Concussions & Mobile Apps – PediaCast 261

Dr Thomas Pommering and Dr Jason Mihalik (from UNC Chapel Hill) join Dr Mike in the PediaCast Studio to talk about concussions. Topics include the cause, evaluation, and treatment of concussions. We also cover mobile apps for concussion care, neurocognitive testing, return-to-play progression, and Ohio’s Concussion Law.

 

Topics

  • Head Injury

  • Concussion

  • Neurocognitive Testing

  • Return-to-Play Progression

  • Mobile Apps for Concussion Care

  • Ohio’s Concussion Law

Guests

Links

 

Transcription

Announcer: This is PediaCast.

[Music]

Announcer: Welcome to PediaCast, a Pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It is Episode 261 for August 14, 2013. And we're calling this one Concussions and Mobile Apps. And yes we will link those two together and make them relevant to one another.

I want to welcome everyone to the program. We are back from a two week break and I'm excited to share the big news that I have promised before taking off for our family vacation in Florida for nothing like leaving in suspense from hanging out the beach, right? Trust me the timing was not design that way, it's just worked out.

01:13

The vacation was a great time, hot, yes. But time spent with family's always sweet and as many of you know my mother lives in the Sunshine State so the kids had a nice visit with grandma. We saw mouse sang by the old neighborhood. Did a little roller skating with Karen watching from the sideline, she wasn't too happy about that, but overall great times and we're Buckeye State now, well rested and eager to share our exciting news.

Before we get into that I know just a tiny bit longer to wait. I do have a great show lined up for you today, we're talking Concussions and expanding on our usual knots and bolts approach of the topic with some discussion on recognizing and managing concussions with smart phone, mobile app technology. We're also going to talk about Neurocognitive testing and the specifics of returning can cause athlete to the playing field or the playing court is the case maybe.

02:05

Also, Ohio has a new concussion law which will affect the football crowd for the first time this fall, so briefly covered that as well. I do have a couple great studio guest lined up to help me with this topics. Dr. Thomas Pommering, who is no stranger to this podcast. He's the Chief of Sports Medicine here at Nationwide Children's and Dr. Jason Mihalik, he's an Exercise and Sports Scientist from the University of North Carolina at Chapel Hill.

And we'll get to them in a moment but many of you out there saying, "c'mon speak it out, what's the big news already?… Well, here it is you've more than likely heard of "I Heart Radio… from Clear Channel. It's an industry leading digital music service that gives users instant access to more than 1500 live radio station from across the US plus user creative custom stations with a catalogue of more than 16 million songs, it's available on multiple platforms including web, mobile, tablet, automotive televisions and gaming consoles. OK, so what's I heart radio got to do with PediaCast?

03:01

Well, clear channels introduced a unique new dimension of the I Heart Radio Service it's called "I Heart Radio Talk… and it offers instant, on demand, fully customizable access to top news, sports lifestyle, entertainment, finance and comedy, talk shows. I heart radio enables listeners to stay connected with their favorite talk personalities anytime, anywhere and enjoy this shows when, where and how they want. And our big news is this, you'll find PediaCast and I heart radio talks inaugural line up making it super easy for you to connect with the show from within the I heart radio app on the web, on iPhone and android devices as well.

And along with our debut on I heart radio talk, we're introducing a new way to consume at the show. So this is really a diversion from the way that we presented the show to you in the past which will continue to have the big program each week, but the new way to consume the show is something I'm calling Pediabites. OK, so what are Pediabites? Well, these are 5 to 10 minutes segments each covering a single topic with a handful of pediabites release each week and available on I heart radio talk.

04:06

And here's an interesting feature of the service, you can create a custom talk radio station called the daily pulse and select which talk shows you'd like to hear and then I heart radio talk will knit together segments from your favorite shows including Pediabites if you subscribe to those and if you like they can also infuse the daily pause with your local news traffic and weather making our heart radio talk the perfect companion for commuting, exercising and working around the house.

You can stay connected with your favorite shows, host, and personalities with top to your content all in one place and the deeper experience than live talk radio because you can enjoy shows, when, where and how you want. So that's the big news be sure to check our PediaCast and the all new Pediabites on I heart radio talk and I will put link to everything in the show notes over at PediaCast.org so it's all nice and easy for you to find. That also means that your questions and comments may end up on "I heart radio talk… during our listener versions at the program.

05:02

And remember if you have a question or comment or show idea it's easy to get in touch just go to PediaCast.org and click the contact Dr. Mike link and I read every one of those that come through, so if you have a questions send away.

Also, I remind you that the information presented in this program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So, if you do have a concern about your child's health, be sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.
Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at PediaCast.org.
All right let's take a quick break and I'll back with our studio guest and we'll talk Concussions right after this.
[Music]

06:14

All right we are back, Dr. Thomas Pommering is an official PediaCast frequent flyer this being his fourth visit to the program. He's the Chief of Sports Medicine at Nationwide Children's Hospital and an Assistant Professor of Pediatrics and Family Medicine at the Ohio State University College of Medicine and he's now around good guy and family friend. So, welcome back to PediaCast Dr. Pommering.

Dr. Thomas Pommering:: Thanks, Mike. Oh it's good to be back.

Dr. Mike Patrick: I was looking back and PediaCast 51 back in 2007, Football safety that was the first show we did together. And then you're here couple years ago, we did — it was PediaCast 171 we did Summer conditioning and PediaCast 177 we did talk about concussions and some of that is similar to the information we're going to present today, although I think that episode goes a little deeper into the science of concussions and we'll review that stuff today and then we're going to expand on it with discussions on mobile apps and return to play progression on Ohio's new concussion law.

07:12

All of these episodes by the way are still available at PediaCast.org in the archives. Actually we have all of our previous episodes in the archive at PediaCast.org, even episode 1 which was a little shaky but certainly has historical importance for the show. Anyway, thanks for coming back really do appreciate it. So, I mentioned mobile apps for concussion care. We're also fortunate to have the guru of concussion apps in the studio today, Dr. Jason Mihalik.

Dr. Mihalik is the Assistant Professor in the Department of Exercise and Sports Science at the University of North Carolina at Chapel Hill and Co-Director of the Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center. Dr. Mihalik primary research interest include head trauma biomechanics and utilization of smart phone app technology to study the common pathways to managing head trauma from the sidelines through the Emergency Department.

08:02

So, welcome to you as well Dr. Mihalik.

Dr. Jason Mihalik: Thank you for having me.

Dr. Mike Patrick: Well, we appreciate you are travelling from North Carolina to join us here in the Buckeye State. So Dr. Pommering let's start with just a reminder for our audience. What exactly is a concussion?

Dr. Thomas Pommering:: The short answer for that is that a concussion is simply a brain injury whether it's mild or more severe people need to remember that. It does an injury to the brain that is a functional injury so that things are occurring in the brain or happening at the cellular level that are causing the symptoms that we'll talk about later.

Dr. Mike Patrick: Great. Now, when an athlete or really anyone gets hit in the head, it's not only brain injury they have to worry about there are other things that can happen with the head injury other than concussion. Dr. Mihalik, what are some of those things that you worry about with the head injury?

Dr. Jason Mihalik: Well and the more severe and of concussion we see instances where athletes have suffered skull fractures and kind of more catastrophic events including bleeding of the brain. So there are more serious incidence following head trauma beyond concussion that when we'll talk about some of the signs and symptoms later where parents can highlight those red flags and take emergency care if needed.

09:11

Dr. Mike Patrick: Sure. And since the head is connected to the rest of the body by then that and the next kind of bit important place, you're always worry about neck injuries when you get hit in the head as well.

Dr. Jason Mihalik: Absolutely.

Dr. Mike Patrick: So Dr. Pommering how from the medical side of things, how do you tell the difference between if there is just a concussion or could there also be a skull fracture or brain bleed or neck injury, I mean how do you go about figuring it out you know, what's going on?

Dr. Thomas Pommering:: Yeah, that's a great question. Sometimes in their first several minutes after injury is difficulty to tell especially if the athletes mental function has been altered and they can't answer questions if they're unconscious but certain issues secure an athlete and watch them on the sideline or wherever you are over the first 10 to 15 minutes if someone remains unconscious or if their mental status is altered or they become worst may go from being pretty elusive and it will talk to you and answer questions relatively well that becoming more lethargic or tired or even unconscious, that's obviously a red flag.

10:13

Other things would be headaches that are out of control getting worst, you know, "worst headache of your life… and the other thing I would mention is uncontrolled vomiting. It's not unusual to vomit once or twice after a concussion but someone who continuous to vomit for several hours after hours afterwards should alert you that they may have a more significant head injury.

Dr. Mike Patrick: Yeah, sure and so, this is something that's kind of — for those of us who practice medicine and for first responders even it's just something that we think about, I mean it's almost second nature. You know, we know it's just a minor head injury or just something I'm going to be more concern about. But what about coaches and parents? Dr. Mihalik, I mean this is kind of scary thing when their kids gets hit in the head, how can they tell whether this is something serious or not?

11:00

Dr. Jason Mihalik: I think, coaches and parents are probably one of the more important members of the medical team in the sense that they probably know the athlete better than any medical provider that's going to provide that care whether it's an emergency physician or sports medicine pediatrician in the clinic a few days later. So, doctor mom know how little Johnny normally behaves and any behavior changes however subtle they may be to the medical professional would be picked up either parent and more times not by their coach and those subtle behavioral changes are often times an indication on something more serious going on.

Dr. Mike Patrick: Yeah. And then in terms of evaluating — so the parents have a good idea if he is my son or daughter acting normally or not but they may not remember all the different signs of a concussion that would be more worrisome. And so, this whole idea of having something in the parents and the coaches' pocket to help them determine whether there could be a concussion there or not in the form of a mobile app is something that your team came up with.

12:02

Dr. Jason Mihalik: Yes, so in working with the colleague of mine, Dr. Gerry Gioia is a Pediatric Neuropsychologist. He actually took the lead on the consumer side of this concussion recognition response app, we'll talk a little bit later about the provider base version of it but essentially what we want parents and coaches to realize is that symptoms and you know themselves don't necessarily dictate a concussion has occurred.

There needs to be a mechanism of injury that kid has to sustain some type of trauma whether it's a direct impact to the head or to the body that causes this forceful head motion, kind of like a whiplash mechanism if you want to — or body tackle cause we see that often times on the football field. So, there needs to be a mechanism and then what the app will do is walk the parent or the coach through all the signs and symptoms that are consistent with concussion but not specific to concussion. Pre-season football North Carolina we see a lot of kids that are very dizzy after football practice but I's because it's 90 degrees Fahrenheit, 90% humidity and they haven't drink water.

13:03

So it doesn't mean they're concussed, just means they're dizzy and so the mechanism has to exist the signs and symptoms have to be present for that athlete to be considered potentially concussed and require further medical evaluation. So, the app essentially walks the coach and the parent through that process helping them to identify signs which is things that they would observe on the patient, on their child and then walk through some symptoms which are things that the patient would report to them and then highlight the number of red flags that would prompt that emergency referral that we're talking about the things that might identify whether or not skull fracture, brain bleed might be present.

Dr. Mike Patrick: Yeah, I really like that it gives definitive answer like, OK based on whether you've answered these questions, you need to call 911 right now. Or your child needs to see a medical professional but you know you can drive and do an emergency department or a pediatric urgent care type facility, or no this is not a concussion at all. So, I mean this I think give the parents some comfort and this is what I need to do.

14:08

Dr. Jason Mihalik: Right and what we enjoyed a lot about the app is the research component to it. So all of those data points get uploaded to a secure server so that Dr. Gioia and myself and other colleagues of ours can analyze those data to start to get a better picture of what's occurring on the field and how that dictates with kind of long term care which we'll talk about later.

Dr. Mike Patrick: Sure. And I did download the app and played with it and I did noticed that it did say "do you want to send this information?… and I would of course encourage folks to use this app to do that so that we can better improve our knowledge of concussions and what kind of symptoms are out there and how common they are, but they don't necessarily and because in there's some privacy issues today. I would encourage folks to do that but there is, you could opt out to that.

Dr. Jason Mihalik: You could actually opt out of it. It's essentially an electronic version of a consent form the first time you log in to the app. If you decide to change your mind you can always go on the settings and change the setting. There's the option of recording name and taking a photo of the patient, that information does not get uploaded, so it's only the de-identified data that get uploaded to the server.

15:19

Dr. Mike Patrick:  Sure, that you know people are concerned about privacy, it's not necessary you're going to figure it out what specific child but I would encourage folks to app in to that so that they can help with the research.

Dr. Thomas Pommering:: Mike, I just want to comment I would really applaud Jason and his colleagues for developing this because I think it's a nice combination of common sense plus education and you get a good result. I think it's really easy for parents or coaches to explain the way one symptom it's all that's just used to that but really is a combination of things that are going on and help you make a decision what to do next.

Dr. Mike Patrick: Yeah, absolutely. And this apple, so in addition to kind of go in to that flow sheet and determining that extent of the head injury if there's a concussion or not and such there's also home symptom monitoring, concussion info and frequently asked questions, postconcussion and home and school instructions, returned to play guide, I mean it's really just a comprehensive head injury concussion app.

16: 12

Dr. Jason Mihalik: Right. And much of the content is based on the CDC toolkits that are available for parents and coaches. So it's a resource like you said earlier that's right there in their pocket they don't have to go find a clipboard or watch a video and heat of a game, that's not going to happen. And so gives more information right there to their fingertips.

Dr. Mike Patrick: And I'm sure many coaches and parents right there like OK, tell me how I can get this.

Dr. Jason Mihalik: So, it's available on the isle flatform, so for iPhones and iPad touches, it's also available for android devices. So it's available on the iTunes store and the Google market, I believe.

Dr. Mike Patrick: Yeah, Google play.

Dr. Jason Mihalik: Google play.

Dr. Mike Patrick: Yup, yup. And that particular app is called a concussion recognition and response coach and parent edition.

Dr. Jason Mihalik: Correct.

Dr. Mike Patrick: All right. And we'll put links to all those things in the show notes. So folks can find it easily.

17:00

And then tell us about — so that was a sort of consumer focus mom, dad, coach focus app. You also have a concussion app that's really more focus on the medical professional. Tell us about that.

Dr. Jason Mihalik: So the medical professional version, the concussion assessment and response sport version is an extension of the parent-coach. So there's a lot of similarities in the sense that it guides the medical professional through whether or not the mechanism of injury occur, what signs and symptoms were, and those are very consistent across both apps which added to the provider base one is from an emergency care standpoint. So walks them through a primary survey of essentially evaluating whether or not the athlete loss consciousness, checking your way breathing those kinds of thing if it is a catastrophic event and life saving techniques are required then it actually prompt them through, it could be a very stressful time for those medical profession, so there's actual timing queue and steps on how to do CPR and do it correctly.

If the athlete is relatively fine and can be remove from the field, there's a detailed walk through, kind of a cranial nerve evaluations and inform the clinical standpoints some of the things that are being done here at Nationwide Children's with doing the balance or scoring system and a standardized assessment or concussion. Those are built in to the app and it also has a function of completing process and baseline so the data are available of what the kid look like before the injury and then we could evaluate them post injury and make those comparisons.

18: 26

Dr. Mike Patrick: Sure. So this is the neurocognitive testing that I have mentioned and entered to the program. So, basically testing to see how your brain works, would that be through balance and exercise and asking questions in terms of orientation and how quickly do you answer questions and things like that and so the ideas if you do a baseline and get a score for particular athlete and then following a head injury, and you do it again and kind of compared what their baseline is and that could help you decide when they're ready to return to play.

Dr. Jason Mihalik: It can certainly help inform the clinical evaluation which really is a paramount. None of this apps or computer test replaced human position interaction with the patient. But yeah, that's essentially the promise of the baseline post injury type comparisons.

19:10

Dr. Mike Patrick: And then this particular app that's aim more toward the medical professional is concussion assessment and response sport version and that one is also available in the iTunes store and Google play. We'll put links to all those places in the show notes as well, so folks can find them easily. So, how did you become interested in designing mobile apps?

Dr. Jason Mihalik: I've always been a techie so working with technology is always been something of interest to me. Dr. Gioia approached me in here worked with psychological assessment resources which is the publisher of these apps on a number of other pediatric neurocognitive test in the past and so you know I just kind of work together, a couple — some content and work with the programmers to get a product that would be useful for the parent and coach.

20:00

The end goal of the consumer version was we were tired of the game of telephone. We were tired of a coach telling a kid who's inherently symptomatic and has memory problems following a concussion to tell their parent how they felt the time of injury. Six days later I've seen them in clinic and the parent trying to recount to us what their child with memory problems told them they felt six days earlier and so with the app we can get that, that information could be emailed, it could be stored so now the physician is looking at the kid knowing the information that occurred at the time of the injury without this game and telephone where the information gets lost, long away.

Dr. Mike Patrick:   Yeah, absolutely, I think it's just a great thing and really applaud you for the effort. So let's kind of focus back in concussions themselves, Dr. Pommering had mentioned that there something going on at the cellular tissue level in the brain with the concussion, Dr. Mihalik as a sport scientist what exactly is happening at the cellular level that cause the symptoms of concussion?

21:00

Dr. Jason Mihalik:   To put it in very simplistic terms the brain is in the frenzy, the brain just as not working right the wiring is hay-wire so to speak, so things still work, memories still works, balance still works but not as well as it used to. And that's because the conduits, the information processing wires essentially that connect the areas of the brain that control those functions aren't working efficiently anymore.

And at the cellular level we see metabolic changes that occur, we see ionic cascades, there is a notion of the neurometabolic cascade that occurs where there's a sudden influx of calcium and other ion into the brain and there's a concurrent decrease sensory with the blood flow and like any tissue in the body the brain needs oxygen to recover and repair itself so during this period of time where the brain is in the frenzy and really going into the hyper drive, we see a decrease in blood flow which prevents that amount of oxygen that's require to heal and it's a mechanism we still don't fully understand and if we did we'd be having a much different interview today.

22:07

Dr. Mike Patrick: So there's really lots of chemicals and reactions and pathways going on in the brain and just that shaking is I mean if you think of the brain being kind of a consistency of jell-o and if it's bouncing around inside the skull those chemicals are going to get messed up.

Dr. Jason Mihalik: Absolutely and you know, I like in it to normally we drive the inter-state and every now and then there's construction and it slows us down and every now and then we think we could detour that and take the side road and that even makes you even slower and that essentially is what concussion is we have these interstates that are very functional, people are processing information and they're working well and then all sudden there's this injury inside, how do we work around that area and that's what slows people down, that's what diminishes their performance.

Dr. Mike Patrick: And Dr. Pommering, what, because of this what sort of symptoms then do we see from a behavioral stand point or from the symptom stand point when we have these pathways being messed up? What do we see clinically?

23:05

Dr. Thomas Pommering:: Yes, so as Jason describe this cascade causes a huge energy deficit in the brain and it takes time to restore the brain function slowly so people will have headaches, they'll be maybe confused, they might be delayed in their answers, they might have that faraway look, they can have dizziness, we talked about balance a little bit, they can have sleep disturbance, they can have trouble remembering things, they might ask the same questions over and over in the acute setting, they even may have difficulty in walking or standing up. So there's a pretty wide variety of symptoms and they can fall under sort of physical symptoms such as headache, to emotional symptoms such as crying, depression, anxiety later on it can be sleep disturbance and then there's a remain categories.

Dr. Mike Patrick: Sure, and then that's kind of a short term, do we see more long term effects from concussion?

Dr. Thomas Pommering:: Luckily we don't as much as you might think, but when we do see on long term effects they tend to be more in the range of cognitive difficulties, you know, sometimes kids go back and they can't perform as well at school that they used to or certain more complex tasks such as math or higher level comprehension if they have trouble getting that back, but usually do overtime.

24:18

The other thing that sometimes happen is, if kids come in to this injury was a pre-existing problems, you know, whether it's depression, anxiety, or pre-existing learning disorder or even chronic headaches, those things can be accentuated after the concussion, so again luckily, most kids probably 90% of the kids with the energy level that's involve with sports concussions or recover eventually completely.

Dr. Mike Patrick: Sure, and Dr. Mihalik, the concussion apps that you have really make use of these symptoms I mean this are the kind of questions that where his parents are going through the checklist they're going to be ask about.

25:00

Dr. Jason Mihalik: Absolutely, the terminology that we might use in the medical facilities very different than terminology that's use in the app for that reason, things like photophobia… it's sensitivity to the light isn't referred to its photophobia because no one would know that men and the lay-public and so then we use common words like "are they sensitive to light, are they having a hard time where memory events after the events… so we're not using words like "retrograde and anterograde amnesia… whereas in the medical facility those are the words we used because that's a training we had.

Dr. Mike Patrick: Yes, absolutely, that's great, Dr. Pommering so, how are concussions treated?

Dr. Thomas Pommering:: Yeah the mainstay of treatment right now is physical and cognitive rest. In other words, the brain is not functioning so well that highway is moving so slowly and we want kids, we don't want to really ask them to do a lot of their brains at first. So we'll shut them down if need be from school, if they can't really function's from school there's no reason to be there and have their head on the desk or be in the nurses office all day, but we also try to limit their screen time in the beginning so things that they live and for in love, I wish to tell my patient I'm going to turn you into a monk for a few days, so we take away their computer screens, their video games and TV at first, especially if they're making their symptoms worst.

If they are having light sensitivity or just a stimulation just from all the screen type can make them worst and we want to make sure they are hydrated and resting well and we will treat symptoms if there's significant enough and they're really affecting their daily life but for a lot of kids it's just taking them away from that stimulation, giving them a chance to heal up.

26:24

Dr. Mike Patrick: Yeah, now, taking that stimulation away, does that help the concussions symptoms get better faster?

Dr. Thomas Pommering:: We'd like to think so, I mean I think, you know, kids are not a hundred percent compliant with staying off their video games but well they often go commit and say like try and play some games and made me really dizzier, made my head hurt but you know we like to think that taking this out of the equation will help them heal up a little quicker.

Dr. Mike Patrick: Sure, and then there's also the fear that if they continue their activity that they could get a second concussion on top of the first concussion and that's a particularly dangerous situation?

Dr. Thomas Pommering:: Yeah, they're definitely more susceptible for period of time after their first concussion, how long is really not clear and I think you're alluding to which is a really rare phenomenon which isn't well understood as second impact syndrome and that most of these are case reports but we think happen is in certain susceptible individuals and we don't know how to predict pseudo folks, are going to be unfortunately, but they do by enlarge end up being a young athletes under the age of 18 or most of the case reports come in.

23:25

They sustained another injury to the brain and it doesn't have to be a big hit, while they're still healing, while that cascade is repairing itself if in some patients for some reason they can go through a very rapid process blood as L.A.D. enter the brain but can't get it out and that's a detrimental situation for the brain because it swells and it's in a nice hard case called a skull and half of time these kids will, it'll be a fatal injury within just a few minutes, now luckily this is a rare phenomenon and obviously devastating to family and a community but we just don't know how to predict who is at risk with this new (27:58)

28:00

Dr. Mike Patrick: Sure so that's one reason to absolutely have that period of an inactivity following a concussion but also if kids are thinking more slowly then they're not going to be performing at their best and then that in it of itself can make them more likely to have another head injury.

Dr. Thomas Pommering:: Yeah absolutely.

Dr. Mike Patrick: So how long really do concussion symptoms last? I know this is the million dollar question and this is what you know, what kids want to know; "When can I get back out there?… parents want to know when of this headaches going to go away, what's a good idea for this?

Dr. Thomas Pommering:: Yeah this is the ultimate question that we try to tell our emergency providers not to give them a number because we just really don't know what's really bearable for each person but for most of a younger athletes, you know, they're usually back on the field safe in returning to play within a few weeks, two or three weeks, but everybody certainly is very different in our whole.

Our saying is if you've seen one concussion, you've seen one concussion and even within the same athletes sustaining a second concussion it can't be completely different from the first, it doesn't nearly end up being worst or better so we really need to treat this on an individual basis and you know rest them, follow them and when there's symptoms are completely resolved 100% for at least a day and sometimes longer if their courses been complicated then we can start talking about a return to play plan.

29:17

Dr. Mike Patrick: So there's really two prongs to these and I think this is why you want someone managing it who knows about concussions in student athletes so I mean one of it is when can they go back and how do they go about giving an accredit back in the play because it is not an immediate, you do what exactly what you're doing before, once you do go back?

Dr. Thomas Pommering:: Yeah absolutely, I think if you hit load in these things oh it'll be about a week, they will hold you to that day, into the minutes, you'll get phone call at noon on Friday, you know why they can't go back and I think the other important big part of treating this patients as education, you know Jason is achieving that through the work that they are doing but you really need to have that parent and a coach and athletic training staff and everyone involve with this on the same page in terms of what you're trying to accomplishing, what its stake and what the goals are.

30:04

Dr. Mike Patrick: Yeah, absolutely. And I think that the fact that some kids were going back too soon was really the input found behind Ohio coming out with concussion law this past April, which really just sort of spells out that kids do need clearance from a physician and there's some interpretation issues and were certainly not going to get in to the legal aspect of it.

I am going to put a link in the show notes for frequently asked question page that the hospital put together and so that folks can look at that. And then I think that in that document there's a link to the actual law so you can read it for yourself. But I think from a parents and the coaches' standpoint, the main thing is this, you want this whole process manage by someone who knows what they're doing, who has some experienced in dealing with student athletes who are concussed.

Dr. Thomas Pommering:: Yeah, absolutely I think you have to understand that researchers show that half of the athlete who have concussion won't report their concussion for various reasons. So it is not always intentional, sometimes they're just our educator or don't know that this is a concussion. So, you know building that report, knowing what to ask, understanding what their demands are in terms of going back to their sports are really helps you to keep their kids best interest of mind.

Dr. Jason Mihalik: I can just add to that it also requires a change in nomenclature, so the you know the air referring to this is ding or bell ringers should be a thought of the past. The far past, we need to be starting to address this as concussion or brain injury which is really what it is. I'll give you an example; I was covering an event at a hockey term. Youth hockey term and one of opposing team players when head first in to the board and lay motionless on the ices, and of course that hockey coach run out usually just a parent volunteer and so I approach the official and said if you can skid over let them know I'm a certified athletic trainer, I'd be more than happy to come around the ice and assist.

And the official just stood there and said "oh no he just got his bell rang… and I looked and I said you realize that's a brain injury, and he said "let's go in the ice… and he brought me in the ice but it's just that one little subtle change nomenclature that made him address that in a very different way.

32:09

Dr. Mike Patrick: Yeah, yeah. And I think that's an important point that sometimes we just shrug this stuff off but to determine and as we're finding out more and more, you know with this cases that didn't help players and ex-college athletes who are having more cognitive problems down the road that seems to be related to multiple concussions. So Dr. Mihalik, we talked this one prong is when can a student athlete get back out on to the activity but then we don't want to just thrown after this, this is return to play progression. Describe what we mean by that?

Dr. Jason Mihalik: So standard return of play progression, if all things go well should last in the five to six day round. And what we want to do is we want to gradually return an athlete to a high level of competition so that we can monitor their progress throughout that course of return.

33:00

So for example, when their symptoms clear and they're symptom free with rest, with very mild exertion cognitive task then we start this return to play progression. And the first step might just be very light aerobic activity. Can they run on treadmill, or ride a bike for 20 minutes without exacerbating symptoms. And if so, then the next day 24 hours later we will progress to the next stage which is more moderate intensity aerobic activities and obviously we want to progress them back to sports specific.

So we want to maybe get him back to practice whether non-contact but they're now in the environment of their support. On the fourth day it might be a non-contact practice; fifth day might be contact practice and then ultimately a full return to competition. And the key here is to do those steps in very measured progressive ways so that we can wait 24 hours and see if that exercise or that level of intensity exacerbated any other symptoms because sometimes we won't see it immediately, we'll see it 10, 12, 13 hours or sometimes the next day. So we're able to walk them to that progression.

34:02

Dr. Thomas Pommering:: And I think it might give important to realize that this aren't Jason's rules, this is a National Standard that we're currently using whether you're youth athlete or lead athlete. And the young athlete's we sometimes we even extend that progression a little bit hanging on how much, how effective they were, how long their recovery was. So that's sort of the quickest path to recovery. Parents need to understand there are young athlete that's taking a while to get better, we might make him stay at a certain stage for more than one day.

Dr. Mike Patrick: Yeah and I think the fact that we do it across the board for one you know it's the safest thing for everyone since we don't know, you know who is going to have that second impact syndrome and we also don't want to put them at risk for further injury because they're not ready to do it yet. But the other thing is that kids get very emotional about this, I mean the fact — often times it's not their symptoms of their concussions that make him cry in the exam room, it's the fact that you've just said that they can't play until you know, have rested and see a doctor and they've said you can return.

35:03

And that seems to upset a lot of kids more and so if you have some kids who can go right back out another kids who can't and it doesn't seem fair and I think that you know, then that makes the parents job harder you know, saying "oh we're going to follow the advice of the medical community and wait….

Dr. Thomas Pommering:: You know I think it help so following the same plan. There are still consistencies there, parents can recognize that, you know they're still going to a process.

Dr. Mike Patrick: This return to play progression, this is something that parents and coaches can kind of go through — I don't suspect that you want necessarily the student athlete to be seen doctor who's managing their concussion between each of these stages every couple of days, right?

Dr. Jason Mihalik: Well, that will depend on the physician and the case. But for the most part what we see in North Carolina or that physician's will sign of her care at that, because at that point there something for you and the physician you should have some level of confidence that they're OK to resume activity at a lesser extent of course. And so those sign of her care to the athletic trainer to school to monitor that day to day because there's that direct discussion between the physician and the athletic trainer.

36:10

If there isn't an athletic trainer then it becomes a more serious conversation, maybe it isn't more conservative approach to say let's go through this, next two faces and come back and see me in three or four days. And so that would be told at the discussion of the physician managing that care.

Dr. Mike Patrick: And then this is where the app also comes in handy because really the return to play progression through five stages is really spilled out in the app, soon to make a pretty easy to follow.

Dr. Jason Mihalik: It is and the app also has the option of tracking the symptoms and so then physician might say "we're doing stage 1 today,… so do stage 1 and tomorrow do symptom inventory and email it to me because that's the feature that's in the app. And so maybe that the way to do kind of telemedicine kind of care for that period of time cause remember that if an athlete has been authorized to start this return to play progression they're outside of that danger zone.

Right, the physician has some level of confidence that the concussion is healed to a certain extent but we need time to get that athlete back to where they were before, much like any other orthopedic injury, we never teach someone how to sprain an ankle and a swelling went down on Saturday night, they play game Sunday, their dysfunctional rehab that we do with them. We do balance training, we do proprioception, we haven't kicked his off at the ballroom practice. We do these things with any other injury. So we should do them with brain injury as well.

37:26

Dr. Mike Patrick: Yup, absolutely. Dr. Pommering, we've talked about head injuries and concussions and what you do for him. It's really best to prevent a concussion, right? So what are some things that student athletes can do and parents and coaches to prevent concussion from happening in the first place?

Dr. Thomas Pommering:: Yeah, this is an area where still learning and developing. I think, your parents ask a certain questions, I guess there's one helmet I should get. I heard about this x, y, z helmet that cause 450 dollars and prevents concussion and unfortunately you know, the data keeps coming out is just not showing you know one specific brand is well above any other.

38:05

So I think in terms of just sports were to use a helmet. It's important to keep the helmet in good shape, make sure they get recondition on a regular basis. Make sure they fit if they have air bladders and you just stay pop up, high school kids are famous for not coming to the athletic trainer often enough to get some air put in to their helmet. Make sure that chins wraps are staying on. Just make sure that your equipments it fits well as in good repair.

As far as other things that parents are being bombarded with from the commercial standpoint news, special extra padding on the helmet and mouth guards and other external devices just having been rigorously tested enough for us to say this will prevent a concussion and really, you know a lot of concussion susceptibility comes from the athlete itself and not the equipment they're wearing. I know Jason has anything to add to that.

Dr. Jason Mihalik: Yeah, if I can add a lot parent think how much can prevent concussion and to a certain extent they can cause they diminish some of the forces and they mitigate those forces but the design of the helmet and the standards that they have to meet are for two things: keep the athlete alive, keep them recoverable.

And concussions don't kill athletes, mismanagement of concussion is very rare cases like but the reality is the helmet is design to prevent those skull fracture and those brain bleed and the things that could kill your child and that's why we went from 50 and 60 that's the year in football to less than four because the helmet do really good job of that.

39:19

Dr. Mike Patrick: Yeah, absolutely. So we really plugged Dr. Mihalik's apps here and I think that they're good there, absolutely great. There's one of the thing I want to plug and that is the sports medicine concussion clinic here at Nationwide Children's Hospital. Dr. Pommering if you could just tell folks what the concussion clinic is about.

Dr. Thomas Pommering:: Yeah, so this concussion clinic really arose out of a need. You know we have young athletes participating in sports all year round, getting concussed and not having good resources to get in too quickly.

So we operate anywhere from 12 to 15 concussion clinics per week, every day of the week at various locations, actually five across the Columbus area and what will happen is we asked young athlete comes in will be evaluated by a sports medicine physician who's comfortable and experience with concussion and in fact the whole treating team has concussion experts.

40:12

And we'll make sure that they get evaluated with some of the different tools we talked about today to see where they are and then to treat their symptoms and monitor them and guide you to return to play. You know I think, this is important resource for patient because we'll make sure that we keep your child's best interest in life.

Dr. Mike Patrick: Absolutely. It's easy for folks to get in touch just like we do with each of our episodes where we interview one of our specialists. There will be a link on the show note that says "Connect Now… with the sports medicine specialist over PediaCast.org and basically if you click that link it will take you to the welcome center and it's just a page where parents can put in their information and then someone from the sports medicine program will get back in touch with the parents in terms of scheduling an appointment or helping them with the referral if a referral is necessary from their primary doctor just to really help you get plugged in. So yup, we'll put that link in there for you.

41:05

And Dr. Mihalik one more time let moms and dads know where they can find your app?

Dr. Jason Mihalik: So, it's available in the iTunes store and in Google Play.

Dr. Mike Patrick: Great. And we'll put on links — actually I think we have the largest number of links of any episode I've ever done. So we have all the I heart radio links so for web, iPhone, android, the PediaCast page and I heart radio talk. The Pediabites page and I heart radio talk. The sports medicine clinic here at Nationwide Children's. The apps that we talked about both in iTunes and in Google play both versions and both places I've links to all of that.

And we have some great concussion resources from Nationwide Children's to tell you about. We have a concussion toolkit and that includes downloadable guides for athletes, parents, coaches, educators, school administrators and that's a different guide for each of those groups of people really aimed at their role in dealing with the student athlete who has a concussion. So definitely check out the concussion toolkit.

42:04

We also have frequently asked questions on neurocognitive testing answered by sports medicine specialist so have that, signs and symptoms of concussions, Ohio's concussion law, frequently asked questions about that and then within that there's a link to the actual what.

So, Dr. Mihalik, is there a similar law in North Carolina?

Dr. Jason Mihalik: There is in fact it's a named in part after Matthew Gfeller, it's the Gfeller-Waller Concussion Awareness Act and it was signed in July couple years ago. We've had some growing pains with it as well but we are — the unique thing about the law in North Carolina is not only concussion focus but it also requires every public high school in Middle School to have an established emergency action plan specific for each venue they participate and if the school has an athletic trainer that athletic trainer bets those emergency action plan and approves them and if the school doesn't they can send those EAPs towards State Athletic Trainers Association and a Committee there looks those over.

43:00

So, it's not just the concussion, we're also worry about the sudden cardiac arrest and the other heat stroke and other emergency scenarios and having appropriate emergency response in those situation.

Dr. Thomas Pommering:: That's great and I know we really have folks who listen to these programs in all 50 states and so this is just one example, Ohio has just recently done this. North Carolina's had it a little while but you could find out about your state wherever you are to see if there is any laws that deals with student athletes with concussions in particular and if you don't, you know this may be a nice grassroots effort for you to start as a PediaCast listener to contact your state representative and your state senator and they can look up laws in other states and you know maybe come up with something in a state that it doesn't have anything right now.

Dr. Mike Patrick: All right we appreciate both of you stopping by, really appreciate it.

Dr. Jason Mihalik: Thank you, it's my pleasure.

Dr. Thomas Pommering:: Thanks, Mike.

Dr. Mike Patrick: All right we're going to take a quick break and I'll be back with the final word, right after this.

[Music]

44:30

Dr. Mike Patrick: All right my final word this week is really just a reminder be sure to check out PediaCast on I heart radio talk, it's an easy way to connect with the show. Also check out our Pediabites again those are going to be 5 to 10 minutes segments on a single topic and those are also available at I heart radio talk that is the only place right now but they're available and you can add those to you daily post. In that way, PediaCast gets to meet together with your other favorite talk shows and infuse with your local news traffic and weather. So PediaCast and Pediabites on I heart radio talk be sure to check them out and that's my final word.

45:05

Well I thank all of you for taking time at your day for listening. We really appreciate you tuning in and being part of the show. Also thanks to Dr. Thomas Pommering, Chief of Sports Medicine here at Nationwide Children's and Dr. Jason Mihalik from the Department of Exercise and Sports Science at the University of North Carolina at Chapel Hill.

Don't forget iTunes reviews are helpful as our links mentions, shares, retweet, repins, and all your social media sites. PediaCast is on Facebook, tweeter, Google plus and Pinterest and be sure to tell you families, friends, neighbors and co-workers about the show. Also tell your child's doctor, so next time you're in for a sick office visit or well-child check just let them know that there is an evidence based pediatric podcast in moms and dads so in language they can understand but we still go deep into the issues and talk about the science just to make it understandable and posters are also available under the resources tab at PediaCast.org, so they can tell their other patients about the show.

Also if you have a question, topic idea, comment, any of those things you said over the PediaCast.org and click on the contact link and then again there's that "Connect… with a pediatric specialist from Nationwide Children's in the show notes each time which will help get you set up with referrals and appointments to the experts here at our hospital.

46:16

All right again thanks for joining in and until next time, this is Dr. Mike, saying stay safe, stay healthy and stay involved with your kids. So long everybody.

[Music]
Announcer: This program is a production of Nationwide Children's. Thanks for listening! We'll see you next time on PediaCast.

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