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Melanie Cole, MS (Host): Sport related concussion is a hot topic in the media and in medicine. It’s a common injury that is likely underreported by pediatric and adolescent athletes. Here to tell us about concussion in a rehabilitation setting is my guest, Dr. Kyle Klitsch. He’s a physiatrist with the Good Shepherd Rehabilitation Network. Dr. Klitsch, let’s just start with what is a concussion and what are you seeing as far as awareness and prevalence of concussion today?

Kyle Klitsch, DO (Guest): So, a concussion, in the most simple definition, is a traumatic brain injury. What essentially happens with a concussion is that the cells in the brain are damaged, typically from a blow to the head, but it can occur from any type of force headed towards the brain that causes the brain to move around in the skull. What eventually happens is that the brain is not functioning properly and not utilizing its energy stores properly, which leads to the symptoms of concussion. As far as awareness, I’m finding that certainly the public and patients are more educated about concussions as the media makes it more prevalent and we hear more about the rehab associated with it. I would say that it’s certainly on most people’s radars, but more education is something that can always be beneficial.

Host: So, speak about the importance of having a thorough concussion evaluation, even if the patient suspects they might have one; and what are your thoughts on impact test baseline screening?

Dr. Klitsch: So, I think probably the most important thing about having a thorough concussion evaluation is to rule out something more serious. So, a more serious brain injury or some other type of neurologic condition that may be contributing to their symptoms. Now the other important part of having a thorough concussion evaluation is to be within a system that can properly treat you and get you, in a timely manner, into proper therapies if it’s necessary.

Host: Do you think, Dr. Klitsch, that there is somewhat of a confusion or myth about the fact that equipment adequately protects an athlete from concussion? Do you feel that parents, other providers, coaches, and the athletes themselves feel a little bit safer because of the equipment? And is that a myth or not?

Dr. Klitsch: You know what? I would say, in some ways, that it’s not a myth because I think that most people are unaware of the fact that most helmets do not actually prevent concussions. What they do prevent is skull fractures, and that’s what they’re actually manufactured to do. So, in some instances with a high-tech helmet or a new helmet, patients and athletes may think that they're at less of a risk of a concussion, which in fact is not really the case.

Host: So, I understand Good Shepherd recently introduced a comprehensive concussion program. Can you tell other physician’s what’s unique about that program and how it can help patients suffering concussion?

Dr. Klitsch: Sure. So, we recently launched, here at Good Shepherd, a comprehensive concussion program. Now we’ve been treating concussion for many years, but what we’re really aiming to do with this program is to make it much easier for patients to kind of navigate through what may be a more complicated process due to the fact that they may be suffering from concussion symptoms. So, the main difference that we have is that we’ll now have a concussion care coordinator that will help guide them through and plan and schedule appointments.

One of the other things we’re looking to do is to get initial evaluations by all therapy disciplines so that we’re getting a thorough assessment and a comprehensive assessment. The great thing about Good Shepherd is that we have all of our therapies under one roof. We have a physiatrist here that can not only treat the concussion but can also treat associated conditions that they may have suffered in their injury. Then we also have a neuropsychology group here that can asses them and treat the patients as well.

Host: Well, while you’re telling us about your interdisciplinary team approach to care and what type of providers are involved, I know that Good Shepherd has a specialized optometrist as part of the concussion team. Can you talk about the benefits of that kind of specialized care?

Dr. Klitsch: Yes. What I’ve seen clinically throughout the years is that patients that tend to have prolonged recoveries with concussion often times have oculomotor issues and visual symptoms associated with their recovery. These types of situations we have a specialized neuro-optometrist that will do a full visual evaluation and then also do an evaluation for oculomotor deficits. If we’re seeing anything in particular that we feel needs attention, that optometrist can provide recommendations such as specialized vision therapy, prisms, and/or referral to an ophthalmologist maybe for further evaluation if she suspects anything underlying in the eyes that may be causing these symptoms.

Host: So as long as we’re talking about symptoms as well, what’s Good Shepherd’s approach to managing headaches from concussion? What role do treatments such as Botox play in treating concussion related headaches? What other types of therapies might you recommend?

Dr. Klitsch: Sure. So, headache is probably the most common symptom that patient’s report with concussions. So, I think it’s very important to treat it and to treat it well in order to help the patients tolerate therapy more. You know it’s not necessarily going to make the recovery faster, but it’s certainly going to make participating in therapy effectively a lot easier for the patient. Here at Good Shepherd, we do use a lot of migraine medications and migraine treatments to treat post-concussive patients and find that to be pretty helpful. We’ve used a lot of Botox in patients with migraine like post-concussion headaches and it’s been very successful. We’ve also used it to treat cervical dystonias that may be related to a trauma in concussion patients.

One of the other things that is unique to Good Shepherd in this area is also our headache therapy program, which aims to treat patients with more [inaudible] type headache.

Host: As a concussion can be a severe debilitating condition, speak about the importance of emotional support during a concussion. And how, if a patient does therapy and they participate in rehabilitation, what they can expect in terms of functional recovery and progress after a concussion.

Dr. Klitsch: Well, I think it’s very important to treat the emotional aspect and mood symptoms associated with concussion. When you consider the fact that depression alone can create a lot of the same type of symptoms that we see in post-concussion syndrome, if we don’t treat the emotional aspect of concussions, likely these patients are going to be caught in a cycle of having their depression symptoms feed back into their physical symptoms.

So, it’s very important to have a neuropsychology team as a support system for our patients to provide evaluations and treatments for the patient. They also will provide recommendations in regard to medication if it’s appropriate for specific patients. Or provide full neuropsychological testing evaluations for our patients that may need more comprehensive cognitive testing.

Host: Dr. Klitsch, as we mentioned the media before, and a big issue that arises and on the field is return to play. What are your thoughts on that and how would you like other providers to counsel their patients, coaches, and parents about prevention?

Dr. Klitsch: So, again, I think it comes down to education. I think the more the providers that treat concussions educate coaches, coaching staff, trainers, parents, and athletes themselves in what causes concussions, what specific activities during sports which may put patients and athletes at higher risk is only going to help prevent concussions.

Host: Then wrap it up for us what you would like other providers to know about the concussion program at Good Shepherd Rehabilitation Network and really your best advice.

Dr. Klitsch: So, I think the main thing that I would want providers to know is that we are the only comprehensive concussion program to provide all treatment under one specific location. So, like I said, we have a physiatrist who will be the main treater for the patient, as well as neuropsychology here. Then all three therapy disciplines as well as a neuro-optometrist. I think the best advice that I would tell other providers is if you suspect a concussion to refer to a concussion specialist as soon as possible. Even if the patient has a normal recovery and doesn’t require any type of specialized treatment, you're providing, I think, the best care and getting them within a system that can get them as quickly as possible and to treatment if needed.

Host: Thank you so much Dr. Klitsch. It’s great information. It’s so important for other providers to hear about the comprehensive concussion program at Good Shepherd Rehabilitation Network, and the information that you’ve given about recognizing it and what patients can expect in terms of functional recovery. Thank you so much again for joining us. This is Be Well, a podcast for rehabilitation providers from rehabilitation providers. For more information on resources available at the Good Shepherd Rehabilitation Network, please visit goodshepherdrehab.org. That’s goodshepherdrehab.org. This is Melanie Cole. Thanks so much for tuning in.