Toxic Stress & Concussion Update – PediaCast 362
- This week we consider communication strategies for helping kids deal with toxic stress. We also cover concussions with Dr Kevin Walter, a concussion expert from the Children’s Hospital of Wisconsin. He recently visited Nationwide Children’s and stopped by the PediaCast Studio to talk about concussion care and guidelines for returning student athletes to action. We hope you can join us!
- Toxic Stress
- U.S. Presidential Election
- Head Injuries
- Neurocognitive Testing
- Sports Medicine at Nationwide Children’s
- Concussion Information for Students, Coaches and Parents
- Concussion Clinic at Nationwide Children’s
Announcer 1: This is PediaCast.
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's a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio.
It's Episode 362 for December 7th, 2016. We're calling this one "Toxic Stress and Concussion Update." I want to welcome everyone to the program.
We have two very different topics for you today, but they're both important. The first is going to be toxic stress. You may have heard me batting this term around a little bit in recent episodes. This whole idea, that significant ongoing stress in a person's life and particularly in children, but in adults as well, that can lead to other problems, both physical and mental, emotional down the road.
And sometimes very long down the road, because the stress response sort of alters the chemicals in your body, including things like cortisol, which is one of your steroids inside your body. Stress, you feel different when you're stressed. And you feel different because your chemicals are in a different balance. And that can actually have health effects down the road.
So it's an important thing to talk about. And in particular, we're going to consider communication and engagement as a family as one way to deal with toxic stress. So that's coming up.
And the reason that I got this idea to talk about it in this way, I have to give credit where credit is due. I got a letter from the CEO of the American Academy of Pediatrics. And she didn't just send this letter to me. It went out to all pediatricians. And it basically was ways in which parents can communicate.
Just very practical common sense ways to engage and communicate with your kids as it relates to the presidential election. So just the long hard fought election and then the aftermath of the election has really created stress in many kids and families and adults' lives.
And so, just communication techniques of dealing with that stress. And I got to thinking, really, these ideas can pertain to any sort of toxic stress or even the minor stresses. It's great to talk about things. And so, she had some ideas and practical points and I'm going to share those with you as we consider dealing with stress.
We're also going to talk about concussions today. I'm really excited about this part of the program. Now, I know, we have talked about concussions many times in past episodes. But in my mind, you can't talk about concussions too often.
Number one, because they're very common. Number two, they cause lots of concern among student athletes and parents and coaches and school officials.
Also, recommendations regarding concussion care — they've made some recent shifts. We want to get those out to you. They take into account the latest research findings. So our earlier episodes on concussions, things have changed since then.
And when you have a pediatric podcast that's been around for ten years, we like to keep our archive out there. We want to update things as it becomes important to do so. And so, we're going to have a concussion update as we consider the latest thinking about concussions.
And, of course, talking about concussions also seem like a nice follow-up to our last episode which considered safety inside the home, and in particular, tip-overs and falls. Because lots of kids hit their head when they fall which can easily result in a concussion. So concussions seem like a nice follow-up to our previous episode with safety expert, Dr. Lara McKenzie. That was Episode 361.
We talked about safety around stairs, furnitures and televisions tipping over on kids, high chair safety, bunk beds, stairs, windows. So all of those things. So you if you want to shore up the house for the winter, your kids are going to spending a lot of time indoors, make sure things are safe. And you can do that by listening to our last episode, 361.
Our Concussion Update, I do have a great guest joining me. Dr. Kevin Walter is Program Director for Sports Medicine at the Children's Hospital of Wisconsin. And I'm really excited that he's going to be joining me on the program because he's really widely published in the realm of concussion research. And he's been leading the way in our knowledge of sports-related concussions and returning athletes to play. So really excited to have him in the studio.
Before we get to both of our topics — toxic stress and our concussion update — I do want to remind you, if there's a topic that you'd like us to talk about, you have a question for me, you want to put me in the direction of a journal article or a news story, it's easy to get in touch. Just head to PediaCast.org and click on the Contact link and ask away.
I do read each and every one of those that comes through. And we'll try to get your question or comments on the program. Also, I want to remind you, the information presented in every episode of the show 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 to call your doctor and arrange a face-to-face interview and hands-on physical examination.
All right, let's take a quick break and I will be back. We'll talk about toxic stress and we'll get Dr. Kevin Walter in the studio to talk about concussions. It's coming up right after this.
Dr. Mike Patrick: All right, we are back. And as I mentioned in the introduction, I want to take a few minutes to talk about toxic stress. And I also mentioned that, really, the reason that this idea sort of came to mind is in the context of the recent presidential election here in the United States of America. We're about a month out now from a very long and hard fought political campaign and an election day that left Americans and folks all around the world wondering who our next president would be.
Now, you probably noticed we didn't talk about the presidential campaign at all on PediaCast. Because we're not a political podcast. We're a pediatric podcast. And as pediatricians, I think I speak for most of us in saying that we want to work with all elected officials regardless of their political persuasion to best advocate for the health and wellbeing of kids and families and communities.
Now, of course, we also have personal opinions as individual pediatricians, as we consider candidates and issues, just as you do as parents and your family and your community.
And from a pediatrician's point of view, I think many of us really try to consider the needs of kids and how those needs intersect with policy, as we personally think about the candidates. And to be honest, for me, it really does come down to those kind of issues and not just a particular political party.
So I have voted Republican. I have voted Democrat. Really, it just depends on the candidate and the issues and where individual candidates come down on issues that affect kids. And then, I match that up with my own personal and family and community values and come up with a decision.
It's a very personal decision, just as it's personal for each and every one of you as you look at the issues and consider your values and make a decision that seems best for your family and community. And that's the beauty really of the American system of government. And because these kinds of decisions are so personal and because we're a pediatric podcast and not a political podcast, we generally avoid talking about elections.
On the other hand, as I read the news, and watch TV, and engage online with parents from all over the country and with my fellow pediatricians, there is a common thread of discussion that is important to address in the context of a pediatric podcast. And that is the stress that this election season is having on our children.
And as a parent, how do you deal when your kids are upset or anxious or worried or angry? And especially when that arises to the level of toxic stress where it's really significant stress over a prolonged period of time. And when we're talking about things as personal to families as immigration issues, there is definitely toxic stress that can occur when a child has to wonder, "Where am I going to be living in the next couple of years?" "What about my family members? "And, "How am I being treated in school because of my family or things that I believe?" "Am I being bullied?" "Am I feeling prejudice and discrimination?"
Those things are always there. I think they're just magnified because of the recent political climate and the election.
And again, this is a general observation that I think a lot of you have seen. And certainly, it has been portrayed in the news and pediatricians talking about it so much to the point that the CEO of the American Academy of Pediatrics, Dr. Karen Remley, sent a letter just reminding pediatricians everywhere of some common sense principles that are important for families and kids and schools to consider as we're dealing with stressed-out kids.
And the first of her points, which I think is just so important, is really to take care of yourself first. So children depend on the adults around them to feel safe and secure. So if you, as a parent or a child caregiver or a school official or teacher, if you are anxious and angry, children are more likely to be affected by your emotions than by the words you speak. So, they see how you're acting and what your tone is and how you're coming across, how you're feeling.
So, if you are having an extreme stress response that's ongoing, make sure you take care of yourself. Talk to someone that you trust about your concerns. That may be your spouse. It might be your partner. It could be someone that you trust at work, a counselor, your physician, someone in your faith community. All sorts of people and places, but just make sure you're getting help yourself and talking these things and talking these things out.
The next thing is really to listen. What is your child saying? What have they already heard? What have they heard at school? What are their friends saying? What have they been exposed to online? In social media channels? On television?
And then, what is their understanding based on what they've heard of any situation? Again, whether it be election related or anything that's going on in the community that would stress out kids. And you could come up with countless examples in the last few years, and there will be countless more examples in the years to come.
So kids get stressed out about things that are happening around them, whether it's in the local community or on the national or global level.
So what has your child been exposed to? What have they heard and what's their understanding that they have reached based on what they've heard?
And as you go through this, you do want to listen for misinformation. Don't necessarily interrupt them. Let them get their words out and their thoughts out. But as they do that, you notice, wait a minute, that's not exactly true. You want to correct the misinformation from a reputable source and you can take them there and show them, "Hey, look, this is what I think really is going on. You may have heard or been exposed to some misinformation."
So you want to, as best as you can, hear from both sides, set the record straight, put things into context. And then, after you've listened and you've talked through misinformation, then you want to explain what is going on from your point of view — what are your feelings on it — very simply and directly, with age-appropriate details.
And that age-appropriate details depends just as much on your child's maturity level as it does their actual chronological age. So you know your kid best. You know what they're ready to hear, what they've already been exposed to. So you have to take all of that into account as you give them maybe more details, but still, that's appropriate for their age and maturity level.
In addition to just explaining the facts simply and directly, then you want to share with them your conclusions and your feelings. As we talk about when we said you ought to care for yourself, you may be also feeling many of the same feelings your child is feeling. You may be anxious or angry or worried. And it is okay to share those and feelings and thoughts and conclusions with your kids.
But it's also important to balance those concerns with hope and reassurance. Let your kids know that you love them, that you are for them, that you want to protect them. And point them in the direction them in the direction of other adults in their lives who also love them, and support them, and want to care for them, and protect them. Because, hopefully, those adults exist and your kid should feel loving relationships.
And that's one of the things that really creates toxic stress, is when kids are worried and anxious and angry and upset and don't feel loved. That really is a critical part of this. And so, you want to point them in the direction of where their hope and reassurance is and who is going to care for them at school, online, in their extended family, and certainly, certainly, in the home.
And then, you also want to share your own values and beliefs and have those intersect with the concerns that your child has. And this, of course, would be an ongoing dialog. It's not a once and done conversation.
Encourage your kids to ask questions. If they seem upset, and they're not talking about it, just continue to extend multiple invitations for them to discuss. Let them you're comfortable talking with them when they're ready to talk about it. Be there physically and emotionally for them, but don't sit them down and force the issue, saying "Okay, we are going to talk about this now and I want to know all of your feelings." That's probably not going to work.
So you just want to be there when they're ready to talk about it. Extend to them the opportunity to discuss it. And it may also be helpful to discuss these issues as a family. So maybe one of your other kids is more likely to talk about it, which will be a benefit to your quiet one who's also concerned and upset about something that's going on in your home, in the local community, or nationally. And again, you can think of lots of examples.
So it may be helpful to talk about it, a shared concern as a family that may help bring out more issues and afford the opportunity to provide hope and reassurance and love, while you're still dealing with the issues straight on.
Another really important part of all this is you want to ask your child if they have personally experienced whatever it is that is stressing them out. Hearing about it in the news, worrying about what could be based on what you're hearing, that's all important and it's one thing. But it's another thing if your child has actually experienced prejudice, discrimination, bullying, any number of other stressors in a kid's life.
Is there worry about a family member and immigration and deportation and these sort of things, this kind of issues? If that's a real concern and your child is personally experiencing that, make sure you talk about it. Again, reassure them. Allow them to express their fear and their anxiety, their anger. But be there for them, love them. Reassure them. Listen again and again if necessary.
They may want to talk about. You had the one kid that didn't want to talk about it at all. And you have another kid that just keeps wanting to talk about it. And that's okay, keep talking about it. But also keep supporting and loving and pointing them in the direction of hope and reassurance, not to discount the negative feelings but to balance them because hopefully, in their life, there are people who love them and support them and want to take care of them.
And then, after you've listened and you've talked and you've listened again. And you've talked again in this ongoing dialog, along with that, it is time to act. And the most important way I think that a parent can act is really on their child's behalf to protect them in their world.
So especially if your kid is experiencing discrimination or bullying in wherever it is, whether it's at school or online, I mean, really understand what's going on and be there as their primary advocate to protect them. Find folks in the school who were onboard with your values and what you see is going on, someone who can love them in that environment and protect them, a trusted adult that the child could go to when they feel threatened or bullied. And whether that's at school or online or wherever they find themselves, that they know there's someone they can go who's trusted, who cares for them, who loves them. It's very important.
And then, engage in activities that demonstrate your family's values. You can volunteer for organizations whose mission is dedicated to a cause that you and your family care about. And really think about practical ideas for individual actions that help fight the very thing that your child is worried about, whatever that is.
How can you make a difference in your family, in your community, in your state, in the nation? How can you make a difference in other people's lives? And work on that as a family, and that can be very helpful.
As pediatricians and parents, I mentioned this, that the election is what sort of spark the idea for this conversation. And so, I want to go down that route, just a little bit longer and say that we really want to work with all of our elected leaders regardless of their party affiliation to advocate for children and promote health and wellbeing, both physical and emotional, to support family security and build strong communities, and continue using evidence and policy and passion to ensure that the United States is a leading nation for children.
We're all in this together, folks. There'll be more stress in the future and that's always true, regardless of the political party of our elected officials. Stress has a way of hiding around many corners. But by listening and talking and acting, we can help our children reach their full potential every single day. And that is something to get really excited about.
Dr. Mike Patrick: Dr. Kevin Walter is Program Director for Pediatric and Adolescents Sports Medicine at the Children's Hospital of Wisconsin and an associate professor with the Department of Orthopedic Surgery at the Medical College of Wisconsin. He has an interest — in fact, I would take that a bit further and say he has a passion — for studying concussions in student athletes and best practices for concussion care and returning athletes to play in competition.
He's widely published on the topic of concussions with articles in the journal Pediatrics, the American Journal of Sports Medicine and Adolescent Medicine: State of the Art Reviews. That's what he's here to talk about today, concussions.
So let's give a warm PediaCast welcome to Dr. Kevin Walter. Thanks so much for joining me today.
Dr. Kevin Walter: Thank you very much for having me. It's an honor.
Dr. Mike Patrick: Really, really appreciate you taking time to stop by. So, concussions are common. And we've talked about them many times and in many contexts over the years on this program. But you can't talk about concussions too often.
First, because they're so common and result in much concern for students and parents and coaches. And also because recommendations have shifted a bit as new evidence becomes available. And that's why we're calling this segment Concussion Update, as we consider the most recent up-to-date recommendations for now, November 2016.
But that also means if you're coming to this program long after November 2016, you may want to check to see if we have any newer discussions in the future, just to be sure you have the latest and most up-to-date information. Because, really, wouldn't you say it's an emerging field, right?
Dr. Kevin Walter: Very much. It changes yearly.
Dr. Mike Patrick: So let's dive right in. Remind the audience, what is a concussion?
Dr. Kevin Walter: So a concussion technically is a mild traumatic brain injury. It's a pretty complex process that affects the electrolytes and energy use in the brain. But basically, it starts with the trauma, usually an impact of the head. That trauma, simplistically, you shake your brain, throws off how the nerves of your brain use energy and electrolytes and how the nerves communicate with each other. They do a bad job, your brain becomes very inefficient. And then that makes you feel bad, and function slowly.
And the good thing with concussion is, it's temporary. So usually then, it spontaneously resolves over time. The hard part is it's kind of hard to predict how long it's going to last for each individual person.
Dr. Mike Patrick: So it's really more of a functional injury than a structural injury?
Dr. Kevin Walter: Absolutely, yes. You cannot see concussion on a standard CAT scan or CT scan of the head or standard MRI. And another thing that I think is a common myth is you don't have to be knocked out to have a concussion. In fact, arguably, less than 5% to 10% of people have loss of consciousness.
Dr. Mike Patrick: So really, any type of head injury can end up — and we'll cover exactly what a concussion looks like symptom-wise — but really, any sort of head injury can result in a concussion.
Dr. Kevin Walter: It could. It could.
Dr. Mike Patrick: And sometimes, even maybe they don't hit their head on anything. So you may see a kid like in a car accident and the brain because your head goes forward and back, the brain kind of crashes into the front part of the skull and then bounces off and hits the back part. And that sort of thing can cause a concussion too, right.
Dr. Kevin Walter: Yeah, that whiplash effect can cause it. And I see kids in clinic that they get hit in the chest. So you're playing football, you get tackled in the chest and it's same thing, that whiplash effect can injure the brain.
Dr. Mike Patrick: Now, besides a concussion, what other problems then can result from head injury? So rather than functional problem, but really structural problems, what are some injuries that you can see when you hit your head?
Dr. Kevin Walter: So the big two that we worry about are do you have a skull fracture? Have you broken your skull bone? Or do you have a bleed inside your brain or inside the skull? So those are two very alarming things that have the potential to be life-threatening. Thankfully, they're rare and especially with sports, they're very rare but they do happen.
And then, neck injuries can go along with head injuries, so you want to make sure that you don't have a neck injury along with that.
Dr. Kevin Walter: Absolutely. Absolutely.
Dr. Mike Patrick: So then, how do you differentiate after a kid has a head injury, whether it's concussion that they're experiencing or they really do have a brain bleed or a skull fracture?
Dr. Kevin Walter: So if you're playing on a team that's lucky enough to have an athletic trainor on the sideline or a team physician on the sideline, the healthcare provider can do a detailed assessment and an exam, and look for those signs. If this is a youth team, where it's just a bunch of parents on the sideline, then really, what you want to look for is are they getting worse?
If they're knocked out, if they had a seizure, if they had repeated vomiting, or if it's the worse headache in the world. Or shortly afterward, it's a little bad, but then it just keeps getting worse and worse. They get more foggy, more kind of disoriented. Those are kids that I worry about. They could have more than a concussion in the form of a brain bleed. And those are the kids that I say, "You want to go the ER."
Dr. Mike Patrick: And then, how would you determine… So if you had a kid who that you're a little bit more worried that it could be more than just a concussion. So the symptoms were there's more of an increased risk for there being a skull fracture or brain bleed, or intercranial hemorrhage is another word for that. So they have confusion and maybe persistent vomiting, altered level of consciousness. Then, how do you diagnose those other issues?
Dr. Kevin Walter: Realistically, through neuroimaging. CAT scan is usually what you would get because you can get it quickly and it tells us is there bleeding or is there fractures real time in the ER.
But a lot of times, you'll go and the ER doc will look at you and think "Geez, you look bad but you may not, you don't look bad enough to potentially have this bleed. Let's sit and observe you". And then, you get observed for four hours. If things stabilize, you start to look better or don't look worse, then they send you home. And I get families, they come in all the time and say, "Oh, I went to the ER and we sat around and they did nothing." And I said that's the point.
Dr. Mike Patrick: Sitting around was the something.
Dr. Kevin Walter: Exactly. And I tell him, everyone thinks I need a CAT scan approved. No, because CAT scans aren't necessarily good for you either with the radiation dose. And so, you need a CAT scan only if you really need a CAT scan and you have those alarming signs.
Dr. Mike Patrick: Yeah, absolutely. So we know that radiation exposure is a risk factor for developing cancers and brain tumors down the road. So we don't want to scare folks unnecessarily. But there really is a risk there. And especially if you're looking at a kid who may have a reason to have other imaging studies over the course of the next 20 years, any radiation exposure that we can avoid is helpful in terms of decreasing the risk for problems down the road.
On the other hand, you don't want miss those things. And so, it really is looking at the benefit versus the risk. And the best thing there is to go to an emergency department that's used to taking care of kids and being seen by a provider who can help walk you through that risk-benefit analysis and most of the kids end up not needing CAT scans.
Dr. Kevin Walter: Correct. And I absolutely agree with you, because I think there's really a big difference when you look at pediatric-based emergency care and adult-based emergency care. The comfort level with kids is just much better obviously at the pediatric center. With adult-based centers, they may get a little more nervous and be more willing to obtain that CAT scan when they don't necessarily need one.
Dr. Mike Patrick: And not to belittle their practice because they're not used to seeing as many kids with head injuries and concussions. And so, from their point of view, I don't want to miss any child who has a serious injury. But at least at the pediatric facility, they're going to have seen a lot more head injuries in kids and sort of know what to expect in terms of who really needs the CAT scan and who doesn't.
Dr. Kevin Walter: Correct.
Dr. Mike Patrick: We talked about what's happening in the brain in terms of it's not functioning quite right because there's a disruption in the normal cellular processes and neurotransmitters and electrical impulses and all that. So what kind of symptoms then do you typically see that would make you think concussion?
And I guess we can talk about the short-term symptoms and then more long-term symptoms. So in the short term, what do you usually see?
Dr. Kevin Walter: So in the short-term, there's the trauma. And then, usually, quickly thereafter. But sometimes, it can take a few hours, three to four hours to really show up. You get physical symptoms, which are things like headache, dizziness, nausea. You get cognitive symptoms which are memory problems, fogginess. They answer questions slower. They just don't respond normally, something seems off is what people will say.
And then, you can get two other subgroups. You can get emotional symptoms, where kids get really moody after the concussion. But sometimes, even right afterwards, they can be really moody and weepy or really irritable and angry. And then you can get sleep problems, where a concussion may make you more fatigued, can make you sleep more. Strangely enough, it can make you sleep less and interrupt sleep and make it hard to fall asleep, too.
So it can do a whole host of different symptoms, but the main ones are really those physical symptoms. Then, that cognitive or thinking how do you act and interact kind of stuff.
Dr. Mike Patrick: A lot of these kids, when we see them after concussion will be really clingy. When they sit on mom's lap, they're like, "This is not my kid. Usually, my child will be running around the room and trying to open the drawers and getting into your pockets." And so, a parent is really concerned that they're just sitting on mom's lap quietly and that's not their child's usual demeanor.
Or, just sitting on the exam table and kind of almost having a depressed affect. Just not as jovial, and the sense of humor seems to be gone. And parents find that really concerning.
Dr. Kevin Walter: Yeah, they do. And it's true, those behavior changes. But when you really think about it, how an eight-year-old versus a 13-year-old versus an adult can describe how they feel is going to be very different. And sometimes, kids know they feel bad and so they just do the smart thing and they mellow out, and kind of try and relax as much as possible, which is usually a pretty different thing.
Dr. Mike Patrick: I think it's important for a lot of families to know, "Hey, does my kid have a concussion or not?" Because then, the way that you manage the kid on down the road, when they can go to school, when they can return to sports hinges on do they have a concussion or not?
So my question is, the kids who might have a mild to moderate headache after a head injury, they just last two or three hours. They take some Tylenol or Motrin, it goes away. But no other symptoms, just a little headache afterward. Would you consider that a concussion or no?
Dr. Kevin Walter: Probably not. But I wouldn't let them back to the sport that day. So if I stood up and if I got out of the car and I smash my head on the frame, it's going to hurt. I'm going to have a headache. I'm going to close my eyes and "see stars". But that headache is going to be very focal over the spot of the trauma. And it will persist for a few hours for that day, but it will be realistically gone the next day. And I don't have nausea. I don't have dizziness. I don't have behavioral changes, all of these other things.
So if it's truly just localized, isolated headache for a few hours, I would say odds are that's not a concussion. But again, in the context of youth sports, if I think that, I want to prove that and you can't really prove that within a day. I would say…
Dr. Mike Patrick: Especially since some of the symptoms can take a few hours to show up.
Dr. Kevin Walter: Exactly, exactly. So that's the kid where if there's the trauma and there's the headache, you want to keep them out. You want to sets them for the rest of the day, make sure everything is going well. And then, the next day, if there's really truly no other symptoms or problems, then you can come back and say, "Hey, that probably wasn't a concussion."
Dr. Mike Patrick: Yeah, definitely makes sense. From a long-term perspective, what kind of things do you see in terms of concussion
let's say a few days out? Or if they're having prolonged concussion syndrome, what kind of symptoms do you typically see with that?
Dr. Kevin Walter: So, well first off, my expectation with pretty much every concussion that I see is it goes away and resolves. So I don't expect long, long term issues after concussion. That being said, it could go away in two days, two weeks, two months. You can't really predict one.
So as time goes by, all the symptoms that we talked about in the beginning, the headache, the dizziness, the nausea, those can persist. But I think in younger people, having to get back into school, that's really where the spotlight shines bright. Because they just can't focus as well. So they can't pay attention and learn as well. They can't process as well. So doing their homework gets harder.
And, "Oh by the way, I didn't focus on class as much. So then, doing my homework is now even harder, too." So you've got a double whammy there. So then it takes longer to get the homework done. So now, you've got a little bit less sleep. You're stressed out because you knew you're not doing as well. So there's a little bit less sleep quality.
And these things start to snowball and move in the wrong direction because we're just overwhelming these kids academically, unless we can get them to take a little bit of a break or adjust how they learn.
Dr. Mike Patrick: Yeah, absolutely. And that kind of translates on to the playing field too because if you're processing more slowly, you're going to have more difficult time with motor coordination. And maybe your judgement may not be quite as good. So then, you're at risk for more injuries.
Dr. Kevin Walter: Yeah, and that leads to a critical point. If you think you might have a concussion, then you should be off the field to play immediately. So you've got to report the injury as soon as you have it. And there's emerging research showing that even if you play for five or ten more minutes and you don't have another head impact, you will take longer than somebody who immediately report it and got off the field.
So it will take you longer to get better even if you play without any further injury. But if you get off the field to play, that removes the risk of repeat injury. And the reality is repeat injury is where the problems, I think, happen. Makes it take longer. If you get a hit on top of a concussion, you feel worse, prolong your recovery.
But the alarming things is if you get a concussion or an impact on top of the concussion, your brain is already not working right. And so, that poor regulation goes haywire and there's a thing called second impact syndrome, which thankfully is rare. But again it happens. And you don't want to be that statistic, that one in a 100,000, or whatever it is.
Dr. Mike Patrick: And that can be devastating.
Dr. Kevin Walter: Yeah. And that's brain bleeding, swelling, brain damage stuff. Those are the terrible stories that we read about in the paper. And if you really read them, odds are, that kid was playing on an concussion and didn't admit it. Or the simple thing is nobody just removed that athlete from play.
And it's an easy thing to do, but we need people to report it. We need people to be removed from play. That's where the trouble is. And that's why with sport, you just don't go back until you're 100%.
Dr. Mike Patrick: And in addition to possibly hitting your head again, you're also at risk for other injuries if your reaction time is less and you have maybe poor judgment, poor eye, hand, coordination, that sort of thing. It's going to be often. Then you may end up with other injuries as well.
Dr. Kevin Walter: Yeah, that's true. And I think there's also emerging research looking at after coming back from concussion, there's a higher incidence of muscular skeletal injury too. Just because like I said, your balance is off and your coordination is off, you're more likely to sprain your ankle or twist your knees, something like that.
Dr. Mike Patrick: So you mentioned, sometimes concussion can last a few days. Sometimes, the symptoms last longer. And as we're thinking about symptoms like concentration problem, memory issues, coordination and balance, some of the personality changes, depression, sleep disturbances, either too much or too little.
So for most kids, we say it last a few days. How long can it last?
Dr. Kevin Walter: It can lasts months. It can lasts months. If you look at the research, most people recover in about two weeks. But there's also an ample amount of research, specifically based at youth and adolescent saying that it's not uncommon to take over a month to get better. So there was a paper that came out earlier this year saying that almost one out of every five high schoolers that got a concussion took over 30 days to return to play.
And at the youth, the younger than high school level, it was about 16%, 17%. So what we know is kids take longer than adults. But the hard part is really trying to pin down what is that expected timeline and what modifies that timeline. Why does someone get better in two days when it takes your next door neighbor two and half months to improve. Those are the question and the timelines that we still need to figure out.
Dr. Mike Patrick: Is there anything that we do have now that could predict who is going to have more severe symptoms or long-lasting symptoms? I mean, there's a lot of variables out there that we don't necessarily know. But are there some that we do have a fair idea about.
Dr. Kevin Walter: There are. And it's nothing as in anything in medicine. Nothing you can say is a 100% accurate. But people who would have had a history of concussion will take longer to recover. So the more you have in theory, the longer it takes to get better. People with mental health concerns, anxiety, depression may take a little bit longer.
People with ADHD, learning disorders, even things like headache disorders and seizures disorders have been associated with longer recoveries. Now, that doesn't mean you will have one but those are people that I worry may take a little bit longer.
Dr. Mike Patrick: Yeah, each concussion is pretty unique.
Dr. Kevin Walter: It is. It is.
And then, even symptom-wise, what we've noticed — in our institution, we did a research project, whatever, that's pending publication. I don't know if that's what you should say — but we looked at people who had a higher symptom load before the injury took longer to recover afterwards.
So even just in general, kind of how you feel, what kind of stress you have. And to me, that makes sense. If your parents are going through a divorce and you got concussed, you've got a great deal of stress in your life at the get-go. You got a concussion and it affects your brain and your brain relates to how you deal with that stress. So now, we make your brain not work well, which means it deals with stress less effectively. It means he's going to take longer to get better because you've got just more baseline stress.
Dr. Mike Patrick: Yeah. Before we started recording, we were chatting about concussions a little bit over lunch. And the idea came up that some of these kids, maybe their… Especially depression, attention problems, sleep issues maybe aren't all just from the concussion itself. But maybe these were pre-existing conditions and the kid really does have an attention issue or depression issue. And concussion just sort of got them into the medical system to be aware of it.
Dr. Kevin Walter: Yeah, we see a fair share of that in our concussion program. After the concussion, people and parents really evaluate how their kid is acting and how they're feeling and much more than they did before. And they realize that these behaviors may be less than ideal. And yeah, maybe, they were there before.
And so, these lower level unrecognized attention issues and depression, things like that, kind of really seem to blossom due to the concussion but they were there before. The concussion just kind of focus you on them.
Dr. Mike Patrick: Yeah, yeah. To get real practical win, should kids return to school after a concussion?
Dr. Kevin Walter: So this is just like every concussion is unique, that answer is every kid is unique. So some kids feel well enough that they could probably go back in the next day. Some kids do need a few days off from school because they feel so bad. And so, my personal philosophy is I don't want to keep anyone out more than five days.
And even then, I try and shake it to less and less and less because — and what I will tell families is — as your brain is recovering, you want it to recover with good habits, "I'm going to school." Because if you have the option of staying home or going to school, or "I have the option of staying home or going to work, and it didn't penalize me in any other way in life, I'm going to stay home and read and lay around and watch TV." You'll select that easy way out.
So we don't want to make kids school-avoidant. And we see it happen all the time, even in really good students and kids that love school. They actually get very nervous about what they're missing, falling behind in homework. And that stress level kind of puts big walls up with school and they become more school-avoidant.
So the key thing with getting back to school is if you have a brain working at 80%, and we give you a 100% of the workload, we're going to overwhelm you. And that's going to be bad. That's going to prolong recovery, it's going to stress you out.
But if we can get you back in school, give you some breaks, give you extra access to tutoring, cut back on the amount of workload that you have to do. Increase the time that you have to do it so you're not rushed and under the gun. You can still learn, keep up your grades, be at school, and get better.
And so, and then as you make improvements, you just progressively increase back to a 100% school. And I make sure that all of my patients, you are 100% school before we even start talking about sports.
Dr. Mike Patrick: How do you get the schools on board with that program? How do doctors and parents and schools, how can they — and individual communities — best partner to do what's right for the kid?
Dr. Kevin Walter: You know, it's something that seems like it would be so easy because we say the stuff, and we're like "Oh, yeah, common sense." And reality is, schools do this for kids that are ill or have other problem, but getting it done with concussion just seems really difficult.
So I've met a lot of resistance to implementing plans in our area from schools. And I don't really know why. So I think it's just persistence. We give in our office a very detailed note of, "This is what I want to do. My phone number's on here. If school has any problems, have them call us."
We ask the families to sign a release form to allow me to talk to school only about their concussions. So that way, if the kid's having trouble, I can call school and say this is why I do what I do.
And I think what happens is school at first is, "Oh, this is a lot of stuff." But then, they see that it works. And the next time they do it, it works. And then, they become a little bit more open to modifying. And when they do the modifications and the kids get better faster, now it's even just a less stressful event for school, because they don't have to worry about this kid going on for the rest of the semester when it could be two weeks with a few simple changes.
Dr. Mike Patrick: Yeah, yeah. So the take-home to parents out there. If your child has a concussion and the school's giving you some resistance, direct them to this podcast.
Dr. Kevin Walter: Yeah.
Dr. Mike Patrick: And they can hear from the concussion expert exactly what we should be doing in terms of best practice in getting kids back in school.
There's also been some studies that show that the more prolonged and drastic brain rest that you have, that then those concussion symptoms themselves may become a little bit more severe and long-lasting. So there really is this sort of sweet spot between the right amount of brain rest, but not too much.
Dr. Kevin Walter: Yes, there is. There is. There was a study done out of my home institution, Medical College of Wisconsin that I love. It looked at people coming into the ER, gave you five days of strict rest, no school, no work, nothing like that. And then, the other group got five days of "Do what you can do so that you don't feel horrible."
And not only was there no difference at ten days out between these two groups, no difference than how they felt or recovery outcome times. The group that had strict rest actually reported more symptoms.
So it's one of those things where when I work with families, I say, "Hey, if you overdo it, too much TV, too much reading, too much schoolwork, you will feel worse. Feeling worse has a potential to prolong recovery. If we cocoon you in a dark room and let you do nothing, you will feel worse and you will slow recovery."
Because in the dark room, all you're going to do and sit about and say, "Oh my God, I'm so bored. I can't do anything." "I'm falling behind in school," "I miss my friends," "Oh, I have a really bad headache," "Oh, I feel so dizzy." And you just focus on everything negative and that triggers all that emotional reaction and stress, which works against you, too.
Dr. Mike Patrick: While you're waiting to return, is there any specific treatment other than just that right amount of rest?
Dr. Kevin Walter: Sometimes. But again, same thing, unique in individual. So that right amount of rest, doing some things but not too much, avoiding things that make you feel significantly worse. When it comes to activities, some people can tolerate 10-, 15-minute walks around the block. So we take these really active kids, athletes, tell them do no activity. And, of course, they're not going to feel like themselves.
So even if you can get up and do an easy walk, that doesn't make you feel worse, that's moving and doing something. And to old guy Dr. Walter, 15 minutes of walking is exercise. But to the high school football athlete, it's laughable. But it's moving. And that helps.
And then, you look at like you talked about before, do they have neck muscle problems? Could they benefit from PT because the neck-muscle stuff will trigger more headaches and problems? Do they have eye movement problems? There's a thing called vestibular oculomotor dysfunction, where basically the vision-movement imbalance and the brain don't communicate well. And you can retrain that system through specialized physical therapy.
And then, sometimes, mood-wise, if their mood gets really affected and they're really emotional, you can do cognitive behavioral therapy and use that to help get them better. So for each kid, there may be more than just rest but not every kid needs all of it. And some kids need it all.
Dr. Mike Patrick: And I think what you practice in Wisconsin and here at Nationwide Children's, we both have pretty developed concussion programs at the Sports Medicine department, which then kids get plugged into physical therapy or psychology to get those additional things that they may need. So, really getting your kid into a concussion program especially if they're having severe prolonged symptoms may be very helpful.
Dr. Kevin Walter: Yeah, I agree. I think realistically, if you got one or two concussions and you have symptoms going on two, three-ish weeks, that's where I would expect athletic trainers, primary care docs, wherever you are to kind of handle that. Because most of the people are going to improve in that timeline. But when you start drifting out beyond that, the 4+ weeks, that's where you may need more the bells and whistles of the specialty program.
So when should kids return to sports? So once they're in school, do they need to be completely symptom free before they go back? And then, do they need to do it gradually or can they just run out and do what they have been doing before? And who should manage those decisions?
Dr. Mike Patrick: So I think whoever the medical provider you were working with for you concussion. And I know obviously, as a physician, I am a true believer that you need a healthcare professional working with you with every concussion, be it your high school athletic trainer, your primary doc, or a concussion specialist.
But returning to sports, there's two things. I think there's sport and there's exercise. So for people with really prolonged symptoms, post-concussion syndrome, stuff going on, 1+ month, there is a role for exercise. Not sport, but just working out, jogging, et cetera, stuff like that. But it's very controlled, managed by the doc, that's treating you, "Here's how much you can do."
So I think even with symptoms, if you've had it for awhile, there's a role for exercise to help you improve early on. That role, like I said, is very minimum, maybe just walking. But when you return to sport, my rule is you got to be 100% no symptoms, feeling great. Got to have your parents agree with me or agree with you. So the boss needs to report, "Yes, I agree."
You got to be back at 100% school. Because I think if you're 50% homework and you're telling me you're back to normal, and you want to go play in the big homecoming game, you're not back to normal, because you're not back at full school.
And then, you've got to be off all medications that you may have used to treat those symptoms. Once you have that, then I say "Okay, now, we can talk about return to play."
And then returning to sport is a best on as a gradual stepwise thing, where you start off day one, low level, exertion; day two, moderate; day three, high level. Then I have them call and touch base with me if they're doing well.
Now, we can add in if there will be contact or risk with practice and then move on the next day of the competition and away you go. So it takes from feeling good for one full one day to two full days to back to full speed play about a week. A little bit less.
Dr. Mike Patrick: And again, depending on the head injury, the kid, and each one is a little bit unique. And that is another reason you really do want a medical provider kind of walking you down that path.
Dr. Kevin Walter: Yeah, and if you've had longer symptoms, the return to play is longer. If you've had multiple concussions, it depends on when that return to play gets a little more complicated. So that's where with multiple concussions are prolonged symptoms. The more expertise you have, kind of the better it can go.
Dr. Mike Patrick: Yeah. Let's talk a little bit about neurocognitive testing. So this is, well, first tell us that that is.
Dr. Kevin Walter: So neurocognitive, as a non-neuropsychologist — all the neuropsychologist listening will laugh at me — but basically, I call it brain functioning testing. It's how your brain works and processes what you can remember, your working memory and learning and things like that.
Dr. Mike Patrick: And of what use are those kind of tests?
Dr. Kevin Walter: I think they can be helpful. So the main ones that you'll hear about are the computerized testing. And so, you'll hear NFL games, these players all for concussion. They need to pass their concussion test. Most of the time, I'm talking about this computerized test.
And it's nice because it can give you wide access. This is a test that you can take on the computer, so it can go out across the country to all high schools and all clubs. And it really, it has wider access than just a traditional neuropsychologist, but I don't think it's as good as traditional neuropsychologist because they can look at you as you take the test and see where you make mistakes, how your performed. Did you just get nervous and you blew it on Question 2 and that sets you off for the next questions, but by the next subtest, you were fine and back to normal?
Whereas, the computer test doesn't have that flexibility. But what it can do in theory, if you have a baseline or pre-injury test, your scores are at a certain level — with the expectation that after the injury, when you've had full recovery and were making decision about can we return you to play or contact, we'll have you do the computerized testing — and in theory, your scores should be back at that baseline level.
And if they're lower, then we say, "Well, you may have not recovered yet." And when that happens, I'll get people that say, "Oh, yeah, well, I still have mild headaches." And they'll fess up that "Maybe I still am symptomatic."
But then, I have other people that really truly say, "I'm fine," but I think brain wise, their processing and functioning maybe hasn't recovered. And then we take that a week later. And it comes back up towards normal, and we say "Okay, great."
Dr. Mike Patrick: Now, to get to baseline testing, someone then have to see a sports medicine doctor to get that? Or is this something that regular pediatricians have access to? Or do school athletic programs have access to the computerized test to get a baseline?
Dr. Kevin Walter: All of the above. But it just depends. So some schools have them, some private sports club do it. Some pediatric offices have it. Some of them don't.
Truly, I think your best baseline is going to be what I call multimodal, where we look at computer test, where we look at eye movement test and where we look at a balance test and put all those things together.
Most of the time, you're getting that from more of a special tea type program. One of the worries that I have about baseline testing at the school in the club level is they tend to do it just in a big group. There's a 20-person computer lab at school. We're going to fill up all 20 computers during football practice and those 20 athletes are going to do the baseline test.
And so, meanwhile, you've got kids looking around at everybody else, so there's a lot of distraction. There's distraction because you're supposed to be at football practice, what am I missing? So you tend to see a relatively high invalid rate for those baseline, sometimes as high as more than one out of every ten.
And that can be tough because if the athletic trainer doesn't look for those invalid test or whoever is administering the test doesn't look for those invalid test, then you've got a kid that had a baseline, that is not really valid that is not going to be any help whatsoever down the road.
Dr. Mike Patrick: And so, if they get the neurocognitive testing at the school or club level, and then they're following up with their primary doctor after a concussion or sports medicine, do they have an account or something with that first test that they did? So they would have access to taking it again? Is that how that works?
Dr. Kevin Walter: Yeah, usually, when you sign up, they give you an account. And different platforms for computer testing have different names for the accounts. But those accounts then, if you keep your number, whether you move from Columbus Ohio to Maine or San Diego, you can take that with you and it can be accessed.
Now, the key thing is does the person you're following up with, does that pediatrician have experience in using this computerized test? Are they going to know how to interpret it? Because not all of them do.
Dr. Mike Patrick: So it's helpful but there are some pitfalls involved at this point. And I would imagine, there's different systems and some people may be more comfortable with one than another.
Dr. Kevin Walter: Correct. It's a great tool but it's just a tool, and what everyone wishes is could there be there's one great thing that tells us "Yes or no concussion," and "Yes or no, is it gone?" And no, there's not.
Dr. Mike Patrick: And part of that is that there's money to be made with these tests and companies who build them and say, "Mine's better," and you get the whole…" I mean, competition is a good thing in many ways but it can also kind of inhibit progress to a degree in some other situations.
Dr. Kevin Walter: Correct.
Dr. Mike Patrick: We'll just leave it at that.
Dr. Mike Patrick: I wanted to also touch on sort of more long-term consequences of recurrent or repeated concussions. So I think there's been a lot more awareness with the NFL stuff and with the concussion movie that came out. Just what are your own feelings on, is this a real thing or are we making more out of it than it really should be?
Dr. Kevin Walter: I think it's a real thing. So when you talk about the NFL stuff and it's that chronic traumatic encephalopathy which is where the brain simplistically starts to prematurely break down. I think that's definitely a real thing. I don't think we understand how you go from young athlete to chronic traumatic encephalopathy.
And so, when you look at some of the research, there's research that professional athletes have higher risks for those problems. But there's not necessarily evidence showing that high school athletes do. And so, that looks at things like Parkinson's and Alzheimer's and things that we know NFL players and boxers have higher risks for than general population.
High school football players versus high school band players, there's been no difference between the two. So what I think it is, is number one, again, I don't discount the fact the multiple concussions can play into it. But I think if you take care of them and are seen and evaluated and treated effectively, you can figure when to stop before this become more problematic.
But I also think it's this, people will call it subconcussive, but I call it a non-concussive head impact. So over years of time with practices, when you go head to head with people and you don't get concussions, that's not good for you either. So I think it's that additive effect of all these non-concussive head impacts mixed in with concussions.
We can be honest and say, really, do all collegiate and professional athletes report and effectively treat every single concussion as much as we want to say yes? Probably not. Just like I don't expect all young athletes and high school athletes, they don't. I want them to. But I know they lie to me, too.
Dr. Mike Patrick: Yeah. So a lot of parents then ask how many concussions is too many? So is my kid going to be at more risk of problems down the road. I'm sure that's a question that you get asked sometimes. How do you answer that?
Dr. Kevin Walter: All the time.
Dr. Mike Patrick: How many is too many?
Dr. Kevin Walter: We can't tell. It's not a simple number. And the myth for families, usually the number that I hear the most is three. Because there were all the neurology guidelines that said "Three in a season and you were done," and stuff like that. The reality is more. I've had people and I've retired them after one, and I've let people back after six.
And I think a lot of it is just how did you get the concussion? Is it coming from easier mechanisms of entry? Are you more concussable if you will? How long is it lasting? If the first one's two days, the next one's two weeks, the next one's two months, you're clearly moving in the wrong direction.
But then, also, how else does it affect other things in life? I mean, so the kid that I retired after the first one, it was six months of symptoms, really, really struggled in school. And this kid knew, "Hey, I'm playing basketball for fun. I enjoy it with my high school team but my future is in academics. I want to go on an be an aerospace engineer. And not pulling good grades in high school is going to negatively affect where I go to college. And I think it's time that we hang it up."
And I think that was a very mature decision for that kid and that family, very difficult to make. But that's when we say, "You know what you're right." Because if you get another concussion, the rule of thumb is it's going to last as long or longer than the previous one.
And knowing that you just had a really rough semester, do you really want to go through that again in high school when you're looking at colleges and, "How do I get in and what GPA do I need?"
And so, it's life that kind of factors in there. But I think there's those distinct how quickly, how frequently are you getting them, how long do they last and how are you getting them? To me, those are some trends that you need to watch as a healthcare provider. And if you're moving on the wrong end, those are kids that I pull the plug on earlier.
Dr. Mike Patrick: Yeah, and that's even more reason to recognize that each concussion is unique. Each family situation and the kid's context is unique. And you really want a provider that can walk through the benefit risk of that unique situation to come up with an answer that's right for that family.
Dr. Kevin Walter: Yeah, and I think it's easy to say "Hey, you should be done playing contact sports because you've got permanent symptoms or we've documented a decline in function." You don't need a medical degree to say that. Yeah, I can probably pull people on the street, and they're going to say yeah, that's bad.
I think for us, as physicians in the healthcare profession, we need to be more proactive. We need to say, "Hey, you're moving. You're showing bad trends, moving down the wrong road," whatever you want to call it. You could be someone that is at risk of these things happening. And the youth level, you don't even want to be in that neighborhood. So that's why I say treating you like a professional is not always in your best interest.
Dr. Mike Patrick: Yeah, definitely makes sense. At the beginning of our conversation, we talked about the fact that if you're coming to this program long after November 2016, the talk might be a little bit different depending on what research has come out. Since this is sort of an emerging field.
What are some of the hot topics right now in concussion research that could potentially change things?
Dr. Kevin Walter: So coming up in 2017, there will be two big papers. The first one, there's a group called Concussion in Sport and they provide the guidelines that most physicians follow. They just had their meeting this Fall in Berlin. Unfortunately, they did not invite me to Europe, but maybe one day.
Dr. Kevin Walter: But those papers will be coming out, and that's kind of the leading guidelines that most of us look to.
And then, the American Academy of Pediatrics, I have the honor of being involved with this paper. We're revising our clinical report on concussions focused exclusively on kids, pediatric, youth and teenager.
So those two papers are coming out in 2017. That will have some changes.
I think when you look at specific topic for focus, there's going to be biomarkers. So is there anything from blood testing that we can do to look for concussion, diagnosed, or look at outcomes? That's a big research push.
Sometimes, that you'll get biomarkers with imaging like this fancy functional MRIs and CAT scans and stuff like that. Right now, all this stuff is just experimental research-based, not really clinically applicable. I think you'll see a lot more on returning to learn and how to get kids back into the classroom. And the American Academy of Pediatrics has a wonderful statement on that one.
And then, I think you'll see a lot on this active rehab. Like we talked about how much rest is too much, what can you actually do? Not necessarily sport, but just exercise. Exercise generally tends to be good for everything. How can we use exercise most effectively to help people get over the concussion? How much rest is too much? What can you do?
Dr. Mike Patrick: Great. Interesting stuff. We'll definitely keep our eyes and ears open on future results and have more updates for folks as we know more about concussions.
Dr. Kevin Walter: It's like I said, it changes every year. It's the fascinating fast-changing field.
Dr. Mike Patrick: Yeah, great, great stuff.
We're going to have lots of links for you at the Show Notes page for this episode, 362, over at PediaCast.org. We'll put a link to the Sports Medicine Program at your institution, at the Children's Hospital of Wisconsin. And we'll also put a link to the Sports Medicine Program here at Nationwide Children's.
Here at Nationwide Children's, we have a specific concussion information page for students, coaches, and parents. And it has lots of information about concussions. Some of the stuff that we've talked about here today. There's also toolkits for coaches and athletic programs that you can use. So we'll have links to all those resources. And then, of course, a link to the Concussion Clinic here at Nationwide Children's Hospital as well.
And if you're not in the Milwaukee Area or the Central Ohio Columbus region, if your child does have a concussion, especially if there's significant symptoms or long-lasting symptoms, it is a good idea to check with the local… The first place to check is with your regular doctor, of course. And they're going to know what resources are available in your specific area. But you do want to see a pediatric concussion expert if you're running into those prolonged or severe symptoms.
All right, well, once again, thanks so much to Dr. Kevin Walter, Program Director for Sports Medicine at the Children's Hospital of Wisconsin. Thanks so much for being here today.
Dr. Kevin Walter: Thanks for having me.
Dr. Mike Patrick: All right, that is all the time we have today. PediaCast is a production of Nationwide Children's Hospital. I want to thank Dr. Kevin Walter again. That was such a great interview. I really enjoyed that. Such great information for folks.
He is the Program Director of Sports Medicine at the Children's Hospital of Wisconsin. So I really do appreciate him stopping by.
And, of course, I appreciate all of you stopping by, too. And taking time out of your day to make PediaCast a part of it. Thank you very much for all your support in 2016. And the many shows that we'll have for you coming up in 2017.
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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.
Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.