As the focus continues to grow on concussions and their short-term and long-term effects on a patient, treatment options have expanded and evolved.
Dr. Robert Miller, emergency room physician, discusses the evolution of concussion treatment, the role of the athletic trainer in concussion management, and the Concussion Management Clinic.
Selected Podcast
Emerging Treatments for Concussions
Featuring:
Robert Miller, MD
Dr. Robert Miller is a critical care specialist in Columbus, Nebraska. He works in the Columbus Community Hospital's Emergency Department. He received his medical degree from University of Nebraska College of Medicine and has been practicing for more than 20 years. Transcription:
Bill Klaproth (Host): As the focus continues to grow on concussions and their short term and long term effects on a patient, treatment options have expanded and evolved. Here to talk with us about emerging treatments for concussions, is Dr. Robert Miller, an ER physician at Columbus Community Hospital. Dr. Miller, thank you for your time. First off, can you tell us in general about the programs offered at Columbus Community Hospital regarding concussion treatment?
Dr. Robert Miller (Guest): We have a Columbus Concussion Management Clinic where we have patients that get referred from either the emergency room or the offices of their primary care providers and we evaluate them for where they’re at in their concussion. Some of them are newly diagnosed and some of them have had symptoms for a period of time and then we will evaluate them and then see which specific treatments may be beneficial to them such as occupational therapy or physical therapy or even sometimes speech therapy.
Bill: Okay, take us through this. You’re an ER physician. When someone walks through the doors, what treatment do you give them when they come in with a head injury?
Dr. Miller: So initially when they come into the emergency department, we will see and evaluate them and first of all, we’ll go through the typical ABCs depending, airway, breathing and circulation to make sure that they’re stable and then provided that person is stable, then we’ll plan on seeing what the next step should be. In some cases, if they have certain signs or symptoms, we may feel like a CT scan or sometimes other imaging such as an MRI scan may be indicated or warranted. Not all the time is a CT necessary when a person has a concussion. If their symptoms are fairly mild then we may choose to just manage them based on their symptoms from that point on.
Bill: And what are the signs and symptoms of a concussion?
Dr. Miller: The most common sign would be a headache. Typically a concussion refers to shaking of the brain, so sometimes it can be an injury to another part of the body that they may sustain a vast acceleration or deceleration or rotation injury that would cause some concussion or shaking of the brain, and the most common symptom as we said is the headache. Sometimes they’ll experience dizziness, trouble with focusing. Some of the later signs may be trouble falling asleep, sometimes balance issues come into play. There’s literally about 20 to 22 different symptoms that can be associated with concussion and we give people a list of those and tell them to watch for what symptoms may show up right away and some symptoms that may show up later.
Bill: You mentioned an MRI or a CT scan, what do you need to see to order one of those tests?
Dr. Miller: So declining mental function or a declining level of consciousness would be one of the termed red flag symptoms that would say this may be a more serious head injury. Sometimes persistent vomiting may be another sign or a blown pupil, so one pupil is significantly larger than the other or the pupils aren’t reactive, then those would be signs that may push us on to get a CT scan.
Bill: Dr. Miller, concussions are not a new issue. Can you tell me how treatment has evolved over the years, and if there are any new treatment options out there?
Dr. Miller: Sure, so initially concussions were going back into the 70s and 80s, people were considered not to be concussed unless they had loss of consciousness, that obviously has changed significantly. We now diagnose things as being concussions that back in those days were not considered concussions because they didn’t have a loss of consciousness. So even the diagnosis has shifted so we call a lot more things a concussion than we used to. As far as the management goes, initially going back 5 to 7 years, we would typically instruct patients to get strict bedrest. Sometimes they used to call it cocoon therapy. Basically you would almost lock a player or a student athlete in a room and turn off the lights and say we’ll come back and check on you in a day or two. So initially it is still recommended to get a period of rest, but now we’re starting to get people trying to move towards their normal activities a lot sooner. So you’re seeing even sometimes where we’re starting to let people exercise or move within a day or two of their initial injury, although we want to keep them out of harms way. So we don’t want them back on the field where they could get another injury. We’re trying to avoid a thing called a Second Impact Syndrome, which is fairly rare but it can be life threatening when it occurs, so that’s the main reason that we take people off the field and out of play immediately when we suspect a concussion. So that part has evolved as far as what we allow to happen right after the concussion. So there’s a period of rest and now we let them get up and move and be a little bit more active.
Bill: Are there any medications that you prescribe?
Dr. Miller: We try to avoid medicines if we can, but it’s not uncommon for us to say go ahead and take a little bit of Tylenol. Some people feel that ibuprofen may be a little bit controversial, but in most cases, we do allow for either the Tylenol or ibuprofen to be given just to try to manage symptoms. We try not to go to any stronger pain medications such as opiates because that may cause vomiting, and then that would give us a confusing picture of are they vomiting from their head injury or are they vomiting from the medication? So we try to keep the medications to a minimum. Sometimes I’ll have people take between 1000 and 1200 mg of fish oil up to three times a day.
Bill: How does someone know when they are okay or clear to return to normal activities or sports?
Dr. Miller: So as they start to improve on their concussion, we typically see their symptoms resolve as far as their dizziness should continue to get better. We initially look for, what we call, headache free periods of time where they have no headache for a period of an hour or two, and then we look for that to continue to get longer, and then we look for them to have completely headache free days. Once they get to where they have completely headache free days, then we’ll let them continue to increase their activity level, and those two are going simultaneously now, whereas before we used to make them get completely over their symptoms before we let them start to exercise and move. Now we’re having them start to exercise and move even when they might be having more mild symptoms. Ultimately to get back to return to play, people have to be symptom free and go through a progression where they increase their activity to rest to light aerobic activity to harder aerobic type of activity such as spring and then we try to have them simulate their sport activity. So for soccer players, we may have them do quick sprints and hard running and then some jogging in between. For someone like a basketball player, we’ll have them simulate like they’re on the basketball court and doing cuts and maybe doing the traditional line drills. Football players, we might have them initially practice with the special jersey on where they aren’t taking hits, and then eventually get them back into a full participation or full contact practice and then we get them back to clearance. In the state of Nebraska, once they’ve been diagnosed, especially in the high school level, if they’ve been diagnosed with a concussion, they need to be cleared by a medical professional that is knowledgeable of concussion management.
Bill: Dr. Miller, you just mentioned high school. What is the role of an athletic trainer when it comes to concussion management, especially at the high school level?
Dr. Miller: Athletic trainers are the absolute key to the management of concussion to all levels, especially the high school and even now in the Jr. High level because they’re right there on the field. They’re with those athletes, basically most of the days of the week, or in the cases of the larger schools, they’re with them essentially every day of the week, so they know their baseline and then they can asses them immediately after there’s some type of contact that looks like it may have caused a concussive injury, so they are just absolute key for making the diagnosis. Then they make the initial call to say this athlete is not going to participate in today’s practice or game, and then they may reassess them later that evening or the following morning and they can take them through the return to play process as well, so the athletic trainers are the absolute keys to the entire concussion world, working the way it should.
Bill: Well Dr. Miller thank you so much for your time, we appreciate it. For more information on concussion treatment or the concussion management program at Columbus Community Hospital, visit columbushos.org, that’s columbushos.org. This is Columbus Community Hospital HealthCasts from Columbus Community Hospital. I’m Bill Klaproth, thanks for listening.
Bill Klaproth (Host): As the focus continues to grow on concussions and their short term and long term effects on a patient, treatment options have expanded and evolved. Here to talk with us about emerging treatments for concussions, is Dr. Robert Miller, an ER physician at Columbus Community Hospital. Dr. Miller, thank you for your time. First off, can you tell us in general about the programs offered at Columbus Community Hospital regarding concussion treatment?
Dr. Robert Miller (Guest): We have a Columbus Concussion Management Clinic where we have patients that get referred from either the emergency room or the offices of their primary care providers and we evaluate them for where they’re at in their concussion. Some of them are newly diagnosed and some of them have had symptoms for a period of time and then we will evaluate them and then see which specific treatments may be beneficial to them such as occupational therapy or physical therapy or even sometimes speech therapy.
Bill: Okay, take us through this. You’re an ER physician. When someone walks through the doors, what treatment do you give them when they come in with a head injury?
Dr. Miller: So initially when they come into the emergency department, we will see and evaluate them and first of all, we’ll go through the typical ABCs depending, airway, breathing and circulation to make sure that they’re stable and then provided that person is stable, then we’ll plan on seeing what the next step should be. In some cases, if they have certain signs or symptoms, we may feel like a CT scan or sometimes other imaging such as an MRI scan may be indicated or warranted. Not all the time is a CT necessary when a person has a concussion. If their symptoms are fairly mild then we may choose to just manage them based on their symptoms from that point on.
Bill: And what are the signs and symptoms of a concussion?
Dr. Miller: The most common sign would be a headache. Typically a concussion refers to shaking of the brain, so sometimes it can be an injury to another part of the body that they may sustain a vast acceleration or deceleration or rotation injury that would cause some concussion or shaking of the brain, and the most common symptom as we said is the headache. Sometimes they’ll experience dizziness, trouble with focusing. Some of the later signs may be trouble falling asleep, sometimes balance issues come into play. There’s literally about 20 to 22 different symptoms that can be associated with concussion and we give people a list of those and tell them to watch for what symptoms may show up right away and some symptoms that may show up later.
Bill: You mentioned an MRI or a CT scan, what do you need to see to order one of those tests?
Dr. Miller: So declining mental function or a declining level of consciousness would be one of the termed red flag symptoms that would say this may be a more serious head injury. Sometimes persistent vomiting may be another sign or a blown pupil, so one pupil is significantly larger than the other or the pupils aren’t reactive, then those would be signs that may push us on to get a CT scan.
Bill: Dr. Miller, concussions are not a new issue. Can you tell me how treatment has evolved over the years, and if there are any new treatment options out there?
Dr. Miller: Sure, so initially concussions were going back into the 70s and 80s, people were considered not to be concussed unless they had loss of consciousness, that obviously has changed significantly. We now diagnose things as being concussions that back in those days were not considered concussions because they didn’t have a loss of consciousness. So even the diagnosis has shifted so we call a lot more things a concussion than we used to. As far as the management goes, initially going back 5 to 7 years, we would typically instruct patients to get strict bedrest. Sometimes they used to call it cocoon therapy. Basically you would almost lock a player or a student athlete in a room and turn off the lights and say we’ll come back and check on you in a day or two. So initially it is still recommended to get a period of rest, but now we’re starting to get people trying to move towards their normal activities a lot sooner. So you’re seeing even sometimes where we’re starting to let people exercise or move within a day or two of their initial injury, although we want to keep them out of harms way. So we don’t want them back on the field where they could get another injury. We’re trying to avoid a thing called a Second Impact Syndrome, which is fairly rare but it can be life threatening when it occurs, so that’s the main reason that we take people off the field and out of play immediately when we suspect a concussion. So that part has evolved as far as what we allow to happen right after the concussion. So there’s a period of rest and now we let them get up and move and be a little bit more active.
Bill: Are there any medications that you prescribe?
Dr. Miller: We try to avoid medicines if we can, but it’s not uncommon for us to say go ahead and take a little bit of Tylenol. Some people feel that ibuprofen may be a little bit controversial, but in most cases, we do allow for either the Tylenol or ibuprofen to be given just to try to manage symptoms. We try not to go to any stronger pain medications such as opiates because that may cause vomiting, and then that would give us a confusing picture of are they vomiting from their head injury or are they vomiting from the medication? So we try to keep the medications to a minimum. Sometimes I’ll have people take between 1000 and 1200 mg of fish oil up to three times a day.
Bill: How does someone know when they are okay or clear to return to normal activities or sports?
Dr. Miller: So as they start to improve on their concussion, we typically see their symptoms resolve as far as their dizziness should continue to get better. We initially look for, what we call, headache free periods of time where they have no headache for a period of an hour or two, and then we look for that to continue to get longer, and then we look for them to have completely headache free days. Once they get to where they have completely headache free days, then we’ll let them continue to increase their activity level, and those two are going simultaneously now, whereas before we used to make them get completely over their symptoms before we let them start to exercise and move. Now we’re having them start to exercise and move even when they might be having more mild symptoms. Ultimately to get back to return to play, people have to be symptom free and go through a progression where they increase their activity to rest to light aerobic activity to harder aerobic type of activity such as spring and then we try to have them simulate their sport activity. So for soccer players, we may have them do quick sprints and hard running and then some jogging in between. For someone like a basketball player, we’ll have them simulate like they’re on the basketball court and doing cuts and maybe doing the traditional line drills. Football players, we might have them initially practice with the special jersey on where they aren’t taking hits, and then eventually get them back into a full participation or full contact practice and then we get them back to clearance. In the state of Nebraska, once they’ve been diagnosed, especially in the high school level, if they’ve been diagnosed with a concussion, they need to be cleared by a medical professional that is knowledgeable of concussion management.
Bill: Dr. Miller, you just mentioned high school. What is the role of an athletic trainer when it comes to concussion management, especially at the high school level?
Dr. Miller: Athletic trainers are the absolute key to the management of concussion to all levels, especially the high school and even now in the Jr. High level because they’re right there on the field. They’re with those athletes, basically most of the days of the week, or in the cases of the larger schools, they’re with them essentially every day of the week, so they know their baseline and then they can asses them immediately after there’s some type of contact that looks like it may have caused a concussive injury, so they are just absolute key for making the diagnosis. Then they make the initial call to say this athlete is not going to participate in today’s practice or game, and then they may reassess them later that evening or the following morning and they can take them through the return to play process as well, so the athletic trainers are the absolute keys to the entire concussion world, working the way it should.
Bill: Well Dr. Miller thank you so much for your time, we appreciate it. For more information on concussion treatment or the concussion management program at Columbus Community Hospital, visit columbushos.org, that’s columbushos.org. This is Columbus Community Hospital HealthCasts from Columbus Community Hospital. I’m Bill Klaproth, thanks for listening.