Dr. David Taylor (Host): Good morning. This is the On Call podcast from Riverwood Health Care Center in Aitkin. I'm David Taylor, your host. Today, my guest is Marc Carley, and our topic today is going to be concussions. Hey, Marc, how are you doing?

Marc Carley, DPT, ATC: I'm good. How are you, Dr. Taylor?

Host: I'm doing great. Marc, could you start by telling us a little bit about yourself for the listeners?

Marc Carley, DPT, ATC: Sure. I'm a Physical Therapist and Certified Athletic Trainer. Been doing this now for over 30 years, and I've seen assessment and treatment of concussions vary and change quite a bit over that time. So it's been a, an interesting part of our field to watch evolve and improve.

Host: Yeah, for sure, over 30 years, which when I tell patients very similar things in the emergency room or in the clinic, I feel like I'm also signaling that I'm experienced, yet I'm old.

Marc Carley, DPT, ATC: Yes.

Host: Ha!

Marc Carley, DPT, ATC: It cuts a little.

Host: Yes, it does. So let's start by discussing about, I think a lot of people have an idea in their head what a concussion is, but it may vary amongst people. And why don't you give us a good basic definition of a concussion?

Marc Carley, DPT, ATC: Well, medically, there's not any single agreed upon definition. Typically, I like to describe them as being a mild traumatic brain injury. Simply a trauma induced disruption to the brain's normal function. So symptoms are quite varied since the brain does a host of different things.

Host: Yeah, for sure. If somebody gets hit in the head, if they, if it's somebody who falls, trips and falls and hits their head, or a football player, how would you help determine whether this is a concussion or whether it isn't a concussion?

Marc Carley, DPT, ATC: Well, that needs to be determined through a, a thorough exam that collects information, from a bunch of different tests and information gathering. And it's really a kind of a determination that you make after you've completed that exam and just getting a comprehensive look at it.

Unfortunately, there's not a single metric or test that we can use to positively identify a concussion. It just requires a, a thorough exam and then a clinical determination if all the information in the exam adds up to a concussion or not.

Host: Okay, that's a good description and that's, it's understandable how it's hard to package it up in a neat bow for patients and for listeners. Well then let's talk about some common symptoms of concussion.

Marc Carley, DPT, ATC: Well, again, as the, the brain is obviously responsible for well, everything, we'll see symptoms that can be physical, balance loss, headache, visual disturbances. There can be emotional symptoms. Patients with concussions can sometimes have extreme emotional swings. We'll see cognitive issues such as memory loss, difficulty completing some complex reasoning.

In severe cases, you can actually see a loss of consciousness. It can affect the vestibular system. That's the part of you that gives you sensation of moving. When you go up and down in an elevator and you feel that little weird sensation, that's your vestibular system. When you turn your head to the left, your eyes know to go the same direction, again because of your vestibular system.

So there can be some vertigo, dizziness from that. Just a loss of coordination, difficulties concentrating, sensitivity to light and noise. Really, the symptoms can cover a broad spectrum and requires lots of unique little tools and techniques to kind of pick all of that apart in an exam.

Host: Yeah, for sure. Do you still use some sort of grading system for concussions?

Marc Carley, DPT, ATC: That has come in and out and in and out of favor, in the medical field a number of times. There's never again, been a real solid medical consensus across the board about how to do that. Typically right now it is either they are concussed or they are not.

Host: That's fair. That's, I remember the days of grade one, two, three. At least when I was training, grade three was defined by if you had loss of consciousness or not. Then amnesia started to be considered to be a more important factor, and I don't know where that stands, whether there was antegrade amnesia or retrograde.

And for people listening, remembering events that had happened previously versus having trouble remembering events after moving forward after your injury. Yeah, so it, it, I'm not as involved in concussion management or treatment as I was, but I can concur. The grading systems have come and came and gone.

The experts have had very different opinions on what's the most important features, it seems like, and it sounds like that's still going on today.

Marc Carley, DPT, ATC: It is. Yeah, I can remember three grade categories, five grade categories, and then with each one of those, a specific recommendation about how to proceed and how long a person should or shouldn't be pulled from their activity. It's been an ever evolving field that I'm happy to say that we've gotten much, much better at both assessing and then in dealing with these, post injury.

Host: Yeah. Well, let's maybe pivot to that because while I was trying to trap you into, uh, packaging it up into a neat bow for people, like, this is what a concussion is. I think you did a good job pointing out how that just isn't possible. But let's talk about when, like, how you manage them.

So, part of what's going to be involved in concussion care is going to be seeking a health professional and having examination and potentially testing. I'm guessing there isn't any specific guidelines. It's going to have to be going on, what a person's symptoms are, what the family is seeing with regards to how the person is acting, what the nature of the injury was, and it's going to be a judgment call as to seeking care or not.

Marc Carley, DPT, ATC: Yes, it is helpful to have people that know the individual, with you when you're conducting the exam. I'll give you an example. I examined a soccer player once who, one of the common questions we'll ask sometime, you know, is tell me your address. So I asked this young man his address and he rattled off an address and his buddy sitting next to him said, well, that was true four years ago.

I didn't know his address, but his teammate was very helpful in determining this guy had no idea where he currently lived. So that's a helpful tool, but again, to get to your question, I guess the examination is going to involve coordination testing. It's going to involve vestibular testing. It's going to involve some cognitive testing. I like to ask people to count backwards from 100 by sevens, cause that's not something you memorize and rattle off typically. We'll also give people words to remember and then ask them a few minutes later, if they can recall what those words are.

 We'll check oculomotor function. That's just eye movement, look for coordination there. And you as a, an individual feel you have a concussion or you have a family member, you think something's not right. Definitely get them checked. And if a concussion is determined to exist, again, we can't do a CT or any medical imaging because typically these are not accompanied by actual tissue damage or something that would show up on imaging.

If that concussion exists, you want to start treating that symptomatically. Typically that initial 24 to 48 hours just involves rest, both physically and mentally. So low lights, reduced screen time, things you just basically, you know, if you sprain your ankle, we rest your ankle. If you injure your brain, we need to rest your brain. Moving forward as the symptoms resolve, we want to gradually reintroduce activity, to make sure those symptoms do not return as you exert yourself. Typically most of these concussions, approximately 80%, are cleared and ready to go within 10 days to 2 weeks.

Host: That's a good, comforting timeframe, knowing that most of them are going to be cleared in a relatively short period of time. Not comforting to a high school player with only one or two games left.

Marc Carley, DPT, ATC: Correct. The tricky part with these is that 20 percent that don't resolve in that short period of time. Currently that typically gets called post concussion syndrome, where we're dealing with symptoms in a more long term manner. And that typically requires therapy. There are multiple ways we can address lingering symptoms in, in PT, whether it be dealing with ongoing headaches, balance and vestibular dysfunction, just problems with being able to perform physically at a high level without triggering a headache or some other type of symptom or problem.

 And there are ways we can walk people through that and return them to their activity, be that work or sports or quilting.

Host: Yeah. I actually want to put a pin in post concussive syndrome and circle back to it before we get away from visiting you or visiting your primary care provider or how evaluation would work. People may not be aware there are some commercial testing packages that are out there.

And I don't know if we have these in Aitkin County or not. I don't know if there's more products than the two of which I'm aware, which are Impact and Cogsport. And I don't know if they're actually still being used because again, I'm out of the concussion treatment world for the most part. Can you talk about those a little bit?

Marc Carley, DPT, ATC: The Impact hasn't been utilized in quite a while. Making full use of that is difficult here in rural Aitkin County to have a physician, credentialed to do that program, required seeing a volume of concussed patients that we just aren't anywhere near approaching, which is a good thing. But there are some simpler tools that we can make use of.

One is called the Sports Concussive Assessment Tool or the SCAT. And then there's a, uh, forget the acronym at the moment, but, another simple inventory, that we can use, just as kind of a metric to gauge progress andcan complete this. It's a fairly simple form with a series of questions and tests that we'll do and get a score.

And we can periodically revisit that and note, in some way, some objective improvement and change in the patient.

Host: Does that involve doing a score? Like, if you're looking at a high school team, does that involve doing a score at baseline, so that if there happens to be a concussion during the season, you then have a score to work back to? Or is this typically something you start at the initiation of concussion treatment, and then you use it to mark progress?

Marc Carley, DPT, ATC: This is typically a post injury assessment. The Impact that you mentioned, does collect data pre injury. So at one time we would have all athletes, sit and take this computer based assessment tool and have a baseline score to which we could compare them post injury, which is a very helpful piece of information to have. But sometimes hard to make use of and then sometimes tricky because patients can test well, but still be symptomatic and not necessarily ready to go back. And that can create as many problems as it solves.

Host: Sure. That can be one of the limitations.

Marc Carley, DPT, ATC: Yes.

Host: Well, that's good to know. I always remember we had purchased Cogsport in Indianapolis during my fellowship, and that was what we were using with our teams there. I believe that was out of Australia, but basically a competitor to Impact, and I remember how challenging it was in a sports medicine dedicated program in a big city to implement it. So it doesn't surprise me to hear that it's not necessarily still having widespread use or, or definitely having use in small communities where you're just not seeing the volume of concussions necessary.

Marc Carley, DPT, ATC: Yeah. That was, I think, ultimately what led to high school deciding they weren't going to continue to spend money on the licensing necessary for that because it was of limited value and again, we explored one time trying to get a physician fully credentialed through that program and, it just was not feasible here in rural Minnesota.

Host: So a couple other topics before moving on to post concussive syndrome, or one's more of a comment from years ago, and to see if you want to react to it, if it still would be applicable to today. And then the other one is just a question about resting your brain, which you referenced before.

Let's start with that one. Has that been more challenging in today's age with phones? Focusing mostly on, you know, the youth who have concussions, is that a challenge to get them to rest their brain in the setting of cell phones?

Marc Carley, DPT, ATC: It is. The recommendations for rest have improved as far as the amount of time now typically that kind of real shut it down rest has been recommended for 24 to 48 hours. And then actually reintroducing in this case, a young person back to school with perhaps some accommodations for test taking, that type of thing. Some light physical activity sometimes can help get those symptoms to resolve a little faster. So that's something we can also help guide the individual through in therapy or at the school in the training room. But getting kids to put their phones away and not

spend time scrolling is, is tricky and that's kind of an important thing in those initial days to really limit that. A few weeks ago, spoke with a young lady over at the school who had hit her head and it was feeling okay until she was sitting in class and there was some kind of video on the screen and made her head start to hurt and she felt nauseous and just that bright visual input caused her symptoms to reappear.

So that rest time initially is important in, in trying to mitigate that type of experience moving forward. That was about two weeks after she had, had her initial injury. So a surprise at that point for her to still not be feeling 100%.

Host: That's a good takeaway point. That initial rest period is really important, and that involves decreasing stimulation of all kinds, and really trying to focus on that. It's not a super long time. It may, to a teenager, it might feel like a really long time, but, I think taking that point away, if you have a concussion or a family member has a concussion, and trying to focus on that seems like pretty important.

Marc Carley, DPT, ATC: You know, and that's where some good education to the, the patient and of course their, in this case, their parents, or caregivers who can just to help monitor that and help encourage the individual to really just shut it down for a little while.

Host: So the other point I wanted to bring up before going on to a little more talk about post concussive syndrome. It's just something that was brought up during, it would have been about 2004, 2005 NFL Physicians Meeting that I happened to be at, and the team physician for the Pittsburgh Steelers, who also happened to be involved in the Pittsburgh high school system, presented a study that basically, we may have been grading concussions at the time or not, but he described concussions where you would call, where a player would say, well, I got my bell wrong. So, a hit on the football field that would just be, yeah, I got my bell rung, no loss of consciousness, everything else is functioning fine, but, that kind of description was found to be associated with decreased math and reading performance for the next week in high school players. And that to me, was really eye opening, and I don't know exactly, what metrics they used to describe decreased math and reading performance, but most people who've played sports or have had any, you know, a fall, anything like that, kind of have a concept of what having your bell rung means, and to realize that there is some impact on your mental functioning for a week. And what they were recommending in Pittsburgh, and he, and he could get this done.

I don't know that this would work in many locations, but they were able to actually get all of the Pittsburgh high school teams on board with having like, you know, two or three days rest, even if you had your bell rung. And I don't know if that's still applicable today. I bring it up, one, to ask you if it's still kind of applicable thinking today, but two, it was an illustration to me how even what is a seemingly mild head injury has more short term effects than you may think.

Marc Carley, DPT, ATC: You know, back in the day, Oh, it just you got your bell rung. You're fine. That was the mantra. You know, we've now come to, to treat that as, well, you got your bell rung. That is, that is a concussion and we need to address it as such. We now will have really good cooperation from coaching staffs on this if a kid has their quote unquote bell rung, they are considered concussed. And then we, we move forward. And even if it is a mild thing and you know, 24 hours later, they are asymptomatic as far as headache, nausea, dizziness, any of that type of stuff; we still want to gradually reintroduce activity, cardiovascular activity at increasing intensities, followed by some more ballistic stuff, jumping, cutting, and then some sports specific things, making sure each time that they aren't having recurrent symptoms.

And that's a safe way to reintroduce activity. And, bottom line when, when these are present, is reducing the risk of re-injury which typically can be more severe.

Host: Right. I've always felt like a functional progression. So, for people listening, what Marc described was a sense, we, at least I was always taught, was a functional progression. So, you add in activities until you get to sport specific activities. In the case of, contact sports, contact would be the last thing.

Making sure that whatever your injury, whether it's a concussion, whether you had a, MCL sprain of your knee, and you're working back into whether you can get back into play; you're doing a step wise progression backed activity that helps basically promote safety and your ability to return without re-injuring.

Marc Carley, DPT, ATC: Correct. And that we can perform that same type of functional progression for work activities as well.

Host: Oh yeah, right. Great point, but not limited to sports. You brought up something that I hadn't remembered to touch on, but is probably a pretty important point, and I don't know if it's still considered second impact syndrome, but that second impact on an injured brain. Can you talk about that a little bit, and the importance, or why that can be such an important thing?

Marc Carley, DPT, ATC: Yes. Well, second impact syndrome, still a term used. It's rare, but when it does occur, it's, potentially fatal. When a concussed individual is still symptomatic from an initial concussion and they suffer another blow to the head, even if it is not, not severe, can trigger a fatal progression of symptoms in the brain that lead to swelling and permanent neurological injury or even, death. Fortunately it's, it is a rare occurrence, and is happening with decreasing frequency now that we're better at dealing with these issues. But you know, that's always on the back of our mind is making sure that people are not symptomatic when they're exerting themselves and that they have, in fact, fully recovered from the initial trauma before running the risk of suffering a second.

Host: Well, good. I'm glad that came up and it's not something to, for everybody to be extremely scared about because it is rare, but also something to take seriously and why we don't want to not treat concussions, why we don't want to be very careful about, or very deliberate and intentional about getting people back to play in contact sports.

Marc Carley, DPT, ATC: It's just why it's a good idea not to rush.

Host: Right. Good point. Excellent. Let's finish up with, um, well, we'll finish up with two things. A little more talk about post concussive syndrome and then any other things that you want to touch on before we end. So one of the like I gave the eye opening point that was brought up at the NFL Physicians Meeting, one of the other eye opening experiences I had in my understanding of concussions over the years was, a very public one.

 It was a meteorologist that some people who are listening may have watched, Ian Leonard, and I don't know him personally, I didn't treat him, I'm not giving away any patient information. He was or is a meteorologist for Fox in Minneapolis, but I knew him growing up in Iowa, he was a meteorologist at a news station down in Iowa.

And so when he went to Minneapolis, I would occasionally, if I saw the news, I would see him on there and then found out that he was gone for a while, because he suffered post concussive syndrome. And I believe he made it public so that he could bring awareness, and, you know, have people understand that this is a thing, it's very debilitating, and, I feel like his lasted for months, which is sometimes the case.

I think maybe you touched on it before, but talk a little more about the importance of therapy and treatment and, and awareness of post concussive syndrome. You kind of defined it as maybe symptoms past ten days, roughly. I assume that's not a hard and fast rule. But go ahead and give a little more information.

Marc Carley, DPT, ATC: Not hard and fast rule. Again, symptoms that last longer than that usually a two week period. So, if we're moving into week three, week four, and an individual's just not coming around, things are lingering, it would typically get that designation as post concussive syndrome. And then require a more elaborate plan of care as far as addressing those symptoms.

And these can potentially last for months and be very debilitating. I mean, I can imagine a weatherman trying to work in front of a green screen with all the monitors around. And, that's a lot of stimulation. I remember a patient one time, several months after their concussion, I was wearing

a necktie with an elaborate pattern on it and looking at it, made this individual dizzy. So I had to take the tie off. It was a good lesson for me. The pattern in the carpet in one area of the department also was hard for her to walk on it. This particular individual was suffering from a lot of vestibular dysfunction following her injury.

And that's one of the more common things we'll see long term is, just kind of a, in-coordination dizziness, balance problem, along with some cognitive. You know, you mentioned the temporary reduction in math scores in those mild concussions. That type of thing can linger quite a while as well, as far as being able to really concentrate on reading. Sometimes scrolling on the phone at that point in time will continue to be difficult for the individual.

 So it can really interfere with not just work, but day to day life. And, they are things that fortunately can be addressed with, with physical therapy.

Host: That's a good, great message because I think, I think in those longer situations after you had a head injury, it can be challenging both for the person who suffered the head injury and people around them to be like, why am I not just getting better? Is this just in my head? Other people will look at this person and be like, what is wrong with them?

Are they faking? And that's, it's a real thing. And yet there's definitely hope of if you hang in there and focus on treatment, you're going to come out of it the vast majority of the times.

Marc Carley, DPT, ATC: I mean, that's part of the long term care is dealing with that, disappointment, that depression, that frustration that comes with, why aren't I better by now? So that's something we certainly try to address when we're treating these individuals is looking at the whole patient. And understanding the difficulties that can come along with just those symptoms, the emotional and mental stress it creates.

Host: I've really enjoyed this discussion. Are there any other concussion topics that you feel are important to get out to our listeners? Any, anything else you want to touch on before we adjourn for today.

Marc Carley, DPT, ATC: The best way to deal with concussions is really prevention. Wear your seatbelt. Wear a helmet if you're on an ATV or a bicycle. If you're playing sports, make sure you have the proper protective equipment. I will say that Aiken High School on the football team, they do a very nice job of getting the very best equipment for the kids to be in.

So take care of your head. Make sure if you're going to be on a ladder, make sure it's stable and secure. Be cautious in the winter of icy conditions. Salt your sidewalk. Pay attention. It's easy to take a slip in a fall and end up with a head injury.

Host: I'm glad you touched on that. I hadn't thought about focusing on prevention, but that's a really good point. And the one thing I can tell you from working in the emergency room, in a small community, it is amazing, especially in the winter, but not just the winter, how many people we see who slipped, fell and hit their head. And most people are fine, but not everybody is. So doing anything you can do to avoid that slip and fall is really important.

Marc Carley, DPT, ATC: It is.

Host: All right, Marc. I really appreciate you coming on the podcast. Thanks for sharing your expertise and knowledge with the community and with me.

Marc Carley, DPT, ATC: Thanks for having me.

Host: Yeah, absolutely. And we'll find some other topics for you as we keep this series rolling.

Marc Carley, DPT, ATC: Outstanding.

Host: Okay. Have a great day.

Marc Carley, DPT, ATC: You too.

Host: Okay, bye bye.