Hello, my name is Aaron Jekyll. I am a psychiatrist here at Vanderbilt University, and I have with me. Hi, I'm Bong Vu. I'm a fourth year psychiatry resident at University of Wisconsin. We are both very much interested in sports psychiatry, and at the end of the day what that ends up being quite a bit of is sport concussion. So we're here to present you Dispelling Myths About Head Injuries, an impactful look at sport-related concussion. It's a really fascinating field that we're both very passionate about and eager to share with you some information, hopefully clear up some misconceptions, and at the end of the day leave you a better provider for having listened to our presentation. Our goals are to understand some of the physics and pathophysiology associated with sport-related concussion, and explore some of the mental health correlations associated with this type of injury. Very crucially, to have a better understanding of what a typical recovery from concussion looks like, as opposed to an atypical concussion recovery or something that we call post-concussion syndrome. We're going to look at some of the epidemiological factors associated with sport concussion, talk about some of the treatment options that we have for caring for these kinds of individuals, and then very importantly, how to talk to patients, family, coaches, trainers, anybody who has experienced or come close to this kind of injury, how to talk to them in a way that helps them understand concussion. There's so much misinformation and disinformation and confusion about concussion out there, that we really hope to help you be a better informed provider to combat some of that that's out there. A big caveat and an area that we're going to kind of steer clear from in this talk is chronic traumatic encephalopathy. That's an extremely important topic, a very controversial topic, and really one deserving of its own entire seminar. So we're not going to be discussing that here and now, perhaps next year, but of course we'd be very happy to discuss that or answer any questions about that on an individual basis if you were to want to get in touch with us at some point. So like all great presentations, we want to navigate through this with a case report. So this is not any specific individual who I have worked with, but this is very representative of many of the individuals who I've worked with who has experienced a concussion, and we'll kind of revisit this individual throughout the talk. So this is a 16-year-old male football player. It's Friday night in the second quarter, and he experiences a helmet-to-helmet impact. His helmet is knocked clean off, falls down to the ground. For several seconds, he is out of it, brief loss of consciousness, and his teammates get him up, and his coach and trainers get him over to the sidelines where he's dizzy, he's nauseous, he's a little bit confused and disoriented. He mentioned that the lights hurt his eyes and the band sounds extremely loud, and then he gets to the point where he is ill on the sidelines. His trainer comes over and asks him, hey bud, what quarter is it? What stadium are we in? Who are we playing? What's the score? Who's our quarterback? And he's fumbling some of those questions. He's testing positive on the sideline concussion assessment tool, and he can't actually even remember getting hit, doesn't remember who brought him to the game. So very justifiably, the trainer gets him off the field and ready for more medical care. Whenever I deal or work with an individual who has experienced a concussion, I like to ask them, so listen, you've had a concussion, what is a concussion? And I get answers that really range the gamut from accurate to very wildly inaccurate. A lot of people think they've experienced something like a stroke. Their brain is bleeding or swelling or bruising. I hear a lot of bleeding type injuries when I ask people that question. They say that their brain has moved around, which is kind of true, sort of true. And now it's sore, better than of a stroke. A lot of people are worried they have permanent brain damage and that their brain will never be as good as it had been before. And probably most commonly, people say, I have no idea. This is discouraging because I'm usually the fourth or fifth provider down the line that they're seeing after they've had a concussion. It would be helpful if by the time they got to me, they had an idea of what a concussion is, what the injury that they have experienced entails. This is made more difficult by people going home and getting on Google and talking to Dr. Wikipedia and they see images like this. And anytime you see an image like this, there's always bright red and a scary looking red. When people see people in the general population see red, they think they think blood. There's just countless images like this. And this individual appears to have experienced some kind of a crushing bone injury to his frontal lobe or excuse me, frontal bone. And there's possible sinus damage and his brain is shrunk to two thirds of its original size. And this one kills me on howhowstuffworks.com, how concussions work. There's the bright red and they explicitly say bruising. Bruising is by definition some kind of a bleed. And that's not what happens in a concussion. So there's a lot of dis and misinformation out there. A concussion, by definition, is a mild traumatic brain injury. And when you have bleeding in the excuse me, bleeding in the brain, you've gone full on to moderate, even severe traumatic brain injury. So, again, a lot of mis and disinformation out there that we're hoping to correct throughout this talk. And we're going to do that by addressing some of these myths. Myth number one, there is a concussion proof helmet. The sports protective equipment industry, a multimillion dollar industry with just as much money put into advertising, absolutely will advertise helmets that are concussion proof. And the truth is there is no concussion proof helmet. We do not have an Ironman helmet where you can sustain a fall from a building and not have some of that impulse transmitted to your brain. Now, certainly there are helmets that are better at reducing risk and they've got all sorts of cool contraptions and machines that engineers have come up with where they will they can they can detect what kind of impulse is being transmitted through the protective equipment. And one cool thing is that we're developing so much helpful and useful data on this is that we're able to develop helmets that are position specific, especially in a sport like football, American football. We know that quarterbacks, for instance, they get tackled from the front, fall to the ground, hit the back of their head on the turf. So a lot of their their impacts are at the back of that helmet. Linemen get hit in the front of the helmet. Receivers get hit on the side of the helmet. So we can now develop helmets that are position specific to reduce risk for different different types of athletes, NFL, NHL, really any major sports league or major sport where people are wearing helmets. There certainly are gradations of quality in helmets and there will be helmets that are approved. And then there's helmets that players are not allowed to use. And you'll hear veterans put up quite a fight when they're told that they can't wear their favorite helmet from 20 years ago. But leagues and safety bodies and players, associates make that decision with a lot of good data and reason reasoning behind it. Helmets have been an incredible tool for the collection of data and development of safety improvements throughout the years. The first so so using accelerometers has been a tremendous resource. Some of the first accelerometers were actually used in race car drivers where we've been accelerometers in their helmets, but probably the most prolific has been in the NFL. And they've done really fascinating studies in the NFL where they found that the average number of G force, the average forces of gravity for a concussive concussive impact in the NFL is around 98 G's, which is a really tremendous force, 98 times the force of gravity. And it's an impulse that's really transmitted very, very rapidly on and off. You'll hear about fighter pilots who are losing consciousness after 10 G's, for instance, but that's because the blood is kind of being forced out of their brain. And those are G's that they're experiencing over seconds. But these types of football injuries are very brief and very intense. High school football athletes have experienced concussion from impacts ranging anywhere from 60 to 90 G's. And then fascinatingly, NFL players have had concussion or excuse me, have sustained up to 160 G's without experiencing a concussion. What this should tell you is that there is no cut off where a certain number of G's will precipitate a concussion. Football players can experience a significantly lower number of G's and experience a concussion or higher number of G's and not experiencing a concussion. A lot of this deals with the type of injury. So for those playing at home, which is more likely to cause a concussion, a rotational or a linear impact? A linear impact is like a like a straight and boxing where your head kind of is pushed back versus rotational where you're a hook, you're hit from the side and it causes your head to rotate very quickly. Maybe a second to to guess and play along, a rotational impact is far more likely to cause a concussion than a linear impact. And this has to do with how the force is transmitted to the brain. What we're going to talk about here is the most succinct and simplified explanation of what a concussion actually is. To me, more probably more elaborate than I would expect you to explain to your patients, but as providers, this is really helpful and useful to know. So an individual sustains an impact to the head and that impact hits the threshold to kind of set off this cascade, this neuro metabolic cascade. So that impact takes place and then immediately glutamate is released from neurons up to 90 percent. Potassium goes whooshing out of the cell up to up to 90 percent. Potassium goes whooshing out of the cell up to up to the cells up to 400 percent. And potassium is actually is a marker where a certain amount change can reliably predict a loss of consciousness. And then you've got calcium coming into the cells immediately after the impact. You've got cerebral blood flow decreasing by up to 50 percent within several minutes and then staying decreased for minutes, days, weeks, potentially even months in some extreme cases. After the impact, you have a brief spike in glucose, which then goes back to normal. But within several hours, your glucose availability is decreased and remains decreased for the duration of time. Now, you've got all of these metabolic changes in the brain and the brain wants to bring everything back to homeostasis. So the sodium potassium pumps throughout the brain kick in and they're working overtime to try and bring the calcium back to where it was and get the potassium back and restore these metabolic normalcy. So you've got the sodium potassium pumps going. They need glucose to work, to function. So effectively, your brain is in a period of what it wants to be hyper metabolism to get everything back to normal. But you've got a decrease in cerebral blood flow and you've got a decrease in glucose availability. And because you have a decrease in cerebral blood flow, you also have a decrease in oxygen availability to the brain. So you're in this period of hyper metabolism that lasts for six to 10 days. You have a disparity between the energy demand of what the brain wants to get back to normal and what it's got available. This window of cellular vulnerability, this this energy disparity is what causes people to have concussion symptoms. Now, the window of cellular vulnerability is extremely important to understand. So this was a paper that Vagnosi et al. did in 2005. This is an animal study, so not directly applicable to humans, but still the the point made by this is is really crucial. So it took a group of a population of lab rats, divided them into four groups plus a control group, one through three. Group one through three each got a mild traumatic brain injury on day one. Group four had a severe traumatic brain injury. And then for each of these groups, 48 hours after the last impact, their brains were examined to look at some to see what kind of metabolic changes were present. So group one had a mild TBI concussion on day one, brain examined shortly after. Group two had a mild TBI on day one. And then three days later. So within that window of cellular vulnerability had another mild TBI, another concussion, and then their brains were examined two days after that. Group three had a mild TBI on day one, and then their brain was allowed to rest for for five days, and then they had another mild TBI, and then 48 hours after that, their brain was examined and they group four was given a severe traumatic brain injury. And what they found was that groups two and four, their brains look more similar in groups one and three, their brains looked more similar. So groups two and four. Ultimately, one of the animals who had a concussion and then a second concussion while its brain was still vulnerable, the metabolic changes there more resembled a severe traumatic brain injury, whereas an individual or one of the animals who had a mild TBI on day one, and an individual who had a mild TBI and then was allowed to rest and then had another TBI, their brains look more similar, worse than the control group, but significantly better than groups two and four. So what this tells us is that during sport concussion, the brain or during that window of cellular vulnerability after a concussion, the brain is vulnerable. The second impact syndrome is a controversial diagnosis and idea in the concussion world. When you look a lot of those when you look at a lot of those case reports, there's confounding factors. The types of injuries seem to be beyond a mild TBI or concussion. There's talks of like brain bleeding and swelling and edema and those kinds of things. But nonetheless, a second head impact during that window of cellular vulnerability has the potential to be a really extreme injury and certainly to prolong recovery significantly. OK, so just jumping off of that, so one other potential complication or I should say two other potential complications is axon shearing and also diffuse axonal injury. And these are I want to emphasize that these are potential complications of sport related concussion and not a cause of concussive symptoms that would be seen. Axon shearing and diffuse axonal injury are often or more commonly seen in moderate to severe presentations. And there there is a more correlation with loss of consciousness or coma. It should also be emphasized that mild concussions are the most common, most commonly seen, the ones that will will walk into your office. And so these things with axon shearing and diffuse axonal injury are less likely to be seen on a regular basis. Next slide, please. So this is just a brief graphic representation showing the gray matter and then the white matter. And then what we want to emphasize is that when shearing does occur, it's most often at the gray white boundary. And there will be multiple slides to show that. So here's the boundary. And then during a concussion, there will be a mechanical force imposed either directly or indirectly. And we'll get into that. And for as I want to say again, for a diffuse axonal injury or axon shearing, this will be a force great enough that would cause moderate to severe injury. But you see the injury and then this will happen globally throughout the brain. Also, there has been a study done where the diffuse axonal injury commonly occurs in the white matter tracks in the corpus callosum and the brainstem regions as well. And then the next slide is just a pictograph of how if there is this much injury, then it will cause reduced processing speed. And then this next slide. So excitotoxicity is more of a secondary result of, as Dr. Jekyll pointed out, with the neurometabolic cascade and disruption of homeostasis and the imbalance of the supply and demand of energy. This leads to inflammation and excitotoxicity where there is dysregulated neurotransmitter release. And then one final point about axon shearing and diffuse axonal injury. So there is a small study done in 2017 by Dr. Shaheem where one thing that people have been trying to find is, is there a biomarker? Because as we'll mention, there aren't many for concussions. There aren't any neuroimaging studies where you can see it on a CT or MRI. But through a potential serum study with the neurofilament light, then this could be a potential marker. And it was two prospective cohorts in boxers and also hockey players versus controls. And briefly, in one part of it, they measured the levels at seven to 10 days after, and it was significantly greater compared to the controls, and then even still elevated three months after as well. So just something that is in the works and potentially a biomarker to look at for concussion in the future. Effectively, there is no biomarker, no finger prick or saliva sample. But if someone was to find a reliable biomarker that positively indicated concussion, that is a slam dunk for the Nobel Prize. And then just to carrying forward, so talking about pathophysiology. So as Dr. Jekyll mentioned during the neuromenopausal cascade, the effects can be seen within minutes, but then even lasting for weeks as well. And we'll get into what persistent symptoms would look like. And for adults, it would be after 10 to 14 days. And for children, persisting longer than one month. As previously mentioned, the concussed brain is less responsive to physiologic neural activation. So that becomes very important when we begin to discuss return to school, return to play protocols, because the brain is much more vulnerable during that time period. And then we haven't touched on this yet, but the immature brain or even the brain of a youth is much more vulnerable. And so we have to be much more careful for our athletes playing in youth sports as well. And then the last point of needing cognitive, needing recovery before returning is very important, but also wanting to emphasize that it's not complete rest, but a gradual return to activity. All right, our next myth, and possibly our most controversial myth of the day, subconcussive injuries can build up and damage your brain. This is a red hot assertion in the medical and sporting community. There have been multiple studies out that have suggested that accumulation of non-concussive impacts throughout life, potentially those experienced at a younger age, can later on lead to a neurocognitive decline, can precipitate later in life, emotional cognitive neuropsychiatric disturbance. This is a very, excuse me, controversial and complicated assertion. A number of studies have been unable to replicate these findings and have contradicted those findings and contradicted that data. Ultimately, the questions you need to ask, if someone were to say that the subconcussive injuries can cause all of these problems, what is a subconcussive injury? Like we've shown before, there is no G force that makes something a concussive injury or not. An aggressive sneeze can be three to five Gs. A roller coaster can be five to seven or eight Gs. Somebody, a track athlete who's doing the long jump is gonna experience some kind of a subconcussive impact. Someone doing a hammer toss in track, that rotational acceleration is going to cause some kind of a force transmitted to the brain. So we don't have any kind of a consensus as to what is a subconcussive impact. We don't know how many subconcussive impact it takes to have an effect or over what period of time. A lot of the studies that have found a correlation do experience some kind of a confirmation bias where individuals who experience psychopathology, psychoneuropathology later on in life are more likely to enroll in these studies. Ultimately, at the end of the day, what we need to be focusing on is making sport as safe as possible. We have empirical data to support that participation in sport is extremely helpful, especially team sport. And we need to make every effort possible to make sport safe and inclusive and available, maximizing benefits and minimizing risks. All right, so our next myth, you need to get hit in the head to have concussions. So this will just launch us into the definition or the definition set forward by the concussion in sport group consensus statement. And this is from 2017. The group actually meets every four years and they were set to meet the end of this year. However, it is currently delayed due to the current pandemic. However, there will be another updated statement within the next year. So just going forward, what should be emphasized is that sport-related concussion can be caused by either a direct blow, which is common to the head, face or neck. But however, I want to emphasize that it can be a blow elsewhere on the body that causes an impulsive force transmitted to the head. So as you can see in this image, there is a tackle from both ends to the torso and then that gets transmitted up to the head and that can cause a concussion as well. The other part is that symptoms can be rapid but then they also can resolve very quickly and spontaneously. So when we talk about treatment later near the end of the talk, those are all if the symptoms persist for multiple days, but for most cases of concussion, they should only last for a couple of days, if any. And moving forward, so with the neuropathologic changes, these are acute, however, they are functional rather than structural. So there won't be any abnormality seen on standard neuroimaging. And one way to think about that is that analogous to a computer system, hardware will look fine. So nothing seen on the image, however, the software might seem like it's glitching. And then the next important point is that previously thought was loss of consciousness was a hallmark of any kind of concussion. However, it's been found that loss of consciousness really only occurs in about 10% of concussions. So that is one big myth to dispel is that loss of consciousness is not required and it's actually not very commonly seen. And then the last point is kind of making sure that these signs and symptoms are not caused by substances or medications or other injuries or other comorbidities. All right, next myth. This is one of my favorite myths and I still hear it commonly. And that's, if you have had three concussions, you can't play sports anymore. And more commonly, if you've had three concussions, you can't play the sport that you were participating in when you experienced those concussions anymore. This was first proposed by Quigley back in 1945. Thorndike reinforced it in 1952. Thorndike made the most relevant statement for this. He was referencing Martland's 1928 seminal paper on concussions, Punch Drunk, that was published in JAMA. I highly recommend you to read it if you're interested in this kind of thing. It's a fascinating piece of medical history. And so anyway, Thorndike in 52 said that three concussions involving loss of consciousness for any period of time, that athlete should be removed from contact sports for the remainder of the season. That's it. This is the first big statement as far as that three concussion myth is concerned. What's important is that the conceptualization of a concussion in 1950, and especially in 1920s, concussion was an entirely different animal back then. We didn't have the nuanced understanding of what this injury was. You look at some of the medical papers from the 1910s and 1920s, where they're considering banning college football because multiple people were dying every year. And they were talking about individuals coming off the field with a concussion and blood coming out of their ears and a clear fluid leaking out of their nose. They were experiencing moderate, severe traumatic brain injuries. And case in point, that Thorndike mentioned that in his workup of concussion, he recommended a lumbar puncture. So we're already talking about injuries in the realm of which people are experiencing brain bleeds, which right there by definition is not a concussion anymore. It's a moderate, severe traumatic brain injury. Thorndike himself, even in the paper mentioned that how much one should permit a re-experience of concussion is a matter of opinion. And that in his own experience, there was no case which the end result was complete removal from all sports. So ultimately the three concussion and no more sports myth has no empirical basis, but it's an important decision to be made on a case by case, patient by patient, provider by provider basis. You need to take a very careful consideration of the risks and benefits of sport participation. You would want to consider how severe the concussions were, how long the recovery was and what kind of sequela we're experiencing from the concussion. As I've said, and I will continue to say, our goal as physicians and sports medicine and sports psychiatrist providers, we need to maximize safety of sport, encourage participation in a safe way and make sure that our athletes are happy and healthy so they can continue to get this physical activity and participate in sports. All right, so now we're gonna continue with talking about the clinical presentation of acute sport-related concussion and we're gonna continue with the case report now. So the patient comes back two days later and starting to notice that there are some changes from baseline that would be the important thing to keep an eye on. So headache, some issues with, so altered sensorium, changes in concentration, emotional lability. So also again, reminding whatever the patient is experiencing at their baseline, this is a change or either it's low mood, sadness, or even more anxiety. And then the other major thing is that if this does continue in adults or in children, more than 30 days, then it would be appropriate to refer to a more specialized care. So the other important thing to gather in the history is to get a very clear personal medical history and as well as a psychiatric history for the patient. So recognizing that they can have prior concussions as well, a family psychiatric history as any history of mental illness and family members can place the patient at risk of having prolonged recovery as well. And then family medical history, specifically any headaches or migraines that can point to information on what the patient may or may not experience. So just to look at our individual here, he does not have a psychiatric history. He has had two previous concussions. He has a positive family psychiatric history and a family history of migraine. Okay, and then now, so there are what we like to say are four symptom clusters. And one thing we do wanna mention is that even though these symptoms can be found, it's very important to show that individually, some may only have one cluster or even bits of one and some may have all four, but not all patients present similarly or identically. So this is a very individualized injury. And then some athletes may not experience any of these symptom clusters whatsoever. So in the somatic cluster, there's dizziness and drowsiness, nausea and vomiting. Those, and when we get to the SCAT, you'll see that some of these symptoms are in the red flags where an athlete should definitely be pulled from the game immediately if you notice these things or these changes. On the emotion side, so the emotional lability, those might not be noticed immediately, but within the next hours or days even. On the sleep side, it could be hyper or hyposomnia. And then in the cognition side, you might hear a lot of patients describing a fatigue or even just a cognitive fog. And then memory impairment can be anterograde or retrograde. And then the attention problems, trouble focusing in class or just focusing on anything really. Also worth noting that as psychiatrists, a lot of our patients before ever experiencing a concussion may have sadness, anxiety, irritability, anhedonia, hyper or hyposomnia, difficulty with sleep, if issues with attention, concentration, headache. So all of these symptom clusters are possible to experience before and without a concussion. Yes, thank you. So very much making sure to delineate from previous depressive or anxiety symptoms as they can present very similarly. So just to emphasize again, the loss of consciousness really is only seen in about 10% of concussions. And then amnesia can be short-term or long-term. And then the disorientation happens a little bit more frequently. And also important to note that these are all symptoms, they're not disorders at all. So a patient doesn't immediately have major depressive disorder or generalized anxiety disorder. These are just symptoms. There's no specific tie to developing a disorder. So here is gonna be a video example and it's gonna go a little fast, but keep an eye on the defensive safety number seven in the top right corner. And so Tarko is a player and he's laying motionless for a couple of seconds. Slow to get up. He's like, okay, I'm okay. You can look up that video. And basically the patient lines up on the wrong side of the field. And luckily there are a lot of people would likely notice that, but there are people in the stands called spotters that they would signal down to the sidelines, like, hey, there's a person that doesn't look right and then have them go check them out right away. So they would most likely use the SCAT-5 or if it's in use for such child SCAT. And these are freely available for anybody to use and look up. But essentially wanna emphasize that this tool is really quite comprehensive, but it can be used quickly as well. And using this assessment tool, it's always safer to have a low threshold for removing a player from the field rather than risking exposure of another impact. So, especially in this red flag section, obviously you can't see it very clearly from this slide, but if you just do a quick internet search, some of the symptoms are neck pain, seizure, or even vision changes, loss of consciousness, weakness in extremities, vomiting. And then another component is the Maddox questions as our case report had shown in their presentation. So those questions ask about long and short-term memory testing. So some of the questions are where are we playing today? Which half is it? Who scored last in the match? Where did you play last week? Did your team win the last game? So being able to test both of those long-term and short-term that any individual that wasn't shooken up being able to answer. If a player does have to, if there are enough warning signs that a player must go for a longer evaluation, then they are taken off the field and it should be in an office in a distraction-free environment at least 10 to 15 minutes after so that the patient or the athlete has been able to calm down a bit and then have a more thorough assessment. And then the one thing I wanted to point out about the child version is that the cognitive questions are simpler. And then there's a component about asking the parents as well. And they're usually quite good at recognizing changes from the child's baseline. All right, not a sideline assessment tool, but an extremely helpful assessment tool for monitoring long-term recovery is the IMPACT, the Immediate Post-Concussion Assessment and Cognitive Testing Tool. This is a computer-based study. It's widely used throughout high schools, professional sports, college sports. And the way it works is that an individual does a baseline and the baseline assesses memory, visual, motor speed, reaction time, impulse control, attention concentration, and it collects a total symptom score. We talked about those symptom clusters and it gets an idea of like at baseline does an individual experience headaches or do they experience anxiety or depression? So it gives you a baseline and an individual then may experience a concussion at some point. They do the IMPACT again, and it tells us where they are at relative to their baseline. So if somebody is falling significantly below their baseline, they're certainly not clear to return to any level of activity. They can't do the return to play or return to learn yet. And we expect them to recover their baseline level of functioning and then engage in different return to play, return to learn, return to sport protocols. These measurements are not diagnostic. So impulse control, for instance, if somebody scores a certain amount on the IMPACT, a certain amount on their impulse control measure, that's not diagnostic. It doesn't tell us if someone has ADHD or not. It just gives us a baseline of where they function. Okay, so just talking about the return to sport and return to learn protocols. And the next couple of slides will show the tables that were taken from the most recent consensus statement in 2017 by McCrory et al. Essentially, it's recommended that after a concussion, there's an initial 24 to 48 hours of physical and cognitive rest, and then slowly having them return to normal activity. And essentially, there are five steps and there should be at least 24 hours in between steps. And then if anytime that there's symptom worsening from moving on to the next step, then they're encouraged, well, they would have to go back to the previous step until they can pass it. And then as we previously mentioned, persistent symptoms are two weeks in adults and one month in children. I do wanna emphasize that in both of these protocols, it's basically, so in scholar athletes, it would be a return to school before having a return to play. That's definitely a policy that's instituted by I would say all educational programs. They are scholars before they are athletes. And then that could be used as a encouragement for athletes to slowly get themselves back as well. But essentially, the important way to look at this is that patients are encouraged to handle as much activity as they can with that, as they can tolerate without exacerbating their symptoms and then just gradually increase their activity. And that would be the same for sports as well. Okay. Now we're gonna talk about some epidemiological factors pertinent to sport concussion. So in the United States, every year, 38 million youths are engaged in organized sports. Tragically, I think that number is gonna look a lot smaller in 2020 with the pandemic, but here's hoping that we get back to that soon. And that's a great thing, because as I mentioned, it's empirically proven that participation in organized sports leads to lower levels of depression, lower rates of heart disease, lower levels of depression, lower levels of anxiety, increases feelings of interconnectedness. The benefits conferred from physical activity are tremendous. And then 170 million adults participating in physical activities and sports per year. A consequence of this is that an estimated 1.6 to 3.8 million sport related concussions occur annually. And 20% of children will experience a traumatic, a mild traumatic brain injury or concussion by the age of 10. This number is very likely, this 1.6 to 3.8 million is very likely an underestimate. There's still a number of individuals every year who experience a concussion and don't know about it due to poor medical literacy or just not understanding. There's a lot of old school coaches and trainers out there who aren't able to recognize or refuse to recognize a concussion. I mean, it wasn't but a few years ago or a decade or two ago, where you got knocked out on the field, they would get you over to the sideline, have you sniff some smelling salts and then get you back on the field, tough it out, play through the pain. So we're getting better at detecting concussion. And that's one of the reasons why people, there's talk about us experiencing a concussion epidemic where the numbers are going through the roof. And the truth is that this is a condition that we're getting a lot better at recognizing and detecting and that will make it look like there are more concussions. There might be because there are more youths participating in sports, but the take home point is that we're getting a lot better at recognizing, detecting and ultimately treating concussion. Looking at, so these are high school athletes and the big sports where you're gonna see, this is concussion as a percentage of total injuries. The big sports are any sport where you have large bodies moving towards each other at a high velocity, trying to get in the way of each other. So ice hockey, lacrosse, boys and girls lacrosse, football, soccer, basketball is a non-contact sport, but you've got large bodies moving towards each other at a high velocity. The big exception to this is cheerleading, which instead of having bodies moving at each other at a high velocity, sometimes you have bodies moving towards concrete or basketball court at a high velocity. So these are high risk sports where participating in them confers a higher risk of concussion than some other sports. This is looking at NCAA athletes. So the sports that shift a little bit and in general, just going back, you see some like boys ice hockey, girls lacrosse, cheerleading, football, they're in the 15 to 20% range. So concussions are accounting for 15 to 20% of those injuries. That drops when you look at NCAA athletes. Concussions accounting for a lower percentage of total injuries, the exception being women's ice hockey, which stays pretty elevated. And that's for a number of reasons. Older athletes tend to, or can be less vulnerable to concussion, but also the way that they're playing changes. So they're more likely to experience knee injuries, elbow, shoulder, other kinds of bodily injuries. But regardless, concussion remains a high percentage of injury in youth, young adult, and adult athletes across amateur and professional realms. Now, post-concussion syndrome, this is crucial for us to talk about because as a psychiatrist or mental health care provider, by the time they get in to see us, very often they are experiencing something that we would call post-concussion syndrome. It's a bit of a nebulous term and a nebulous definition. Now, the majority of concussions will fully recover within two to four weeks, especially in adults, but approximately 80% of people will not experience concussion-related symptoms past 30 days, but a miserable minority will go on to experience those symptoms for a longer period of time. We call post-concussion syndrome, this is persistent new symptoms that have occurred after the concussion, excuse me, lasting for a prolonged duration. The ICD-10 wants three new symptoms, excuse me, but doesn't specify a duration of illness. The DSM-IV wanted three new symptoms for at least three months. The DSM-V doesn't have a PCS definition. Ultimately though, relying on a clinical diagnosis of new symptoms lasting beyond a reasonable period of time, typically 30 days, is enough to call it post-concussion syndrome. Now, this is not any specific patient, this is based on anecdotal experience. A typical concussion recovery looks something like this. Somebody is going along, they have none of the symptoms from those four symptom clusters, and they experience a concussion, and then within a short period of time, hours to days, they experience a peak in symptom level, and then over days, weeks, the symptoms gradually come down, and they become asymptomatic again. They engage, and they return to play, return to learn protocol, and maybe they have a bump in symptoms for a brief period of time, but those come back down to normal, and they return to baseline, and they go on to function quite well. That is 80 percent of concussions. Post-concussion syndrome is where an individual at baseline, asymptomatic, experiences a concussion, and then again within days, hours to days, they experience a peak in symptoms, and maybe they get a little better, but they stick around, and they remain clinically relevant and clinically impairing, and they last beyond that 30-day window, and they persist longer, and they persist longer. It's a month, two months, and then gradually, they very often do recover, but somewhere around here, an intervention may be necessary. Here's a case that I see very often where somebody actually did have baseline symptomatology. Maybe they did experience some depression or anxiety or had a headache or migraine syndrome, but had never come to clinical attention. They've never seen a provider for this kind of thing, and then they experience a concussion, and then the symptoms spike, and they stay spiked, and they can be very difficult to treat, and sometimes it's very often we have individuals who like months before the injury even, they did have symptoms. They were experiencing depression or anxiety or any of those risk factors for concussion. Then they experience a concussion, and the symptoms stay elevated. One very interesting phenomenon that I've seemed to notice in many of my patients is I have individuals, very stereotypically young males participating in a hypermasculine type sport who have clinically relevant symptoms. They're experiencing significant depression, anxiety, ADHD, but they're not getting care for it because they're existing in a world where there continues to be stigma against mental health issues in sports, and they're struggling in silence. Then they get a concussion, and their symptoms spike, but now they feel comfortable talking about the depression or anxiety or whatever it was that they were experiencing, and they come to my office, and I'm able to initiate treatment, and then in the long term, the concussion-related symptoms resolve, and they're getting treatment for underlying depression, anxiety, and they actually end up better than they had been before. So this is a very paradoxical situation where a concussive injury actually brings them to clinical attention and provides them the help that they've been needing since before the injury. Looking at some of the rates of these different conditions after concussion, so this was a study that looked at college athletes who had experienced a concussion matched against a control. In the college athletes, the football players, a depression scale was done at baseline and then post-concussion, and at two comparable intervals in the control group, and they found that about five percent of the control group had an increase in depression. Twenty percent of the athletes who had experienced a concussion had a reliable increase in depression. So concussion, absolutely a risk factor for developing depression. So just continuing off of that, so the study that we're referring to was done in retired pro football players, so not necessarily meant to be representative of all athletes that were presented to your office, but it's still good information to have in the back of your mind when you're evaluating athletes or people with sport-related concussion. So yes, definitely an increased risk in depression, and then what this paper is trying to emphasize is especially with three or more, so three times risk. Just to clarify, this paper is different than the one from the previous slide. Yeah, and then even greater risk with five to nine sport-related concussions shown in a different paper as well, so 5.8 times risk, and there has been a relationship shown between sport-related concussion and post-retirement depression that has been tied to somatic symptoms, so having injuries or lingering pain such as in the joints, headache, back pain, etc., and then even increased risk of suicide as well when associated with concussion. Having history of mental health disorders also adversely impacts post-sport-related concussion recovery. And then this slide is just meant to emphasize it, so this study was actually done in athletes and non-athletes, but showing that with multiple brain injuries or concussions, then there can be high incidence of concentration difficulty and mental fog symptoms that can develop. And then this slide emphasizes that the important thing to get from this slide is that sleep recovery is very much correlated with cognitive recovery, and if patients aren't getting better, then it can lead to headaches and irritability. So a disturbance in sleep in non-athletes and athletes can be a very good entry point of being able to get patients to buy into wanting to address the concerns that can be a complication from sport-related concussion. And then when you're not able to sleep and you're having mood symptoms or concentration symptoms, then that could be a good entry point to get treatment, suggest treatment for the patient. And then this particular study by, I'm blanking on the name, but essentially it's showing that in this particular group, the non-sport-related concussion patients actually had a greater incidence of sleep disturbance, but the samples from that group were actually from patients that had motor vehicle accidents or a fall or some other possibly more traumatic injury. So it's important to just see that sleep disturbance can occur from concussion. In this slide, so we're talking about risk factors for sport-related concussion and post-concussive syndrome. Past sport-related concussion has definitely been shown. So having one puts you at greater risk for future concussions, and then especially having more physical, cognitive, and emotional symptoms in the recovery, the young age. So the immature brain has been shown. Gender is actually a very controversial topic where the studies have been mixed essentially, and it's not conclusive. And it could just be that the female gender is, it's not so much a risk factor, but they may just be better historians or reporters of symptoms, and males may be poor historians where they choose not to share. But again, those studies have not been conclusive. And then just talking about the children and young adults, so any of them with pre-injury history and mental health issues or migraines or learning disabilities, attention issues, then they are at greater risk of having persistent symptoms. And then there are also worse outcomes when having these particular symptoms, so dizziness, migraines, disturbed ocular motor functioning, and depressive symptoms. Some of the big correlations, so if you have a baseline history of depression, you are statistically far more significantly likely, statistically significantly more likely to experience depression and or anxiety after a sport concussion. If you have baseline level of anxiety, you're at high risk for a prolonged recovery. This is a big one. If you have a family history of psychiatric illness, like our patient does, if you can remember, our patient didn't have a history of psychiatric illness, but had a positive family history, that's an increased risk for prolonged recovery. This was a study here done by done by the Vanderbilt Sport Concussion Research Group, just a little plug for the work that we do here. They looked at a population of high school athletes and they found that those with a family psychiatric history and a personal psychiatric history were five times more likely to develop post-concussion syndrome, and just having a family psychiatric history conferred a 2.5 times greater risk of developing post-concussion syndrome. The concussion in sport group releases a list of these factors that have the potential to affect and prolong the recovery from sport concussion, and here under comorbidities, you see migraines, mental health disorders, ADHD, learning disability, sleep disorders. Mental health disorders is about as broad of a blanket population as you could think about, especially when we consider the between 20 and 30 percent of Americans on a daily basis who are experiencing depression or anxiety. That's millions of people who, should they experience a sport-related concussion, are at risk for a prolonged recovery based on these, the data found by the concussion and sport group. It's usually at this point where I really make a pitch for psychiatrists to take a seat at the concussion table, because not only are our patients at risk for the development of complications, should they experience a concussion, we're experts at managing a lot of the pathology that a concussion can cause. So especially jumping off of what psychiatrists, how important they would, the role that they would play. So when they get, when they do get to, you know, refer to us, then it's very important to get a detailed history of the sport-related concussion and all the details surrounding it. So very clear, concrete of, did they lose consciousness? Were they wearing a helmet? Were there any specific symptoms such as dizziness, memory loss? And not necessarily, of course, relying on previous history, but getting it directly from the patient from what they can recall. And then also getting collateral history from family members as well, especially if it's a youth athlete. Getting very specific personal and family medical and psychiatric history, as we've shown is important in our case report. And then any previous sport-related concussion and the surrounding details of those, how long it took to recover, what kind of symptoms that they had, and then even previous head, face, or maxillofacial injuries. These are all questions that will help be helpful to determine the risk factors involved in a potential prolonged recovery. So, and then just touching on the studies that have been done for prevention. So helmets have definitely been shown to be effective in helping prevent sport-related concussion in the sports of skiing and snowboarding. The mouth guard, wearing a mouth guard actually has shown mixed results, but still recommended in collision sports such as football. Disallowing body checking. So this is a recommendation. So for children under 18, this is a recommendation. However, it's controversial because even though it's suggested as a form of prevention, at some point, these athletes do need to learn how to hit properly or how to play properly. And if they're not allowed to do it at a younger age, then perhaps when they're older and have larger masks, it could be greater risk for injury with poor technique. So this is definitely a conversation to be had either with the athletic body or whatever policies are in place for the community that the children are involved in. And then, of course, education is on all levels. So of the athletes, of the public, of the administration, and parents and coaches, and then, of course, healthcare providers that are able to give appropriate information and then also asking appropriate screening questions for when these injuries do present to our clinics. So when discussing, when having a patient, it's really important to that we emphasize the biopsychosocial model. So really trying to take it all into account. So if there's an injury, then also thinking about how that affects the athlete from not being in competition, how they're dealing with that, and then potential effects on their identity if it's very important to them. And this is a youth athlete that might have a scholarship on the line or a professional athlete that this is all they've known and done. They didn't finish their education and they could be at a complete loss. So it's very important to really flex our skills as mental health providers to be able to tackle this from all angles and helping the athlete in their recovery. And then just like we pointed out in the past, there's been a study where athletes with ACL injuries actually have increased risk of depression. So an ACL injury and a concussion, you know, it just paints a picture for a greater risk of mental health symptoms. That study actually found that individuals with an ACL injury were more likely to experience depressive symptoms post-injury than a group with just concussion. And again, a biopsychosocial explanation for this is that 80% of concussions recover within a couple of weeks, whereas ACL injuries can drag on for significantly longer. So any injury is a risk factor for the development of depression and concussion is no exception. Our next myth is that you need neuroimaging to diagnose a concussion. It's extremely common for an individual to come in for an evaluation. So our case, for example, very likely would be going to the emergency room after his initial impact and that emergency provider would most likely be ordering an x-ray or an MRI. There is, by definition, we don't expect to see any structural injury with a, any macroscopic structural injury with a concussion. So any traditional neuroimaging study, CT, MRI, x-ray, we don't expect to see any changes. So neuroimaging done after a concussion is more of a rule out that something more significant has happened. It's possible to observe hemorrhages and certainly it's possible to have a brain injury, a concussion, and some kind of brain hemorrhage or fracture simultaneously. But seeing any kind of positive sign in neuroimaging almost by definition kind of boots you up to a moderate, severe TBI and out of the concussion range. There is potential for DTI, voxel-based imaging, other types of neuroimaging that look at metabolism and very precise alterations in blood flow and other markers of metabolism that may at some point be both reliable and readily available for the diagnosis of concussion. But at this point, we don't have any reliable neuroimaging marker for concussion. All right. So carrying on with our case report, we have our initial athlete, a 16-year-old male experienced a concussion playing football. 30 days later, he's in my office sitting across from me because he's still experiencing symptoms. His mood is down, things he used to enjoy, he just doesn't enjoy doing. He can't play football, so he feels down about that. He can't concentrate. He's feeling tired by the early afternoon. He's getting a headache every day, and he's not sleeping at night, probably because he's coming home and having a nap, but then he can't sleep at night because he can't sleep at night. He's tired in the morning. He can't concentrate at school because he can't concentrate. His grades start to slide. His mood goes down. And you get into this post-concussion syndrome vicious circle, this spiral of symptoms. And here's where we talk about some of the interventions, the medical and behavioral therapies that we can use and can be effective for treating concussion. This is a list of the FDA-approved medications for concussion. There are none. There are no FDA guidelines or approved medications at this point in April of 2020 for the treatment of concussion. Our general guidelines are, these are usually, there's a, you know, very often young brains who've experienced some kind of an injury, a metabolic disturbance has taken place in the brain. Go low and go slow. Use medications conservatively. Titrate slowly. Avoid any medication that can increase levels of confusion, cause sedation, fatigue, drowsiness, those kinds of things. Anything that may interfere with symptom scoring. So when somebody comes back in to do the impact, the follow-up impact, for instance, and you have them on a medicine that's causing morning time sedation, that may cause a false positive where they are experiencing a symptom that's due to a medication rather than the actual concussion. And this can interfere with recovery. As we've been mentioning throughout the talk, it's very important to distinguish between persistent and pre-existing symptoms. So an individual comes to see you at 60 days out, they're still feeling depressed and anxious. Were they feeling depressed and anxious before the concussion? Because if so, they're back at their baseline. Or is it new? As I was just saying, you know, it's so common to see individuals fall into this post-concussion vicious spiral where sleep can cause cognitive issues, which causes headache, which causes mood issues. And sometimes the intervention needs to just find somewhere to break this cycle. Very often it's with sleep. But to find a way to break the cycle, get them good sleep so that when they wake up, they feel more refreshed. They're less likely to have a headache. They can pay attention. And things, you know, if you could stop that spiral somewhere, things often fall into place with appropriate intervention. When to use medications. So we always avoid using medications until people have fallen to this post-concussion syndrome for adults experiencing symptoms beyond 14 days. I tend to wait for about 30 days for everybody. And very often by the time that they've been referred to me, it has been around that 30 day window before I'll start to consider using medications. Like any psychiatric condition, we need to see impairment before we're going to want to begin a medication because any medication brings with it potential risks. So we will need to make sure that the benefit of intervening and providing a treatment outweighs the risk of whatever treatment. Always important for a clinician to be knowledgeable and experienced in managing these sport-related concussion symptoms or mild TBI. You know, we're all trained in the management of depression, ADHD, those kinds of things, but these can show up and look a little bit different in these populations who have experienced a sport concussion. And although we don't have good data on it yet, the trajectory of treatment and the duration of the symptoms that they experience are very likely different than the general population who may be experiencing depression or anxiety in the absence of a head injury that may have precipitated it. So going through the symptom clusters, for emotional symptoms, one of the most helpful categories of medications is the TCA family, the tricyclic antidepressant family of medicines. These work by blocking norepinephrine and serotonin reuptake. The big, you know, when we think about the big characteristics of TCA is it can be sedating, can cause dry mouth. There's the risk for cardiotoxicity and overdose. There's a narrow therapeutic window. But TCAs can be helpful for sleep. They can be helpful for mood and anxiety. And they can also be very helpful neurologists or neurologist colleagues very often use these for headache syndromes. As we've mentioned, it's very common to have sleep. You know, half of people who have a mild TBI will experience sleep issues. Depression and anxiety are common and headache is extremely common. So a TCA can be like a really excellent choice to manage many of these symptoms simultaneously. SSRIs in psychiatry are typically our gold standard for emotional disturbance. There have been studies examining the use of various of the SSRIs in our arsenal on athlete, or excuse me, on non-athletes who have experienced a brain injury. But we also know that SSRIs, so first of all, SSRIs are less likely to help with sleep or headache than the TCAs. We also know that SSRIs are gonna take four, six, eight, 12 weeks even before they start to exert full efficacy on the depressive symptoms. And post-concussion psychopathology is very often a self-limiting illness. So if you have somebody who hasn't experienced depression or anxiety before the concussion, and you start an SSRI and within several weeks they have significantly improved, you're left with a poor understanding of, well, did the symptoms resolve or did the SSRI impact a positive change? And if so, how long do we keep them on the SSRI? We know that for young people typically staying on an SSRI for at least a year after returning to baseline and for adults, six months. We don't have empirical data to support the use of SSRIs like that in individuals who have experienced a support concussion. So that just adds a level of complication to using an SSRI. Certainly not a contraindication to using an SSRI for emotional symptoms after a concussion, but another layer of something to consider. We know that using CBT as an adjunct to the treatment with an SSRI is extremely beneficial, and we don't have any reason to believe that that's not the case for managing support concussion. And especially leaning back on our biopsychosocial model, adding some level of CBT and therapy for these individuals can be very helpful. Other medicines that I use very commonly for managing post-concussion emotional symptoms are duloxetine because it can have a very good benefit for managing headache, pain, and mood, as well as remeron, a medicine that we know can be sedating, can help with the sleep. It's an interesting choice. Hypothetically, you have a linebacker who had a concussion, and because of the concussion, they're tired and their mood drops. Linemen work really hard to eat a lot of food and to keep their caloric intake up and to keep their weight up. And I see a lot of linemen who have a concussion, and then they lose 20 or 30 pounds, and then they've got their coaches who are getting mad at them for having lost weight. They'll very happily take remeron as compared to a cheerleader who, the thought of being put on remeron, which may change her weight, is less appealing because it's gonna decrease her ability to participate in something that they love. So definitely an available option, something to consider, but like any psychiatric medication, looking at the risks and benefits. All right, so for the next symptom cluster, talking about headaches, it's important to just approach, like Dr. Jekyll had mentioned, more conservatively, and then go low and go slow. So if it's a headache, then of course, you can start with analgesics with NSAIDs or even Tylenol, but being very mindful of rebound headaches and any contraindications specifically for those medications. As mentioned, TCAs are actually very, very handy medications that can treat multiple different symptoms that can be seen in a sport-related concussion, particularly with a headache, and then also with any pain as well, but also being very mindful of that class that it can cause the anticholinergic, so which can be difficult for athletes. They don't wanna be dealing with dry mouth or any potential sedation, any cardiac history, and then also the possibility of wake-in. So this is, of course, a conversation, and all of these therapeutics are if these are persistent symptoms, so keeping that in mind as well. And then the less common but potential therapies, so gabapentin can be used off-label, same with Topamax, though, of course, there's the cognitive fog that can happen with that medication, and then in more treatment-resistant cases, actually, and especially in neurology clinics, trigger point injections or Botox have actually been found to be quite effective. And then for just over-the-counter recommendations that are quite low-risk, supplementing with magnesium and riboflavin can be helpful in terms of, for prevention of headaches as well. For the sleep symptoms, being conservative, sleep hygiene, and CBT for insomnia, so really emphasizing what their sleep is like, what their sleep habits are like, so talking about stimulus control and sleep restriction, really getting a sense of what their sleep patterns and habits are, and then especially if there's a lot of caffeine or nicotine or any substance involved, and then asking about naps. Trazodone actually is off-label, but it is still frequently used. Phototherapy can be very helpful, especially for athletes that travel across time zones, so it can be used to help phase it forward or backward, and then TCAs, of course, are sedating. We do wanna mention that benzodiazepines and zolpidem are discouraged to be used because of the negative effects, and it actually can interfere with evaluating patients' baseline recovery as well. And of course, it can be very habit-forming. We do wanna make a comment on melatonin as just being a cheap, over-the-counter, affordable, so affordable medication that really has been shown to be less likely to cause any kind of hangover effect that patients can complain about, especially if they were to use a medicine like a trazodone. And it's very effective at resetting the circadian rhythm, well-tolerated, and actually has been shown to have neuroprotective effects as well, so. Potentially. The neuroprotective effects, the study that we're referencing was, I believe, in a military population with more moderate to severe TBI, but again, like we've mentioned, the risk is extremely low, and the benefits are potentially considerable. Moving into some of the cognitive symptoms, and as we've shown, very common to experience cognitive problems after a concussion. So this is because of impaired function in the frontal lobe, the part of your brain, the prefrontal cortex responsible for executive functioning, attention, concentration, planning. Looking at animal models, we've seen improvement in animals who've had a mild TBI concussion. We've seen improvement, functional improvements, when we apply medications that facilitate dopamine transmission. And then conversely, we see negative impact in animals who are on dopamine antagonists, so a typical antipsychotic. So we know that dopamine, medications that can modulate dopamine can have a significant role in recovery. Stimulants are a medication that we often use in recovering cognitive impairments after a concussion. You've got the methylphenidates, which bind to and block dopamine and norepinephrine reuptake transporters. And there's some evidence in non-athlete adults who have experienced TBI, who have demonstrated statistically significant improvement in attention tasks. Other studies have been a little bit more mixed. The amphetamine classes of medication, they block reuptake and promote release of dopamine and norepinephrine. And again, there've been studies looking at non-athlete adults who have experienced TBI and showing significant improvements in attention, memory, response speed, stability, excuse me. And I know that this study done by Trent Montana, there is a follow-up study, I believe, pending publication, looking at youths who have experienced non-sport mild TBI. The big questions whenever I'm applying a stimulant treatment to an individual who has cognitive symptoms, how long do we continue treatment? I always explain to the patients that I work with that we wanna get you back to normal. We do not want you being on a stimulant to be the new normal. Just anecdotally, I typically outline a six-month regimen on a stimulant or shorter but I always let individuals know that we're gonna use, if indicated, we can use a stimulant to get you back to your baseline. And then we need to be paying close attention to how you're doing on days when you're not taking the stimulant and steadily moving over the course of several months to getting you back off of the medication. Oftentimes, if people are struggling to come off of the medication, I'll refer them for neuropsychological testing, it's possible that an individual has had ADHD that hasn't been noticed clinically and then has a concussion and then it comes to clinical attention. But we don't have any evidence that a concussion can create ADHD, so to speak. We think about the different formulations. There's so many different formulations of stimulants, long-acting, short-acting, patches, capsules, tablets, so on and so forth. If an individual ends up going on this medication and gets back to baseline while they're on the medication, it's debatable, like, are they back at baseline if they need to be on a stimulant to return to sport? Is that truly a baseline if a stimulant is working as an adjunct to their recovery? And then different levels of sport will ban the use of these substances, more competitive levels, NCAA, professional sports, without clearance, without a therapeutic use exemption. Amantadine was a medication that was gaining a lot of attention not too long ago for the treatment of post-concussion cognitive deficits, a medicine we use for Parkinson's and influenza, similar to some stimulants, presynaptic release and reuptake inhibition of dopamine, and potentially even increasing the density of post-synaptic dopamine receptors. Ready et al. looked at this in a group with a matched control. Excuse me. They did find greater improvements in the sport concussion group who were receiving amantadine, but follow-up studies were a little bit less conclusive, and there was some, the sample was small, 39 adolescents, and there was some disparity between the starting points in the experimental versus control group. So amantadine is not one that I use as often as stimulants, but if I've had a lack of success in other areas, certainly something worth considering. All right, so this is this kind of catch-all slide. So if I had a concussion, I can't look at screens. If I have concussion, I can't fall asleep. I can't play sports again. So these are all myths that we, sometimes the answers are it depends and really on the level of severity, and it's less about what you can't do and more about when. So the idea is that strict rest for adolescents or people in general after concussion, really that has been debunked and it's not so much. So there is the cognitive and physical rest for 24 to 48 hours after. However, it's really about the gradual recovery that is shown to be best in helping patients recover and return to normal activity. So really it's about having that conversation with your patients. And if screens is what causes worse symptoms, like causes a headache, then yeah, you shouldn't look at screens at least to start and then gradually, or at least figuring out how long that can be done. And then same with return to sports. It's about what your body can tolerate in terms of exacerbation of symptoms or not. Yeah, I've heard quite a few different, I can go back to class, but I can't face the board. I can't look at my cell phone. I can't be in a room with lights on. We've really fallen out of that cocoon therapy where literally people used to advocate for sitting in a dark room without any noise or lights for seven days to recover from a concussion. There's evidence that that actually is more likely to prolong a recovery. So really it's what your brain and body can tolerate. This is how to talk to athletes, parents, coaches about concussion. This is a talk or a method, a strategy developed by Dr. Gary Solomon. He a renowned neuropsychologist and a great mentor of mine who has this great way of approaching people about it. Think about your brain as a computer. You've got the hardware, your monitor, your keyboard, and that's equivalent to like your actual brain, like the matter of your brain, your skull, your cerebellum. That's your hardware. And then you've got your software, the programs that you run, Windows or Internet Explorer or whatever the software is. And your brain has a software program for your emotions and for your balance and for light sensitivity and for like feeling nauseous kind of thing. And after a concussion, your computer has glitched. You bang your head, the software glitches. And like we said in the beginning, this is because of that disparity of oxygen and glucose getting to your brain. The computer is not getting the energy supply that it needs to run those programs. So you get the blue screen of death on your computer. What do you do? You reset it. You walk away, you let it reset. That's the first 24, 48, 72 hours where someone's had a concussion, you let them sleep. You let them rest. You let them avoid any stimuli that might precipitate symptoms. And then after that, you gradually start seeing what they can tolerate. Walking, stretching, moving around the house, totally fine if they can do it. We don't wanna see people using this as an excuse to like sit on the couch and eat potato chips all day. We wanna see the body moving. There's some evidence that mild or moderate cardiovascular exercise can help speed a recovery. And we have a lot of evidence that complete inactivity can prolong recovery. If you start doing something that makes the symptoms worse, stop. If you're doing something on your computer that's making it freeze, you're gonna wanna stop doing that kind of thing. Back off, take a break, come at it again a day later. Just like in the return to play protocol, if you start pushing your physical exertion and it causes headache to come back or dizziness or nausea, stop doing what you're doing, rest, come back at it a little bit more cautiously the following day and gradually progress through those stages until you're returning to a baseline level of functioning. Get back to school as soon as tolerated. I often will write letters advocating for certain accommodations for individuals returning to school, like focusing on more important assignments, allowing a little bit of extra time for assignments, allowing an individual to go to the nurse's station or the nurse's office or something like that to take a 10 or 15 minute breather as needed. But the trajectory should be forward. It really, after those 24, 72 hours, we don't wanna see a plateau. We wanna see a gradual return to baseline level of activity. That's letting your computer restart. Sometimes it takes a little bit longer, but that's our objective as providers. Just some last comments about recommendations when talking with athletes and coaches and parents is just really creating that environment of mental health literacy. And within that, it's just talking about mental health symptoms, really normalizing them that these things will come up and that it's okay to talk about providing that safe environment that if you are experiencing any kind of emotional symptoms or having just somatic symptoms, like with a headache or cognitive symptoms, then it's okay to talk about those things. And if it's coming down from the administration, from the coaches, from the doctors or from parents, then it creates that more open environment to be able to have earlier detection, preventing more long-term injuries or more severe injuries. And really trying to push that de-stigmatization and pushing that idea that it's okay to not be okay and really doing away with this idea of mental toughness. So encouraging care-seeking, encouraging ongoing support, and then just ongoing positive reinforcement. Yeah, well put. It's sad to see an individual who it takes a head injury for them to open up about experiences with depression or anxiety. We do need to foster a shift in the culture of sports. And I believe that we are seeing that. You're seeing it prominently with a number of athletes who are starting to open up about their struggles. That's something that as providers, we all need to take a part in. Just reviewing through our goals and objectives, we've discussed the physics and pathophysiology of sport concussion, that neurochemical cascade. We've looked at some of the mental health correlations and risk factors for sport concussion and development of post-concussion syndrome. We've looked at what a typical recovery looks compared to a prolonged recovery. We've explored a number of different epidemiological factors and risk factors for sport concussion. We spent some time talking about treatment options, and we've given you a potential model for discussing concussions with individuals. Young people, they get computers, and sometimes that's what it takes for them to relate to this kind of injury. Worth noting that when an individual understands what they're going through, they're more likely to comply with treatment. Symptoms typically resolve quicker, and it's just more helpful to have engaged and well-informed patients. We want to acknowledge Dr. Claudia Reardon for her help in assisting us with putting together this talk, as well as Dr. Gary Solomon for his mentorship and helping put together this talk. This is the point where we would be asking for questions from the audience. We're not able to do that, so please feel free to reach out to us via email. Very happy to correspond about this kind of information, answer any questions, comments you might have, and thank you so much for spending the time listening to this talk, and we hope to see you in person next year. Thanks a lot. ♪♪♪

Post-concussion syndrome

Persistent symptoms

Headaches

Dizziness

Fatigue

Difficulty concentrating

Mood disturbances

Risk factors

Pre-existing mental health conditions

Past concussions

Family history of psychiatric illness

Treatment options