Transcription:
Treating Sport-Related Concussions

Melanie Cole (Host):  Sports related concussion is a hot topic in the media today and in medicine. It’s a common injury that is likely under reported by pediatric and adolescent athletes. My guest is Dr. Russell Gore. He’s the Director of Shepherd Center’s Complex Concussion Clinic. Dr. Gore, what is a concussion and who is at the highest risk, because it’s not just athletes, correct?

Dr. Russell Gore, MD (Guest):  Absolutely, absolutely. I think it’s a good way to start this conversation for sure because concussions are often under reported and a lot of folks out there think that they are protected or that they are sort of safe because their children perhaps don’t play specific sports that tend to be higher impact. So, I think it’s important for folks to recognize that the highest risk groups are really active kids. Folks out there that are participating in any sports, you know a lot of my athletes actually end up with concussions even when they are just horsing around with their friends and being normal adolescents. So, a concussion is a short-term change in brain function and there’s a lot of controversy and there has been a lot of conversation over the last decade about trying to come up with a meaningful definition for a concussion and I will say that there’s not a tremendous amount of consensus, so this makes it sometimes confusing for patients. But if you have an insult like a hit to the head or a sudden deceleration let’s say you stopped very quickly but didn’t crash in a car and then you experience symptoms, headaches, dizziness, nausea, confusion, or feeling foggy, then you very well may have sustained a concussion.

Melanie:  Well as we said at the beginning, Dr. Gore, it’s sometimes under reported and one of the reasons I think is because people trust this equipment, especially in the high-risk sports like football and such. Do you think that this is a bit of a myth or a misconception that people are trusting a little too much that these pieces of equipment will keep their children safe?

Dr. Gore:  Absolutely. There are so many benefits and over the years we have continued to develop better and better safety equipment that is geared towards athletes, vehicles, aviators, we developed some amazing tools. The problem with concussion is if we understand the biomechanics of the injury; then what we understand is that helmets don’t prevent it. So, a concussion, because your brain and head speed up or slow down rapidly, is a result of the brain sloshing around within your skull. That can include forces that are direct and front to back like linear forces or it can include turning or rotational forces. The problem is that even if you cover your head with a protective shell, then your brain still sloshes around when it’s stops or speeds up rapidly. So, these sorts of technologies in helmets really what they protect us from are more severe injuries. So, fracture of the skull, lacerations and cuts of the skin, bleeding within the brain and more severe injuries can be prevented with this technology. The problem is, regardless of what a vendor or a company is going to claim; none of these technologies whether they are soft or hard, none of them have been shown to prevent concussions.

Melanie:  What should parents and coaches and other athletes be on the lookout for for symptoms? We discussed a little bit off the air about the buddy system and resources at the schools and so what do you want people to know about what they should be looking for and parents as well?

Dr. Gore:  Well, I think that the first sort of most important consideration for parents is to pay attention to your children. We very quickly get into patterns within our lives and things are hectic for everyone and often it’s just in retrospect that we think gosh you know my child was acting a little bit lethargic yesterday. They weren’t quite themselves. You know looking out for some of those behavior changes in your child, listening for the yellow and red flags that you might hear from teachers that say your child was not very engaged today, is everything okay and then thinking a little bit about what have we been doing for the last few days. Was there some kind of an exposure? Because it’s amazing to me how often I’m seeing kids with concussions and they are not able to really clearly describe the moment that the injury occurred. And that certainly does not preclude the injury from having happened. So, paying close attention to your children I think and keeping your eyes open to look for those warning signs is really important.

And then once that happens, I think it’s really critical to make sure to tap into the expertise that’s already within your network and your community. Athletic trainers for example are phenomenal concussion providers. If you are fortunate enough to have athletic trainers within your school community or school nurses, let’s say your child’s not an athlete and they may not have access to the athletic trainers or not feel comfortable. Tap into the school nurse and say we are concerned. What should we do? And they will connect you A with an assessment for your child, they are going to talk to your child, they are going to get the ball rolling and they are going to connect you with resources within the school community for further assessment if that’s necessary.

Melanie:  When is treatment necessary? What does that look like? Is this considered an emergent condition? I mean you are the director of a complex concussion clinic, but for a majority of these type of injuries; is this something that needs an emergency room visit and what treatment, I mean are parents supposed to look for some of these symptoms and give Motrin? Talk about the treatment a little bit.

Dr. Gore:  Sure, so, so your first question is a really good one. Is this an emergency situation? And this is very difficult for us to sort of prescribe outside of individual situations. I’m always very careful especially with parents to not tell them that if they a level of concern, that they are feeling would warrant having their child seen immediately by a medical professional and that resource is not available perhaps on the sideline or in a training room or within the school setting directly around you then absolutely going to an urgent care center, having a provider take a look at your child is the right answer. I would say that in most cases, concussions are absolutely not an emergency situation. But that’s biased by those of us who manage these injuries and that’s just me thinking well geez, nine out of every ten concussions that I see for example on the sidelines of collegiate and high school level athletic competitions I would never send to an emergency room. But then I’m assessing them as their provider, so for a parent, it’s a very different question.

Some of the warning signs would include vomiting, associated with the symptoms, if their child is really confused and the symptoms don’t seem to be improving at all, certainly if it is difficult to wake up you child, those are the sorts of things where absolutely you should be calling 9-1-1. In most cases, if your child is waking up, if they are communicating with you, if they are complaining of symptoms but the symptoms don’t appear to be very severe; then those assessments can wait for 24-48 hours until you are able to see a provider.  

When we move to the treatment question, really the hallmark for concussion treatment is rest. So, the idea is that we really want to put that child in an environment where they are not being taxed and challenged from a cognitive standpoint. We want to remove them from play, is probably the most important because we do not want to have another injury within a short period after the first which could potentially make them vulnerable to more prolonged symptoms and so we really want to shut this child down. And I think what we have found over the last few years and with the literature and the data is certainly demonstrating to us though is that after that first 24-48-72 hours at the most of strict rest; we need to be thinking about how to reactivate children. So, what we are finding more and more is that early rest is the hallmark of treatment, but we can over rest kids to the point that we make their symptoms worse and we make their symptoms last longer. So, we need to think about some reactivation after the first 48 – 72 hours of cognitive rest.

Melanie:  With athletes, really dedicated ones Dr. Gore, when to get back to play is their most important question and we hear when in doubt sit it out but when can they go back to play and are we supposed to keep them away from overstimulating things? You were speaking about rest, but you know TV, electronics, their computers, their phones, all of these kinds of things are what a resting child would think they are doing when they rest.

Dr. Gore:  Sure. And this is a big challenge as well for parents. So, really, I use a swimming pool as my analogy with most of my patients. And I let them know that for the first 48-72 hours I really want you to get out of the pool. I want you to be resting. I want to really minimize screen time. I want to minimize physical activity. I want to minimize cognitive tasks. After that 48-72 hours, though we have got to get back in the pool. So, I let them know that we are really though need to stay in the shallow end, so we need to find out for a child who needs to stay engaged socially, but we want to minimize screen time; it’s okay to do some limited texting to stay engaged with friends. They are still in the pool socially, but they are not overdoing it and so we will tell them that we want them to do activities to minimize increases in symptoms. If they are noticing an increase in symptoms of one or two points, then maybe we are okay, let’s see how you feel. Once we get above that then we need to disengage, rest until symptoms go back to baseline and then reengage.

And that’s really how we get from the shallow end of the pool to the deep end of the pool is with a little bit of stimulation. We just really want to prevent overdoing it. I would say that that is absolutely appropriate for physical activity as well and we have to think big picture. When I talk about the swimming pool, I’m talking about school participation and cognitive function and we need to be in the shallow end, physical activity we need to be in the shallow end and also social activity we need to be in the shallow end. So, a child who can attend practice and stay on the sidelines just to be around with friends, but they are not noticing a big increase in symptoms maybe they have very mild increase in symptoms but that’s it; I want to facilitate that because when we remove these kids from their social environment; then we generally make symptoms worse. So, we really want to have them stay engaged.

Melanie:  So, speak about prevention and wrap it up for us. What do you want to tell the listeners about preventing a concussion in the first place and do you believe that impact testing, baseline screening is a good idea for schools and coaches and athletes?

Dr. Gore:  Sure, so really when – I mean those are two separate questions. When we get to the question of prevention, I mean really education is key. We already mentioned that helmets are going to prevent concussions, kids are going to continue to have concussions whether they are participating in sports or whether they are not participating in sports. This is a problem that is part of an active lifestyle and there’s so many benefits to active lifestyles that we want to encourage folks to continue to participate and stay active and what that means is we are going to have concussions. So, educating parents, educating coaches, educating peers and friends so that they are on the look out for these sorts of symptoms is what’s most important. What we want to prevent is repeat injuries. What we want to make sure is that folks who are injured are managed appropriately and I think that’s really, that education piece is the most important preventative measure that we can possibly effect.

The question of impact testing and the question specifically of the product impact is somewhat of a loaded question. There is more and more data that tells us that the quality of baseline testing when we look at populations and we are trying to identify who is concussed and who’s not in research studies; the quality of baseline – the value of having a baseline is overstated right now. It’s really more of a business model. If you are baselined on my product, you are more likely to use my product again when you are injured and that’s – there’s a contract set up and so I think what we do and what’s done in a lot of places who can’t afford these expensive products, computerized testing, is that we have a logical protocol for assessment after the injury occurs and when the resources are available; we try to use – we try to have baseline data so that there is a comparison. But the idea that if you are not baseline tested; then the doctors and the clinicians and athletic trainers won’t be able to diagnose you with concussion needs to be dispelled because we want folks to go to those trainers whether they were baselined or not because the value of those tests compared to where we think you should have performed in most studies is showing – we are seeing that there is still a lot of value to doing the testing and even if baseline testing does not occur.

Melanie:  Thank you so much Dr. Gore for such really important information. You’re listening to Shepherd Center Radio and for more information on concussion please visit www.shepherd.org that’s www.shepherd.org . This is Melanie Cole. Thanks so much for tuning in.