Nolan Alexander (Host): This is Health Dose. I'm Nolan Alexander. And today, we're joined by Dr. Michael Rodriguez, Sports Medicine and Musculoskeletal Care Physician from MyMichigan Health, as we talk about concussions in sports, what they are, how to spot them, and how to protect young athletes on and off the field. Dr. Rodriguez, how are you today?

Michael Rodriguez, MD: I'm doing great. Thanks for having me.

Host: It's my pleasure, and I'm excited to discuss this topic. As a former athlete and as a parent, this is always front of mind for me. So for parents like myself and coaches who keep hearing about sports-related concussions, can you briefly explain what it is and how it can affect a young athlete both on and off the field?

Michael Rodriguez, MD: Yeah, absolutely. So, concussion is, by definition, just any sort of traumatic brain injury, either through forces directly towards the head, neck, or body, that result in some sort of temporary change in brain function. And that definition is very broad and that's by design, because we really want to be able to capture these injuries as soon as possible and as easily as possible, because making sure you recognize these sooner rather than later is definitely important for long-term prognosis and being able to return to sport sooner rather than later.

So, what usually happens is that it can affect pretty much anything, right? So, it affects all domains of life, right? The usual symptoms that patients will report are going to be things like your classic headaches, confusion, dizziness, sensitivity to light, right? So, those kind of physical domain there.

It'll also affect into the cognitive domain, right? So, it'll affect their ability to concentrate, their ability to process, their reaction speed. It can affect their sleep. So, maybe they don't sleep as well, it's harder for them to get to sleep. Maybe they sleep more. And then, even their emotional state, right? So, they can be a little bit more erratic anxious. And so, you can imagine how this can bleed into quite a lot beyond just the field.

Host: Those seem like signs and symptoms for that recognition that you talked about for things that may come down the line. What else do you have when it comes to signs and symptoms that parents, coaches, and the athletes themselves should watch out for both right away and then others in the days and hours after a possible concussion?

Michael Rodriguez, MD: Recognizing these initial signs is paramount to the management of concussion. When you're looking at a patient or an athlete rather, you really wanted to kind of almost longitudinally monitor them as well too, because a lot of the times patients will get hit, and they'll feel pretty decent just when it initially happens even.

But you do need to have that suspicion as symptoms evolve over minutes, hours, even sometimes days. So, we do need to make sure that we're monitoring them as they progress through that. And so, that's kind of part of the evaluation as well too, is like they can come off the field and look kind of normal. But as you continue to do an assessment with them, you give them a little bit of time, then they're going to start coming back. They're like, "Ooh, I actually kind of don't feel all that great." So, the things that parents or a coach might just witness is that they're going to notice that the athlete's a little bit slower. Maybe they were kind of harder to get up. Maybe they have a more of a blank stare when they come over to talk about the next play or something like that, or they're maybe not picking up exactly what you're trying to tell them to do.

They might end up coming and talking to you as well, and it would just be as simple as like, "I feel like I have a little bit of a headache. It's kind of hard for me to see out here. I'm just not feeling right." So, those are the things that they're going to come in to you and maybe they might actually tell you that they're having a concussion. And so, it doesn't even have to be the parents or the coaches. It can come from teammates. It can come from the trainers. It can come from the guy holding the camera on the sideline, right? So, anyone that can see these signs, they should try to, you know, alert someone so that maybe they get a little bit of a better assessment.

The important things to be aware of are going to be the red flag symptoms, right? So this is a brain injury, but there can be things that are much more concerning that might happen in the first few minutes to hours that we definitely want to encourage emergent evaluation. So, getting in front of, like, an actual professional who is familiar with concussion. And that would be things like really, really severe headache, uncontrollable vomiting, maybe neurologic signs like they have weakness or numbness. So, that would be more indicative of things like actual, like, brain bleeding or even, like, spinal cord injuries, and those would definitely require more emergent evaluations.

Host: Dr. Michael Rodriguez joining us today. So in that, if a young athlete is suspected of having a concussion, what should happen next on the sideline, in the emergency room or clinic, and then in the days that follow?

Michael Rodriguez, MD: So yes, as soon as you are suspicious at all, you do want to take them out. If it's a pretty obvious problem here, right, they were maybe knocked out on the sideline or something like that, so you're pretty sure this is concussion, important to take them out immediately, and then maybe have a further assessment just to make sure that we're not noticing anything wrong. So, it doesn't require emergent evaluation.

If you're presenting to the emergency room, this is because you're concerned about those red flags we just talked about, which would indicate a more serious traumatic injury. But if it's just concussion, routine follow-up from your primary care provider or, for me and my colleagues at WellSport, someone who's usually equipped to handle concussion protocols, that would be a reasonable next step for you to do.

We definitely want to continue the observation. So immediately after that, right, if we're considering just a pretty routine concussion, the next few steps are just to kind of monitor them for the next few hours. Three hours is usually what we recommend, just to kind of keep looking at them. You don't have to keep them up, like, the whole first night that they have them or something along those lines. We definitely want to get them to sleep. But if they're not noticing any major changes for those first three hours, you could probably safely assume that they're going to be doing okay.

Things that you can also do within those first 48 hours is you're mostly just resting. You're not really doing a lot there. You don't want to cocoon, which is how they kind of used to manage them, right? Where you just sit in a dark room and don't do anything until your concussion's gone. We know now that that's not really too beneficial. A little bit better to have some exercise as your treatment. So with our athletes, we're usually encouraging at least a little bit of low-level cardiovascular activity after 24 hours, just to kind of get the brain moving again.

Beyond that then, another usual common question is, like, things like medications. There's no medication or anything that can really cure a concussion. Really, it's just you have to recover from the injury. But the medications are there to help treat the symptoms. So for example, if you have headache, you can treat that with ibuprofen or Tylenol. You can treat nausea. You can treat difficulty with sleeping and stuff like that. These should all be directed by professionals. So definitely, that's what the follow-up is really intended for. But that's a usual recommendation I make, is to try to control some of the symptoms initially. Ibuprofen, Tylenol is usually pretty safe. The concern with ibuprofen is maybe risk of bleed and stuff like that. So, I think a lot of people just feel safer in that initial period recommending Tylenol.

Host: How do you guide families on the next step, return to play after a concussion? And what are some realistic timelines and expectations they should understand?

Michael Rodriguez, MD: So after that first initial 48 hours, something like that, as long as they haven't noticed any more concerning signs and we get them into the office, then we can talk about the usual return. The first step is always going to be return to learn. So, that's getting them back into their classes, their academics, or their job or something like that. And so, we usually have a pretty graded approach to this as well. So f you have someone, a provider, that's usually accustomed to treating concussions, they should have some notes that they can write for your school to give you these accommodations. Things like maybe reduced time in the classroom, some frequent breaks, allowing you to skip certain subjects that are maybe harder for you, or like being able to retake tests or redo homework if you felt like maybe you did a little bit worse. So, that's the first step, and always the first step.

Once you've returned to school full time and the symptoms are continuing to improve, usually, then it's the return-to-play protocol. And so, this is a very specific six-day protocol in which we gradually return them into activity, increasing their intensity, eventually leading to contact if that's part of their sport. So, they do have to have a full contact practice without exacerbation of their symptoms before we can allow them to return to play. And in all 50 states, it is an absolute requirement that at the high school level, you get a signed form from a provider so that they can clear you back into activity.

And then, I guess as far as, like, usual timeline returns, we usually expect around just under 20 days. At least that's what the data shows us in terms of, like, your mean return times. But it is not too unusual for patients to return sooner than this. It is possible for patients to return within a week, and it does happen somewhat often. It's not something I usually expect, but it is possible. And so, I do want to make that point clear that, even if you do remove someone for a possible concussion, if they can return through this protocol quickly because maybe it wasn't a concussion, it shouldn't take them out of sport or activity too long.

Host: What prevention strategies do you recommend?

Michael Rodriguez, MD: So, this is a really common question we get because obviously we want to stop them as much as possible. And usually, people are looking for answers like, is there a different helmet, maybe those other devices like the Q-Collars that maybe you've seen on some professional athletes. The unfortunate part of that is that there really isn't a really solid answer. You would imagine that changing the forces applied to the head with, like, your helmets or something like that may reduce some of the forces, and they do, but do they prevent concussion? We maybe don't see that very consistently.

So, absolutely, I think it's appropriate for parents to kind of do a little bit more research, make sure that they can have an appropriate helmet. There are certain ratings that they can look into, and so there are helmets that are rated for higher impacts. And so, that might be something to look into.

But as far as, like, the real reason here, the real way to reduce concussion is to try to control just contact, which probably sounds obvious, but there are ways to do this, such as, like, how the NFL restructured the kickoff return, right? Or starting contact later when it comes to sports like hockey and things like that, right? These are the things that we've seen that definitely improve concussion rates, reducing especially the practice amount of contact, right? So, trying to get away from some of those classical drills, like the Oklahoma drill, those definitely increase rates of concussion. So if we can avoid those sort of things, that definitely reduces it.

There's also some interesting studies going on with, like, neuromuscular training, coordination and balance and stuff like this. Very promising studies when we looked at rugby players when it comes to this. And I like this especially because not only would it potentially reduce things like concussion, we already know that these kind of training programs really reduce risk of lower body injuries as well.

So, this is probably the better thing for coaches looking into if they're really wanting to try to add something onto their usual regimen. Some sort of balance or coordination program should only take maybe 10 to 15 minutes of their time in practice might help reduce these pretty dramatically.

Host: That's very interesting. And another question I had was long-term consequences. What concerns are out there? What does that look like?

Michael Rodriguez, MD: Yes. So, there have been a lot of like really big cases where high-profile athletes have suffered from CTE, right? Chronic traumatic encephalopathy. And this is always a big concern when someone comes in with a head injury. Hopefully, to reassure a lot of our high school athletes, it is a very rare occasion if we kind of like stop there with amateur sports, right?

One or two or even, you know, any number of concussions doesn't guarantee that you end up with some sort of CTE. As long as we're recovering within a normal timeframe, and it doesn't seem like it was too dramatic of an injury, there's no real increased risk for CTE. T he only reason that you get them is if you have increased force, so that comes from more of the professional level of sports, so maybe you make it to D1 college football or something like that, as well as longitudinal, right? So, most people that are playing through high school or even into some lower levels of college don't sustain enough of those repeated high force impacts. You really have to have that length of your career along with this to have those effects.

Host: Interesting. So, Dr. Rodriguez, for parents and coaches and young athletes tuning in, what are the top few things you want them to remember about our conversation today when it comes to recognizing, treating, and preventing concussions in youth sports?

Michael Rodriguez, MD: the most important thing about concussion is when in doubt, sit them out. If you have any reason to believe at all that they have had some sort of traumatic brain injury, it's usually not really worth the risk. You can always take your time with them as well, because like we said, the symptoms will evolve over time. And so, giving them a chance to make a more formal assessment or just watching them longitudinally even over just a few more minutes usually is enough to kind of tell us that, yeah, we're probably dealing with a concussion here.

And then, as far as return, most kids are able to return from concussion without any long-term issues. The length of return doesn't necessarily indicate that they had a much worse concussion. As long as they are making progress through that, usually, it doesn't lead to long-term issues. And for sure, if you're wondering about how to progress through that, you absolutely need to be seen by a provider, especially if you're trying to return to high school athletics, you're going to need that return letter anyway. So, it definitely makes sense to at least have a follow-up so that you can be guided on appropriate return.

Recovery, the things to focus on there is going to be you don't want to cocoon, you use the medications to help control your symptoms, and a little bit of activity is always a little bit better, right? Just like a muscle, you want to kind of work the brain a little bit as well, too. And then, we talked about the prevention strategies as well. The big part there is really just reducing contact. So, if you're in a practice and you can find a way to do a drill that doesn't result in some sort of contact, you're definitely going to do a lot better in the long term.

And also, just trying to start contact later, that's always a big concern about parents, being able to get him to kind of like legitimate like contact leagues and stuff like this. we've seen in studies that it doesn't necessarily affect development of the player, and it would also prevent injuries, and so that would actually give them more time. So, I would argue it's actually the opposite.

Host: I learned a great deal of information today. Dr. Rodriguez, thank you so much for joining us.

Michael Rodriguez, MD: Happy to be here.

Host: That was Dr. Michael Rodriguez. Those interested in additional information about the comprehensive musculoskeletal care offered at MyMichigan Orthopedics and Sports Medicine may visit www.mymichigan.org/msk. I'm Nolan Alexander, and this is Health Dose. Thank you for listening.