Concussion Recovery and Return to Play – PediaCast 501

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  • Just in time for the fall sports season, Dr Steven Cuff and Ashley Davidson visit the studio for a chat on concussion recovery and return to play. We explore symptoms, diagnosis and treatment… and guidelines for returning student athletes to the classroom and playing field. We hope you can join us!

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  • Concussion Recovery
  • Return to Play

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Announcer 1: This is PediaCast.

 

[Music]

 

Announcer 2: 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 is a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from Nationwide Children's Hospital. We're in Columbus, Ohio.

 

It's Episode 501 for September 2nd, 2021. We're calling this one "Concussion Recovery and Return to Play". I want to welcome all of you to the program.

 

So last week, we celebrated our 500th episode of PediaCast by opening the archive and sharing some of our best interviews, including ones on food ingredients, the history of the anti-vaccine movement, and seizures in kids.

 

0:01:11

 

Today, we begin the journey of our next 500 episodes covering a topic that we have covered several times in the past. But like all of our recurring topics, we bring it up again and again because it is extremely important. And it's one of those things where if you haven't thought about it in a while, or it has never actually happened to your family yet, then you probably don't have all the details and recommendations within your grasp.

 

And yet, when this condition does come knocking on your family's door, it's best to be prepared ahead of time rather than scrambling to figure out what to do after the fact.

 

This week, our recurring topic is concussions, and in particular, concussions in student athletes. And we're covering them now because school is underway in most places. The Fall sports season is kicking off and we're all a little rusty in dealing with concussions because for most of us, we haven't had to think about them in a fairly long time. Thanks to a pause in many school-sponsored sports programs, courtesy of the COVID-19 pandemic.

 

0:02:19

 

So in order to freshen our memories and prepare us for a concussion that hits close to home, couldn't resist that one, we will cover concussions today in considerable detail, including their definition, what exactly is happening inside the brain when concussion occurs, the signs and symptoms of concussion, how they're diagnosed and treated, how long can we expect symptoms to last, and what to do if the symptoms linger and last longer than expected. And then, we'll cover the return to the classroom and physical activity, and finally, return to full active sports participation.

 

It turns out there are evidence-based guidelines for all these returns after a concussion. The question is are your schools and coaches following the guidelines? Stick around to find out.

 

0:03:07

 

And of course, in our usual PediaCast fashion, we have two terrific guests joining us in the studio, two veterans of the podcast, as it turns out. Dr. Steven Cuff, he is a sports medicine physician, and Ashley Davidson, a certified athletic trainer, both with Nationwide Children's Hospital.

 

Before we get to them, let's cover our quick reminders. Don't forget, you can find PediaCast wherever podcasts are found. We are in the Apple and Google Podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music and most other podcast apps for iOS and Android. If you like what you hear, please remember to subscribe to our show so you don't miss an episode.

 

Also, please consider leaving a review wherever you listen to podcasts, so that others who come along looking for evidence-based child health and parenting information will know what to expect.

 

We're also on social media. We love connecting with you there. You'll find us on Facebook, Twitter, LinkedIn, and Instagram. Simply search for PediaCast.

 

0:04:04

 

And then, there's that Contact link over at pediacast.org. Please do use that if you would like to suggest a future topic for the program.

 

Also, I want to remind you the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your healthcare provider.

 

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at pediacast.org.

 

So, let's take a quick break. We'll get Dr. Steven Cuff and Ashley Davidson connected to the studio. And then, we will be back to chat about concussion recovery and return to play. That's coming up right after this.

 

[Music]

 

0:05:16

 

Dr. Mike Patrick: Dr. Steven Cuff is an associate professor of Pediatrics at the Ohio State University College of Medicine and a sports medicine physician at Nationwide Children's Hospital. He has a particular interest in helping student athletes overcome sports related head injuries and serves as co-director of the Nationwide Children's Sports Concussion Program.

 

Ashley Davidson is a certified athletic trainer with Sports Medicine and Functional Rehabilitation, also at Nationwide Children's. She too has a passion for helping the student athletes and their families recover from concussion.

 

That's what they're here to talk about, concussions and returning to play after one occurs. But first, let's give a warm PediaCast welcome to our veteran guests, both have been on the show multiple times including just a few weeks ago when Ashley was here to talk about the Olympics.

 

So, let's say hello to our friends, Dr. Steven Cuff and Ashley Davidson. Thank you both so much for stopping by today.

 

Ashley Davidson: Thanks for having us again, Dr. Mike.

 

Dr. Steven Cuff: Good to see you, Mike.

 

0:06:07

 

Dr. Mike Patrick: Let's get right into it. I think it is a pretty good time to talk about concussions because school's back in session. Fall sports, hopefully, will return to a more normal season this year, maybe. Certainly, normal compared to last year, but maybe not quite normal normal. But we really took a year off from concussions.

 

So, I think it'll be helpful to think about and be reminded how we get from concussion to back on the playing field and what that process looks like.

 

So, let's start with the definitions, Ashley, remind us what we mean when we use the term concussion? What exactly is that?

 

Ashley Davidson: So concussion is an injury to the brain, so usually caused by like a direct blow to the head, face, neck or elsewhere on the body, which that impulse of force, once they are struck is transmitted then up to head. And so, it can cause like rapid onset of short-lived neurological impairment that kind of varies from athlete or individual.

 

0:07:11

 

And then, a lot of times, it can resolve spontaneously. But in some cases, they are prolonged symptoms and that require a little bit more care to help resolve.

 

Dr. Mike Patrick: So, this is a functional injury, meaning that the brain is not functioning correctly. But if you were to get CAT scan or an MRI or some imaging, everything is going to look okay at the big picture level.

 

So, Dr. Cuff, what happens really to the brain when concussion occurs? How do we get this functional impairment?

 

Dr. Steven Cuff: Yeah, it's a great point you made, Mike. I think that's one of the big misconceptions of concussion. It's a lot of people think of it as a structural injury, like a bruise to the brain. But as you mentioned, it's much more of a functional injury.

 

So, when you have that force, and as Ashley said, most of the time it's a direct blow to the head. But it can also be a transmitted force from like a whiplash injury, a car accident, or taking a charge in basketball or even like a body checking in hockey.

 

0:08:09

 

And when that happens, when the brain moves quickly, and so it's generally accelerational, decelerational, rotational forces on the brain that cause a concussion. It basically changes the way that some of the electrolytes like calcium, potassium moving out of the cells of the brain. And then, there's basically an energy crisis. Your brain's using a lot more energy than it normally would.

 

Paradoxically, blood flow of the brain is decreased for a period of times, so those at mismatch. And then you see some short-term cognitive effects, as Ashley mentioned.

 

Dr. Mike Patrick: Yeah, let's explore those symptoms. So, once we have a head injury, what kind of signs and symptoms can parents expect then? As providers, what are we looking for when we are going to diagnose a concussion? So, what set of symptoms constitutes a concussion in student athletes?

 

0:09:00

 

Dr. Steven Cuff: So, I like to think of concussion symptoms, and there's a lot of ways to group them, but the parietal foramen, one of the physical symptoms, headache by far is the most common thing that we see. Also, like sensitivity, sensitivity to noise, dizziness, sometimes nausea, sometimes some vision problems.

 

And then, you got our cognitive symptoms. So most classically, trouble focusing or concentrating, difficulty remembering. You can also have emotional symptoms. A lot of patients have described this, feeling more irritable or more emotional than normal.

 

And then, finally, sleep disturbance. So, most people find that they're tired, fatigued, they sleep more than normal. Although some patients, after concussion have difficulty falling asleep or staying asleep.

 

Dr. Mike Patrick: The cognitive one, when I see kids immediately after head injury and they have kinds of those early first few hours of a concussion, a lot of times, that's what… You kind of expect the headache when you get hit in the head. But that whole kind of being slower to respond and maybe not your happy normal joking self.

 

0:10:07

 

So, you really see a behavior change in kids and just sort of that slowdown in behavior. And even when you ask them a question, you can see they're thinking about it little extra-long before they answer the question. That's a pretty common symptoms to see in the initial stages, right?

 

Dr. Steven Cuff: It is and that can be very concerning. I think, the parents, a lot of times, when they see their child having difficulty just speaking normally, they're repeating themselves. They don't necessarily understand questions. So, we really remind them that this is something that's going to get better. But also, I think it helps reinforce that this is brain injury and isn't just a headache from getting hit.

 

Dr. Mike Patrick: Now, when I see kids in the urgent care and emergency department, one of the first things that parents ask is, "Do they need a CAT scan?" And of course, scans that involve radiation have their own risk. And so, we have to think about risk versus benefits and that neurological exam, and do they have a severe headache?

 

0:11:05

 

A lot of these concussion kids, it's mild or moderate headache. But like migraine headache, "Worst headache of my life," or multiple episodes of vomiting and of course, any abnormalities on a neuro exam that physician or athletic trainer performs would be a concern and rise to the level of getting imaging. But for the vast majority of these kids, that's not necessary, correct?

 

Dr. Steven Cuff: Absolutely. And I think our hospital does a great job of teasing out those few cases that may need some further imaging. I always explain to parents too, because a lot of times, parents are frustrated if they don't get imaging. They want that. 

 

They don't understand that you can make the diagnosis and you do make the diagnosis without imaging. So, I think it's helpful to explain to them that a concussion is a clinical diagnosis and basically trauma to the brain. And then it needs typical signs and symptoms that we see afterwards. And that's where a concussion, CT scan, MRI, things like that, they're not going to be helpful making that diagnosis. And as you mentioned, can be harmful because of radiation in the case of a CAT scan.

 

0:12:07

 

Ashley, how long can we expect these set of symptoms to last in the individual student athlete?

 

Ashley Davidson: So according to research, overall, these years of concussions that we've been seeing and treating, typically that what you're going to see is about two to four weeks for those symptoms to subside and resolve and those athletes to be able to return back to the normal day-to-day activities or sports specific activities once they are clear from a physician or healthcare provider.

 

But in some cases, these symptoms can be prolonged, post-concussion related symptoms that they might be having for more than four weeks. It's usually like what you kind of term those prolonged symptoms, anything beyond that, to then might need to require a little bit more of a multidisciplinary approach of treatment.

 

Just to kind of see if there's anything else that might be contributing to any of the lag and recovery of some of the symptoms that they may still be experiencing.

 

0:13:11

 

Dr. Mike Patrick: So, your straightforward simple concussion that heals up, as we would expect it to heal up usually about two to four weeks with those symptoms, kind of waxing and waning. But there's no cookie cutter concussion, right? Because each person's body sort of responds a little bit differently or heals at a different rate.

 

And so, there is some individuality in terms of we have to think about the extent of the injury, the location of it, the severity and the individual's response. So, it really can be quite different from one child to another.

 

However, what's not different is how we approach treatment of concussions and their symptoms, especially in this immediate period. We'll get to talking about complex concussions and symptoms that linger in a few minutes. But for those simple straightforward concussions, we're in that two to four-week period.

 

Steve, how do we go about treating those?

 

0:14:05

 

Dr. Steven Cuff: I think it all starts with education, explaining what the injury is, what they can expect. As you mentioned that recovery can be quite variable, they shouldn't get frustrated if they're not feeling back to normal in a couple of days.

 

And then, really, it's basically modifying activity. Traditionally, the teaching was you have a concussion, you need to rest physically, mentally till your symptoms are gone. And we know now from research over the last decade or two that that's not the case.

 

Certainly, in the first 24 to 48 hours, it is important to lay low and take it easy. But beyond that, we do want kids starting to get back in the more normal routines and going to school during the school year, trying to do some light exercise, light exertion and even just as simple as walking to get that blood flowing.

 

As I mentioned, we talked about what happens in the brain with the concussion, there's a decrease in cerebral blood flow initially. And so, you can start to get that blood movement again, that can help kids recover a little bit faster.

 

0:15:09

 

And there's obviously a lot of things that we can do to help with school and providing guidance. And so, we're going to send the kid who's got a bunch of symptoms back to school and say, "Okay, good luck, have at it." And we have bunch we can give to try and transition them back. But no, it's just not a good idea for kids to sit around and sleep all day and not be around other kids. You can imagine, they get quite bored. They can get frustrated. That can make all of their symptoms a lot worse.

 

Dr. Mike Patrick: Absolutely. We do have some resources that we're going to share in the show notes for this episode, 501, over at pediacast.org. One is the CDC Guideline on Diagnosis and Management of Concussion, which was published in JAMA Pediatrics back in 2018. So, we'll put a link to that.

 

And then, also, the National Athletic Trainers’ Association position statement, Management of Sports Concussion. And we'll put a link to that in the show notes as well so folks can view those at their leisure.

 

0:16:04

 

Ashley, we mentioned briefly about returning to school after concussion. What are the guidelines there? It's a tough call for some families because these kids often do have some symptoms. If you wait for the symptoms to go away completely, it could be two to four weeks. And that's just really going to put kids behind in terms of schoolwork. In-person school is really important for kids.

 

So how do you walk that fine line before letting them rest enough but also getting back in the classroom and getting back to work?

 

Ashley Davidson: You're exactly correct. So, there is that balance. And like what Dr. Cuff was saying, it is good to rest initially, maybe in those first few days, just to kind of let some of those symptoms decrease a little bit or just kind of figure out how they're eventually feeling. Because mental rest important during that initial time period since concussions deal with the brain.

 

And the brain, any type of school work or academic type stuff is going to put a lot of those higher demands because you need to do stuff like focusing and memory, recognition, and concentration, which all of those are typically affected or they're brought up as questions is how they're feeling or how they're improving from their concussion itself.

 

0:17:20

 

So, a lot of times, you can give accommodations, like academic accommodations when they do start going back to school. So, any type of like reading or if they need longer time to take tests or just like half day of work and then go home and rest afterwards.

 

So just easing them back into but you don't want to keep those kids out. Like what you were saying, you don't want to hold them up at home two to four weeks, because a lot of times withholding them from that activity, then they have the stress of missing out on school work, feeling behind, just not getting that consistent type of schedule as far as being awake.

 

So, there's a lot can kind of continue to stockpile up if you hold them up for too long. And if they need those type of forms or all that turns out to be able provide for those teachers or academics, those are all the type of things that can be provided when they're seeing their primary care physicians, sports medicine physician, just to be able to provide for those schools, just to be able to get them a good guidance for the accommodation to returning back to school.

 

0:18:26

 

Dr. Mike Patrick: I feel like this is an area that we have seen significant improvement in terms of the school’s sort of being on board and working with individual families. Because I think like ten years ago, it was sort of a struggle, it was an all or nothing kind of thing. Either they're well enough to be in school and they have to do everything the rest of the class is doing, or they need to stay home.

 

But I think that schools, there's been a lot of education that's taken place. And in school districts where maybe there's still needs to be education, the coaches and the athletic trainers can really go far to help teachers and administrators understand concussion and maybe facilitate and advocate for accommodations that may be needed.

 

0:19:07

 

Have you experienced with that Ashley, or have you talked to other athletic trainers that have been pivotal in helping schools understand the sort of accommodations that these families need?

 

Ashley Davidson: Yes, so within the clinic that I work within Nationwide Children's, as well as just working for all the other high school athletic trainers that are employed here at Nationwide Children's, it seems that there is better communication in regards to all of accommodations that are required and just to kind of really help guide because they said, there wasn't always this great guidance. Researchers definitely helped with all of that and just helping to continue to progress with all that. But communication is always huge, with any type of injury, but especially when concussions can deal with so many types of things.

 

Dr. Mike Patrick: So, getting kids back in the classroom is one thing. Getting them back to their sport is a different thing. And before they can participate in sports again, they really have to slowly ramp up their physical activity. What's the best way to do that and why is a slow ramp up important?

 

0:20:11

 

Ashley Davidson: So, like kind of what we've discussed, everything is you want to pay close attention to how they're feeling as you're progressing or reintroducing something, whether it be, like I said, the schoolwork. But now, once it comes to physical, that can quickly change how they're feeling with all those symptoms. So again, can vary from person to person.

 

So, each person might tolerate activity a little bit differently, but it's always important to kind of start off the same. So very light aerobic activity that is not going to exacerbate their symptoms. Honestly, staying away from any type of contact or anything that can easily come in contact with their head just to kind of not allow that same type of force to be applied. 

 

And then they all should be supervised by either some type of healthcare professional, athletic trainers, the sports medicine physician to see how they're feeling as you're progressing back into that activity.

 

0:21:07

 

And also, to make sure they are back to school, so that at least they're tolerating full days at school before reintroducing them back into gym class or physical activity. Because any type of physical activity is going to increase that heart rate, which then heart rate increasing can elevate blood pressure, your pulse rate, which then can increase headache. That's why you're always want to take it slow so their body can adjust and accommodate to all those new physiological changes in accordance to everything else.

 

But, obviously, any type of guidance, educations they know, not clear what to expect as they're progressing, what to look out for if they're feeling this way, how to scale it back and so forth.

 

Dr. Mike Patrick: One thing I find interesting, that's sort of an aha moment for parents, is that if you start back too soon, some of those other symptoms of concussion that we talked about, so being slower to respond, that equals slower reaction time. Maybe there's not quite as much coordination and balance that there is a baseline.

 

0:22:16

 

Sometimes, you may not make the best decisions, so there may be some judgement issues. And so, because of those things, if they return to their sport too soon, they may have other injuries because they're not the same player they were before the head injury until the concussion is completely healed. And so, they're a little bit more likely to get injured in other ways because they're not really back to being fully engaged with their sport. So, we do worry about other physical injuries as well.

 

How do you know then, Ashley, when a player is ready to return back full participation in their sport?

 

Ashley Davidson: So here, at Nationwide Children's, we have a guided step approach that we kind of put them through which also an athletic trainer at their school should be able to work through them as well. Just kind of supervising as they progress through a little bit high-intensity activity.

 

0:23:09

 

Especially if it's like an acute concussion, you always want to make sure they're able to progress to those steps without increasing those symptoms. As they're going through, as long as they're feeling well, you continue to progress then the next day. But if it's one prolonged symptom. and honestly, you have to take a little bit more guidance, a little bit more education and just really seeing how they're responding to those stepwise progressions.

 

But usually once those symptoms starts to subside, again, you start with those lower work activities. So really want to focus on increasing that heart rate slowly by going on a brisk walk or stationary bike or something, that's not too intensive or resistive for them. And just like easy stretching, and once they can start to tolerate that, you start to increase with body rate resistive movements, change in direction just to kind of get that movement to see how their body and their brain tolerates those quick changes of movements.

 

0:24:07

 

Then you can start to slowly add some resistance, and some like jogging. Usually, once they get through those steps, then you can start to reintroduce some sports specific type stuff, just to really work on that coordination and their comfort with the movement, the reaction time. Obviously, all non-contact at this time until they have fully gone through all the steps and then cleared by that sports medicine physician or neurologist.

 

So, like I said, you're just trying to keep track or checking their symptoms as they continue to increase in intensity. Because once they're back to that then sport-specific activities, there's a lot more demands, a lot more coordination and just everything. And like what you said, you always want to make sure they are strong and good balance, that they're not causing an injury somewhere else. Because concussions affect balance and control.

 

0:25:02

 

So when they're either being seen by their athletic trainer at the high school, or in the clinic with concussion rehab, there's are all the big things to focus on alongside that progression of their heart rate increasing as they can tolerate just to make sure they have good control going back into that sport.

 

Dr. Mike Patrick: Absolutely. And this is such an important thing, that all 50 US states have enacted return-to-play laws that really legislate how this process is supposed to take place. Steve, tell us about Ohio's return-to-play laws.

 

Dr. Steven Cuff: So, there's really two main components of the law. There's the education piece. And then there's a removal from and return-to-play piece.

 

The education part of it basically mandates that any coach, official, parent, athlete receives some type of concussion education. And how that's delivered and how often is variable depending on the age level and if we're talking about scholastic versus youth sport. But everybody needs some kind of education there, which is helpful.

 

0:26:02

 

And then, the other is it requires any athlete who's exhibiting signs, symptoms, behaviors consistent with the concussion be removed from play and not return to play that same day. Or subsequently until they've been evaluated and cleared by a licensed healthcare professional that's been approved by the law in Ohio.

 

Those that can clear independently are physicians, MDs and DOs and then certain chiropractors who have additional training with sports medicine concussion backgrounds. And then ancillary providers, so typically athletic trainers, sometimes physical therapists, they can have the ability to clear athletes if they're working in conjunction with the physician.

 

Dr. Mike Patrick: I'm going to put a link in the show notes to it's called Return to Play. It's Ohio's Youth Concussion Law. So, if you like to see who build the law itself, it was passed back in April of 2013 and became effective in September of 2014. And again, we'll put a link to that in the show notes. Also, the Ohio Medical Clearance Return to Play form that you can print out and have your license provider fill out for you to return your child to play here in the state of Ohio.

 

0:27:07

 

And then, we're also going to have some resources. If you're just looking to find out more information about your state's Return to Play Law and just to verify that your schools and your community are abiding by your state law, there is a site called Mom's Team. And it has a state-by-state account of each concussion law for all 50 US states as we can check that out.

 

And then the CDC has some terrific resources. The HEADS UP Concussion Resource Center, Sports Concussion Policies and Laws, the HEADS UP app for iOS and Android, all from the CDC. I'll put links to all of these things in the show notes so folks can find them easily.

 

Another thing related to concussion that parents have probably heard about is a neurocognitive testing. So, Steve, tell us what that is and how it's use in concussion care.

 

Dr. Steven Cuff: So, there's a couple of different forms, probably what most parent are familiar with when they think of that is the computerized version of neurocognitive testing.

 

0:28:06

 

There's five or six major programs out there.  And what they do is take a look at things like memory, attention, processing speed, reaction time. And they can be done as baseline tests. So, for a lot of the contact sports athletes that we work with, with the schools, we contract with, we'll have these kids take a test before the season. And then, if they have an injury, we come in the clinic, we repeat the test and we can see how they changed from their baseline performance.

 

So those that we don't have a baseline on, there are normative values, based on age that we can compare to and say, "Hey, you look like you're really performing below what we'd expect for your age group and this category."

 

The reason these tests are important, we feel like they can pick up some subtle changes in cognitive functioning that maybe the athlete isn't perceiving, even after their symptoms have resolved. Or it's also a nice check for the athletes who maybe isn't being completely honest about their symptoms because they want to get back to playing.

 

0:29:08

 

This is one other thing that we can look at that's objective, that gives us a sense of how their brain's functioning. There's also more thorough, more involved paper and pencil neurocognitive testing. It can be done via a nurse psychologist and I think that can be done in our Complex Concussion Clinic. We have a neuropsychologist or couple of staff that are there for those kids that may need a little bit more than just the 20- or 30-minute computer test that can really help tease out pre-morbid level of functioning, as well as any changes that may occur since the concussion.

 

Dr. Mike Patrick: The baseline tests, how do families get that done? Where do you go to get a baseline test?

 

Dr. Steven Cuff: So, a lot of it can get it done through their school, maybe offered as part of sports participation. Certainly, at Nationwide, we offer both individual and team testing for athletes who aren't able to get it somewhere else. And we also talk about it with some of our youth sports leagues that we work with, so it's definitely available. You can get in touch with Nationwide Children's Sports Medicine.

 

0:30:12

 

Dr. Mike Patrick: Perfect. And we'll put some links to some resources to the neurocognitive testing in the show notes over at pediacast.org for this episode, 501.

 

So, what if symptoms are taken longer than expected to go away? So, we talked about that two to four-week period. There's a lot of kids that symptoms lingers on and then we really get into what we would call post-concussion syndrome when it's lasting quite a while. What do families do when these symptoms just don't seem to be going away?

 

Dr. Steven Cuff: A lot of times when kids aren't recovering as we would expect, that's when we may involve other colleagues to help. And it depends really on what the symptoms are. So for headaches, generally, we try to stay away from a lot of medication, especially early on because kids can get in the habit of taking too much medicine, ibuprofen, Tylenol, things like  that and then lead to overmedication, headaches or rebound headaches.

 

0:31:05

 

So, we're going to make sure they haven't been doing that, that's not the cause for the prolonged symptoms. But then, there's other things that we can use that can help with that.

 

I think a lot of times when kids are having prolonged symptoms, there's generally some type of underlying psychological problem as well. So, if there's anxiety, if there's depression, we know that that can make concussion symptoms worse and last longer. And there can be overlap, kind of tease out which is which. So, involving a neuropsych colleagues can be helpful.

 

If they're having problems with dizziness, balance problems, blurred vision, nausea, vestibular rehab with the physical therapist can be helpful as well. And then, finally, if they haven't been exercising or if they don't feel comfortable exercising, or they don't know how to progress their exercise without increasing symptoms, that's where Ashley and other athletic trainers can really help or get them out of the program. Or we can monitor their heart rate and try to keep them exercising below that subthreshold level, where we can really increase that exercise over time and allow them to improve.

 

0:32:12

 

And so, the nice thing we've alluded to a couple of times already is, over the last five years or so, developed this Complex Concussion Clinic at Nationwide Children's where they can see all those providers in one. There's a neurologist. There's a neuropsychologist. There's a physical therapist. There's an athletic trainer.

 

As opposed to before, we have to piece meal it out and somebody's already struggling with school, missed a bunch of school and now they have to go through four different appointments a week. So now they can get all of that in one place.

 

Dr. Mike Patrick: We did a podcast on the CME edition of PediaCast, PediaCast CME. It was Episode 63 of Management of Post-Concussion Syndrome. So, it's really geared toward providers and athletic trainers and coaches, but I think it's a good one for parents to listen to as well, especially if your family is impacted by lingering symptoms of concussion. So, I would encourage you to check that one out.

 

0:33:02

 

So, it's really a whole hour of talking just about post-concussion syndrome with our Complex Concussion Clinic teams. So, we had a neurologist and a neuropsychologist on that particular podcast. So, lots of great information there. I'll put a link to it in the show notes over at pediacast.org.

 

Ashley, what then are the long-term consequences of concussion. So, you hear about football players like in NFL and boxers, for instance, who have multiple head injuries. And so, parents, when their kid has a concussion, a lot of times they worry. Is this something that's going to travel with them as they age. What do we say to parents about that?

 

Ashley Davidson: Right. I know over the past few years, with those football players, there is the CTE or the chronic traumatic encephalopathy, fear of like concussions. And although that's rare with things, but that's still something that is a possibility.

 

But a lot of times, if these athletes and individuals aren't recovering properly or having those prolonged symptoms, a lot of times, what you can see is a long-term consequences, memory loss, difficulty concentrating. Which are, again, a lot of times those symptoms that are being asked or being brought up initially but they just don't seem to grow away over time, there can always be like noise sensitivity that can kind of linger as they go through.

 

0:34:26

 

But a big thing like what Dr. Cuff was saying earlier is a lot of times you find like some type of underlying behavioral, or if it is some type of mood disasters, so a lot of times they're more irritable. They have higher anxiety. They start to become depressed. They even show more aggression after these concussions.

 

And then, that just seems to kind of take a little bit longer to then go away. Or maybe that's just the consequence that they're kind of continuing to deal with as they continue to try to recover from these concussions.

 

0:35:02

 

And then, there's also the sleep disturbances, either they have difficulty staying asleep or difficulty falling asleep. So that's why, like what Dr. Cuff was telling us with the Complex Concussion, so they can use multiple providers to really with some of those either mood disturbances, sleep problems, vestibular type things, just to kind of help really offset and just recover fully as best as we can, to really try to hit them from all corners just really offset those symptoms that they're experiencing.

 

Dr. Mike Patrick: Yeah, absolutely. Yes, Steve?

 

Dr. Steven Cuff: So, I think, I know it's important to ascertain time by as far as some of the prolonged symptoms we can see. But I think it's also important to point out that parents especially, there's really no good evidence at this point, that having one or two concussions as a child or an adolescent is going to lead to any long-term repercussions. You talk about CTE in some of the professional athletes. I think even that is very controversial and we could probably a whole hour on that as well at some point.

 

0:36:02

 

But for kids, that's not something that parents should be worried about. It's "Oh, my gosh, my 12-year-old got a concussion. Are they going to have CTE in 40 years?" For a lot of reasons, I think one of which being if that indeed becomes true that there is that link there, we treat concussions so much differently we did a generation ago.

 

A lot of those professional athletes that are having those problems played through an entire season with concussions. They didn't stop when they got a concussion. And we do know that if you got a concussion, then yes, you continue to pound your brain, that's not good. It will cost long-term issues.

 

But we're so much cautious now. There's so much more education out there that really parents should not be concerned about long-term repercussions from one or two concussions. And if they do note, once in a while, we'll see a patient who had a concussion, then they're good to go, they recovered. They came back and now they're struggling with school or something else. And I think the parents always concerned "Oh, could this be related to the concussion they had a couple of years ago?" And almost invariably, it's not.

 

0:37:02

 

It's they started a new school. They're taking more challenge in classes. As Ashley mentioned, maybe there's some underlying depression or something like that. It's very unusual for a child to have any really prolonged effects of a concussion.

 

Dr. Mike Patrick: There are benefits and risks to everything that we do, including whenever we get in the car. It's the benefit of getting some place quickly, but there's always the risk that you’ll be in a car accident. So, we take some risks because the benefits outweigh the risks. And in this case, sports participation, certainly the benefits of that outweigh any risks of possibility of concussion, just when you think of physical activity and being involved with a group of peers in a sporting activity.

 

There's both physical and mental health benefits of sports participation. And so, I would just add for parents who are worried for kids getting head injury, if that does happen, you definitely want to treat properly and follow through and not getting them back to play too quickly and all those things.

 

But certainly, I wouldn't let that just risk of concussions stop your kid from playing in sports. At least that would be my perception of the risk benefit. I'm sure you guys would agree with that.

 

0:38:10

 

Dr. Steven Cuff: Yeah, the ramifications of obesity and diabetes and heart disease are thousand-fold greater than the possibility of getting concussion and having any repercussions from that.

 

Dr. Mike Patrick: Absolutely. Remind us about Concussion Management at Nationwide Children's. I know we've mentioned the Complex Concussion Clinic. I know Sports Medicine runs the Concussion Clinic. I think Physical Medicine may as well. So, what are all the different options, and I'm sure they're all multidisciplinary. So, what sort of team members are involved in concussion care.

 

Dr. Steven Cuff: So, for sports medicine, we staff our clinics with a couple athletic trainers who help take our history, initial history, do some of the cognitive and balance testing. And then, they're seen by a physician. We have concussion clinics all over the city and they are all are at various locations.

 

We already talked about some of the other ancillary providers that we can refer to and then that we're trying to play a piece, which is always best managed by a certified athletic trainer at the school or within our clinics.

 

0:39:12

 

Physical Medicine Rehabilitation also has a handful of concussion clinics at Nationwide. And I believe they staff most, if not all, of their concussion clinics with a neuropsychologist as well and made use some of that more paper and pencil testing for their patients.

 

And we sometimes see a little bit different population. We're generally seeing kids over time through college age, young adults. They'll see some younger kids. We generally are seeing athletes, patients who are athletes or are looking to return to sports or physical activity. Physical rehabilitation, we'll sometimes see more the motor vehicle accidents and things like that, in addition to, so they can see athletes as well.

 

And then, for kids who aren't improving as expected, or maybe they're not presenting to NCH until after a few months, that's where the Complex Concussion Clinic comes in and can really help with those kids with longer lasting symptoms.

 

0:40:07

 

Dr. Mike Patrick: And we'll put links to all of those clinics in the show notes so families can find those easily, again, over at pediacast.org for this episode, 501.

 

Ashley, you are a certified athletic trainer. Tell us about the Athletic Training Program at Nationwide Children's.

 

Ashley Davidson: Yes, so I've been here now for five years. So, I have treated a lot of our athletes that come in through the clinics referred by sports medicine physicians or outside physicians as well. So, we treat muscular skeletal injuries, so more the physical side of things, getting them back to sport safely. And then obviously, prevention of injuries as well.

 

And then like what we're talking about today, also deal with concussion, rehabilitation, so more like dysfunctional, getting back gradually, making sure to kind of adjust with their heart rate and symptoms and safely returning back to sports.

 

So, like I said, we just work on the directions of physicians here within the clinic and then we also communicate to our contracted high school of maybe athletes that they might be seeing out there. And they follow up with us here in clinic.

 

0:41:13

 

Dr. Mike Patrick: When we chatted back before the Olympics, we mentioned the athletic training workshop that our Athletic Training Program puts on. It's designed for high school students interested in athletic training, emergency medicine, nursing, physical therapy, other medical and allied health professions. No experience is necessary. And lots of workshop hands-on stuff and introduction to the field of athletic training, enhancing knowledge, and just hands-on lab.

 

So, it looks really cool. It was canceled last year because of the pandemic. I think it's tentatively going to happen in 2022. But I do have a link to that too in the show notes, so folks want to check that out. And hopefully, it will happen and not be canceled, but everything is still in flux at this point.

 

0:42:03

 

All right, so before we go, Steve, you guys don't just deal with concussions in Sports Medicine. There is just a huge wide range of stuff that you guys take care of, including kids who may have gotten COVID and are looking to return to play. And so, there is this concern about myocarditis and such.

 

So just give us kind of a broad overview of all the different things that you guys do here at Nationwide Children's with regards to sports medicine.

 

Dr. Steven Cuff: Sure. So, we see patients in about nine sites around the city. Majority of what we take care of is muscular skeletal complaints, so knee pains, stress fractures, ankle sprain, back pains, things like that.

 

We have some specialty areas as well. So, a couple of our providers are trained in muscular skeletal point of care ultrasound so they can do both diagnostic and therapeutic ultrasound guided injections.

 

We have an Adaptive Sports Program which Ashley is involved in as the rehab with that. And Jon Napolitano's one of our physician who's DMR trained and helps really grown that Adaptive Program.

 

0:43:12

 

Drew Duerson has started a Golf Medicine Program with one of physical therapist and other athletic trainer for some advanced golf medicine.

 

In addition to all the athletic trainers we employ, we have some sports performance people as well who can help training both in our clinics and out of the schools, strength training and doing it safely and improving sports performance that way.

 

Dr. Mike Patrick: There's so much that you guys do, and we will put a link to your general webpage, Sports Medicine at Nationwide Children's so folks can explore that because there's just so many things.

 

All right, we really appreciate both of you stopping by to talk about concussion. It seems like we talk about every couple of years. It's a really good reminder for families and for us providers too in terms of… Because we get rusty during the off season. I think we're even rustier this year because there was a big lapse in a lot of student athlete activities. So, it's good to refresh ourselves.

 

0:44:19

 

Lots of links in the show notes for you this week. I mentioned them as we went along, just a treasure trove of resources for you. They are over at pediacast.org.

 

So, Dr. Steven Cuff, sports medicine physician and Ashley Davidson, certified athletic trainer, both with Nationwide Children's Hospital, thanks again so much for stopping by and sharing your expertise.

 

Dr. Steven Cuff: Thanks, Mike. Good to talk to you.

 

Ashley Davidson: Thanks, Mike.

 

[Music]

 

0:45:08

 

Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.

 

Also, thanks to our guests this week, Dr. Steven Cuff, sports medicine physician at Nationwide Children's, and Ashley Davidson, also at Nationwide Children's. She is a certified athletic trainer.

 

Don't forget, you can find PediaCast wherever podcasts are found. We are in the Apple and Google podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music, and most other podcast apps for iOS and Android. 

 

Our landing site is pediacast.org. You will find our entire archive of past programs there, along with our show notes, our Terms of Use Agreement, and that handy Contact page if you would like to suggest a future topic for the program.

 

Don't forget, reviews are helpful wherever you get your podcasts. We always appreciate when you share your thoughts about the show.

 

And we love connecting with you on social media. You'll find us on Facebook, Twitter, LinkedIn, and Instagram. Simply search for PediaCast.

 

0:46:03

 

Also, don't forget about our other podcast, PediaCast CME. That stands for Continuing Medical Education. It's similar to this program. We do turn the science up a couple of notches and offer free Continuing Medical Education Credit for those who listen. That includes doctors, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists.

 

And since Nationwide Children's is jointly accredited by many professional organizations, it's likely we offer the exact credits you need to fulfill your state's Continuing Medical Education requirements. Of course, you want to be sure the content of the episode matches your scope of practice.

 

Shows and details are available at the landing site for that program, pediacastcme.org. You can also listen wherever podcasts are found. Simply search for PediaCast CME.

 

Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So, long, everybody.

 

[Music]

 

0:47:15

 

Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

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