Dr. Bob Underwood (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Bob Underwood. Before we introduce our guest, I'd like to remind you to claim your CME credits after listening to today's episode. You can do so by visiting cmkc.link/cmepodcast, then click the Claim CME Button.

So, with me today is the medical director of the Sports Medicine Center at Children's Mercy in Kansas City, Dr. Greg Canty. And together, we're going to delve into the topic of pediatric concussion management. Dr. Canty, welcome to Pediatrics in Practice. Yeah.

Dr. Greg Canty: Thanks a lot for having me, Dr. Underwood. Looking forward to our conversation.

Host: Yeah, likewise. So, concussion care in children is evolving and guidelines change as we learn more about their recovery. So today, we're going to tap into your expertise in Pediatrics, Sports Medicine, Pediatric Emergency Medicine, all of those things to kind of highlight what pediatricians ought to know about concussion management. So, can you share any updates specifically right now in pediatric concussion management from recent guidelines? As we were talking before, it's changed a lot since I was first coming out of my training, which was a while ago.

Dr. Greg Canty: Yeah, that's very true, Dr. Underwood. I think it depends a lot about when you finish training and how much exposure you got. As we were talking about our careers, i've been out running the sports medicine center for about 15 years. Back when I trained, we didn't talk much at all about concussion. And it was really around that time that became increasingly recognized and Increasingly a focus of practice. And many state sporting organizations got involved, created what are called Lystedt law, about trying to promote safety in return to sports. We've come a long way in that recognition.

I'd like to think we came a long way in developing tools for physicians to use, but that still remains a little bit of a struggle. You know, early on in my career, I really thought that we would have a blood test by now, thought we would have an imaging test, things that we could do. Unfortunately, those things have not come along. What we have found out is over the years, probably better ways that we could help just comfort, helping athletes and their families have a comfort level of what they can do and what they should do on a return-to-sport basis and return-to-school. And I think we have come a long ways in that we may have been a little overly restrictive when this emphasis first came out 10 to 15 years ago.

Host: Sure. And it's funny you mention imaging. We do imaging, but it's a misunderstanding often for families that the CT scan is somehow going to confirm that they've had a concussion, that's not what that's for actually.

Dr. Greg Canty: That's a very good point. And I think one that has to be emphasized. And when it comes to concussion, their imaging is not required. Imaging is part of looking for intracranial bleed. If you think that is part of the presentation. It's extremely rare for me to image someone with a concussion, and that's someone who's practiced emergency medicine. I work on the sidelines of sporting events and see patients in the office. And so, imaging is not a large part of my practice.

Host: Right. Absolutely. So, how has the approach to rest and activity after a concussion evolved? You know, especially for children, teens, in sporting events, I mean, that's often what we're talking about here is school sports.

Dr. Greg Canty: I really think that that is where we've made some changes in the past, probably five years that are worth discussing. I believe that what we've found out over the years is that if you take an adolescent or school-aged child that has a concussion, there was kind of a trend maybe a decade or so, that we would do what we would call cocoon therapy, where people would kind of go down in the basement, they would get no stimulation to light noise people activity. And then, they would kind of emerge when that basement is a beautiful butterfly.

Well, we found out that didn't work real well with adolescents. And so, that was not an adolescent-centric approach. And so, what we found over the years is actually that's not necessary. And what we found over the years is that early return to school is actually beneficial and that some moderate light aerobic activity, it's not harmful. It may be beneficial even, but it's definitely doesn't seem to be harmful. And even those patients that have marked symptoms seem to improve from a return-to-learn philosophy and a return to some light aerobic activity and maybe less of an emphasis on complete avoidance of technology and activity. We may have gone a little too far on that though.

And I think it's worth mentioning that I think people can do light to moderate physical activity. They can go to school and participate in their way, maybe with some adjustments and accommodations at school. Those should be emphasized probably more than school avoidance. And I believe that when it comes to technology, most of the studies have suggested that no matter what we do in today's world, people are using their technology. And maybe it's looking for a way to emphasize moderation rather than complete avoidance. We don't want them to go haywire on it. I'm not saying complete, you know, 24/7 on their phone. But maybe allowing people to communicate some in moderation is the key in trying to avoid provoking your symptoms and making things worse, but not complete avoidance.

Host: Absolutely. And I think that your point about it being adolescent-centric, and they're going to do what they're going to do sometimes. And being able to work within that context, I think, is important.

Dr. Greg Canty: There were a couple of studies done that they looked at actually how much time people spent on their phone after concussion, even when they were told to completely avoid it. They were spending hours per day on their phone. And those folks weren't showing worse outcomes. And so again, it's looking for in the middle. I think the people that spent no time on their phones struggling, the people that spent hours and hours on their phone were having some challenges. And so, maybe looking for just some light moderation, probably the way we should all use our technology, but we've gotten a little out of hand over the past decade.

Host: Indeed. So, what are some of the key risk factors that might predict a prolonged recovery in young athletes?

Dr. Greg Canty: I think, early on, one of the things folks have pronounced dizziness. We'll see dizziness for a couple of days after concussion, but people having lingering vestibular symptoms are probably one of the key things we see that probably might predict a prolonged recovery.

Host: Let's switch over a little bit to advocacy. How can pediatricians effectively collaborate with schools, sports teams to support a child's return to learning and play?

Dr. Greg Canty: As I tell pediatricians when I give CME talks, a lot is I want to invite them to be part of our team, part of the sports medicine team. And that team involves the physician involvement, involves hopefully having a liaison from the schools and in the area where you practice. That could be a school nurse, a school athletic trainer, but someone that you can serve as a resource and help answer questions. And that comes from things like this and staying up-to-date on concussion management. And so, you can talk with the families and the young athletes that are involved to really kind of help provide evidence-based guidance, but folks are looking for guidance.

Being involved just in your community, whether that's school, sporting organization, school clubs, volunteer coaches, anything you can do to be involved really helps spread awareness about how to properly manage concussion.

Host: Yeah, absolutely. And so, there's been changes in rules in sports. There's been changes in protective equipment in sports. What role do these play in preventing concussions in young sports? Targeting is one that I think we've all seen recently if you watch any kind of football.

Dr. Greg Canty: I think that's a great example of things that we have done to lessen the impact of concussion. We've talked about fancy equipment in the past. Everything from helmets to there's a number of products that are sold to folks. But I think the biggest improvements have really become with recognition and trying to gently change the rules of the sport.

Some sports, we've gone from you take football where they've tried to eliminate certain high risk plays such as kickoffs. We've talked about limiting the amount of contact. In practices in soccer, we've come up with ideas about when you should or shouldn't start hitting the ball. Basically, looking for ways to decrease just the sheer incidence of potential head injury during the sport.

So, we know kids that are healthier both physically and mentally when they're active and playing sports, we really want to encourage that participation, but we want to look for ways that we can prevent concussion incidence if possible. And so, I think continuing to look at the game. And there've been some big strides in hockey also, so you can kind of go down the list of sports. And all these sport organizations have started to take a look at what they do, and I think we should continue to advocate for that.

Host: You've done some work around cheerleading, any kind of activity or changes there in terms of concussion?

Dr. Greg Canty: Yeah. Thanks for asking, Dr. Underwood. That was one of the things they saw in cheerleading is that incidence of concussion had been rising, like it really had in all sports. We talk about the incidence rising, but it's probably as much increased recognition as it is the true incidence coming up, I like to make that point. But what they did in cheer, we looked at over the past decade, there were studies that showed through rural implementation changes looking at trying to lessen catastrophic and head-type injuries.

They took a look at just what surfaces, though they changed what a basket fall is-- that's a certain kind of stunt in cheer and what surfaces it was done on. So, they tried to eliminate it from being done on hard surfaces. And what they saw over the decade is they markedly reduced the number of head and catastrophic head injuries. And so, just looking at little ways you can make differences, and I talk about cheer because I was involved with that policy statement from the AEP. But I used to be a member of the council on Sports Medicine Fitness Executive Committee, and they've done great work on that across almost all sports, whether it's hockey, football, and just looking at and making sure that your athletes and your families are aware of these rule changes and things that they can do. Those aren't quite as fancy, maybe don't get quite as much attention as a new product or a headline, but those are where the real changes and real benefits are coming from.

Host: Got it. Earlier you mentioned being able to provide tools and technologies to schools or pediatricians to improve how we assess or monitor concussions in pediatric patients. What are some of those technologies or tools for assessing and monitoring?

Dr. Greg Canty: To be honest, Dr. Underwood, I'm not a big fan of much of those. I believe actually that some of the basics is, well, I feel like we need to focus on a concussion, which is awareness, patience, trying to establish a daily rhythm that you establish from going to school, getting up, sleeping, light, physical activity. I believe some of the products we talk about for monitoring concussion, which are mostly products have not really panned out to be as helpful in the long run. And one of the things that I worry is that some of those products are sold to schools and families, and they have a false sense of security that it somehow protects their young athlete from getting concussion.

So, what I really try to emphasize in my practice is awareness of what symptoms suggest, a concussion, what your immediate management should be from concussion, which is removal from play. The old saying was "When in doubt, set them out." Make sure they get properly evaluated. They get the key pillars of how you manage concussion. And then, guidance on that return to play. I think those are far more important than any product that we've seen out there and helping families learn that I think is important.

Host: Yeah, absolutely. So, what advice would you give to pediatricians who may not specialize in sports medicine, but they want to stay current and confident in managing concussions? What advice do you give for them?

Dr. Greg Canty: Tell people that one is listening to podcasts and things like this from other folks, and being engaged is a great first step. Learning that with concussion, the things that we do probably don't make the initial brain injury worse. What we're trying to do is help protect that athlete and guide them back to play so that we feel a little more confident that they've had a recovery before they return and put themselves at risk. That's providing good awareness to families and they come in talking about it when they do their pre-participation exams. Offering them guidance, trying to maybe encourage, I like early return to school. I think it's important. I try not to be overly restrictive with school. And I also try to help people do some light aerobic activity in the early stages. When patients really feel like they have returned to their baseline and all their symptoms have resolved, I think it's then important to be aware of the return to sport progression, what's oftentimes referred to as a protocol. Being aware of what those steps look like and how they can utilize other health specialists such as athletic trainers or school nurses and teachers to help participate in that progression. I think those are really the key when you look at it is how do we all provide our role on the team and being a part of that team will really help your patients and young athletes get back to sports and the benefits of sports with the least amount of risk.

Host: So, one of the precautions that we've talked about historically has been kind of a second concussion syndrome where they go through all the protocols, they do things right, put them back out on the field. And then lo and behold, shortly after the return to sports, they end up with another concussion. Any precautions we would want to take in that circumstance?

Dr. Greg Canty: You know, the two big things we talk about is the long-term dangers or concerns make all physicians apprehensive are that so-called second impact syndrome and what folks have talked about kind of the cumulative effect or chronic traumatic encephalopathy that gets mentioned.

I believe the second impact syndrome is interesting. When you take a look at incidence of what's described as second impact syndrome, I think it's a particular risk for pediatricians and those taking care of adolescents. Because that seems to be far more of an issue in younger athletes than it does older athletes. I believe that that may have something to do with the level of healthcare that's directed at that age athlete. And so, that's some big emphasis on educating pediatricians and making sure that they have resources, because I believe second impact syndrome, the best way to limit that is really good management of the primary concussion.

I believe that pressure from, various sources, whether it's pressure from the athlete, pressure from families, coaches, everyone is. eager many times to get them back to return, but I believe that's where it's important to sit down and have a good relationships with these people and really help offer them guidance and understand the value of patients will help keep them playing. They'll spend more time in their sport if one of the early things is early recognition seems to result in early recovery. And so. That's, again, where education is just a key part of concussion management and concussion awareness.

Host: Sure. Anything else you'd like to add before we close?

Dr. Greg Canty: One question I get asked a lot is return to learn and getting kids back in school. The one thing I would like to highlight is that early return to school has actually been shown to be helpful and beneficial with concussion. And take early return to school, meaning after about no more than probably 48 hours, seems to help, regulate their daily cycle, get like physical activity. And I think it's important that we work with schools to develop that as physicians.

I can almost guarantee you that my parents were teachers. As physicians, we never were taught on how to oversee education. And I like to tell people, leave that to the educators, but I believe we can get them back in. We can recommend certain adjustments they can make, such as making fonts bigger on their screens. Maybe early dismissals between classes so they're not out and all the noise and lights are the greatest. But I believe that that return to school can actually be beneficial for many, many young athletes in helping their recovery, both physically and mentally. I believe the isolation that some folks have practiced over the years can actually be counterproductive to what we're all trying to achieve, and nothing in my practice is more challenging than an adolescent who's kind of been asked to live in the basement for three weeks without technology friends or activity, and they still have marked symptoms when they come out. And one of the first things I do is start giving them little snippets of their life back that, again, I think are not risky. That does not mean return to full contact sports or working out. That just means a light return to life, and that seems to be really beneficial. And I encourage physicians to think about that.

Host: That's great advice. We really appreciate it. Dr. Canty, thank you for being with us today.

Dr. Greg Canty: Oh, thanks a lot. I hope the comments were helpful.

Host: You bet. And to our listeners, as a reminder, claim your CME credits after listening to this great episode today. You can do so by visiting cmkc.link/cmepodcast and then click the CME button. And for more information and for other important topics, you can visit that same site, cmkc.link/cmepodcast.

And if you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics that might interest you. I'm Dr. Bob Underwood. And this is Pediatrics in Practice, a CME Podcast.