the risk of long-term symptoms and complications. How would you like providers to counsel their patients, coaches, parents about prevention? And when do you feel that a patient should be referred to a specialist such as yourself?

Dr. Jonathan Aubry: Well, I think, you know, it's essential for anyone involved in athletics to have some knowledge of what's going on with a concussion and be able to kind of be aware what we can do to prevent this. And I think when it's certain sports such as football or basketball or all these things, it comes down to from a coaching standpoint, lots of technique. And I think the things have gotten so much better over the past however many years since we've been, you know, more aware of concussions. And so, teaching how to tackle, teaching not to be aggressive in certain ways or to protect certain players when they're vulnerable. And so it comes from that standpoint, parents and coaches are essential, you know, as far as teaching the techniques. And then oftentimes, they're the firstline people that can be aware of this. They know their athlete day to day. They know that this person's off. They know that, "Hey, he's acting a little bit differently" or "He never complains of this" or "His mood's a little bit different than usual." and so from that standpoint, coaches, parents, those are often firstline people that can kind of make us aware, the trainers and physicians too, that there's something truly going on.

And so the timing of when an athlete should be sent to us is as soon as you see something that is suspicious for a concussion. Because the sooner that we diagnose and start treatment and start resting and doing what we need to do, the sooner that athlete is going to get back, especially if they have some prolonged symptoms. And one kind of shout out that a lot of people don't realize is that, you know, it's not just the MD and trainer that are kind of diagnosing and treating, we have whole teams that can help with occupational physical therapy, all of these things, vestibular therapists, that work when things get complicated to get someone back. So the sooner we know, and the sooner we're able to say, "Hey, this is a true diagnosis" and rule out other scary things, you know, neurologically, the sooner we can get that person back to whatever they want to do. And from our standpoint, the sooner that we can lay eyes on them, you know, I was kind of mentioning some other neurologic issues, the sooner we decide, "Hey, does this person not need any imaging? Or do they need specific imaging?" Because with a basic concussion, you don't need CT scans or MRIs usually, but we could also be alluded to other things that might need to be worked up further neurologically. So I think as soon as a coach or parents or anyone else around the athletes sees any signs of concussion, I would send them our way.

Melanie Cole, MS: What great points you've made and such good information as we head into the spring and spring sports. Thank you so much, Dr. Aubry, for joining us. And for more information, to get connected with one of our providers, please visit carle.org or for a listing of Carle providers and to view Carle-sponsored educational activities, please visit our website at carleconnect.com.

That concludes this episode of Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole.