Concussion Care 101

John Horton:

Hello, and welcome to another episode of Sports Essentials, the workout buddy of our popular Health Essentials podcast. I'm John Horton, your co-host, with Dr. Dr. Lauren Wichman. How's it going today, Doc?

Dr. Lauren Wichman:

Hi, John. I'm doing great, and really excited about the conversation that we're about to have today that is on a really important topic.

John Horton:

Well, it definitely is. And we are going to dive headfirst, figuratively speaking, of course, into the topic of concussions. Now, I know over time, folks have really tried to minimize the seriousness of this sort of injury with cute phrases like getting your bell rung or seeing stars. But the reality is a concussion is a brain injury, and that deserves some serious talk.

Dr. Lauren Wichman:

No doubt about it. I think our education about what a concussion is has significantly evolved over the years. There is still plenty that we don't know about it. But as time has gone on, we've found how important it is for athlete health to make sure that we're managing this in the right way, and getting them back to sport once they've fully recovered.

John Horton:

Well, and that's the key, that full recovery. And as we talked about, there's a lot of misunderstandings as to what having a concussion means, what you can and can't do right afterwards, and it really is important to follow a set process to make sure you recover fully.

Dr. Lauren Wichman:

Definitely. And our guest today, Dr. Rick Figler, he is one of the best in the business to be able to help give us recommendations, guidance, talk through his experience and process when he sees concussions of all different varieties and severities.

John Horton:

Yeah. And he sees a lot of them, because he's the director of the Concussion Center here at Cleveland Clinic Center for Sports Medicine. So this is what he does all day, every day.

Dr. Lauren Wichman:

It'll be a fantastic conversation and really, really informative, I think, for our listeners. If you're faced with a concussion and you're unsure of where to go next, hopefully this conversation will be able to help give you some of that guidance before you may be able to see your doctor about next steps for you.

John Horton:

Let's get to it then. It's too important to wait. Welcome to the podcast, Dr. Figler. Thank you so much for carving a little time out of your busy schedule to come chat with us.

Dr. Rick Figler:

Thanks for having me. Appreciate it.

John Horton:

So Dr. Figler, in sports, I know we're all programmed to try to push through aches and pains and minor injuries, and you might be able to get away with that when you're dealing with a sprained ankle or something. But that approach doesn't quite work when we're dealing with our brains, which has to make treating concussions just a bit challenging.

Dr. Rick Figler:

It's a bit challenging, because it is, after all, the brain, and it's a pretty important component of how we function day to day and minute to minute, and we want to protect it as much as we can for the future. So I think one of the most challenging things over the course of the years has been accepting that... I think we've come a long way, of accepting the fact that when somebody does have a head injury, it's an easier thing to do to pull them out and ask questions later, because the suspicion is always there. And that's why every state across our nation has a rule saying that if you suspect a concussion, that athlete is removed from play, and that's all about protection, because we know that if we pull them out sooner, they get better faster. If we can recognize the symptoms earlier, they're going to have probably less issues down the road, not just we think in the future future, but also in the immediacy of their recovery so they can get back to sport.

John Horton:

That has been such a big change in the last few years where there's so much more attention on it, and I think we're realizing what a big deal it is, especially with how you treat it, how you immediately respond to it, and then what it means long term.

Dr. Rick Figler:

So one of the things that has helped has been education across the board, and some of that is grassroots effort, but some of that has been, obviously, at the national level as well. When you have different organizations, like our national medical organization or the NFL or the NBA, when those concussions happen at that level, it draws a lot more attention to what we're doing on the sidelines and in the locker room and in the office to make sure these kids are back to where they need to be before they go back out and play as well.

But the first-line responders, the athletic trainers are one big group, that they're on the sidelines, they know the athletes, they can figure out is this athlete acting normal, not acting normal after a hit? But it's also the kids, we have kids pulling other kids off. So teammates need to make sure that they're aware that when their teammate goes down or they get hit and they're not acting normal, that attention is brought to that, because again, if we pull them off faster, we get them back faster too. Coaches, parents noticing different things after the game, all of them need to be educated as far as the signs and symptoms of concussion to make sure that they're all aware to make sure that their son, their daughter's doing the best they can for the future, and also for the season.

John Horton:

Yeah. Well, you had mentioned education, and that is what we are all about here on Sports Essentials, and we really want to help people understand what's going on with the concussion and what they need to do. So, I guess, to get us going here, let's just get a little talk going about what a concussion actually is and what's happening inside our skulls when that goes on.

Dr. Rick Figler:

Yeah. So any kind of blow to the head, or even an imparted force that gets to the body and then gets to the head can cause concussive-type symptoms. So what we think happens in the skull itself is the brain gets jostled a little bit, no different than spraining your ankle. You can sprain your ankle and different things go on right away. The healing process starts right away as well after the injury.

So when the brain gets hit, it goes through this metabolic cascade, some dysregulation of blood flow, and things are happening on a cellular level to try to heal it right away. You get a cut on your finger, your body doesn't wait to heal that. It's starting right away to say, "Wait, there's something going on here. We're leaking someplace. We've got to go fix it." And every time that that happens to a brain, the brain's doing the same thing, trying to fix it.

So we think most of this happens on a pretty cellular level, where there's these axons. Axons are like tiny filaments in the brain that are little wires that connect the brain all over the place. I think there's like 90 billion or trillion synapses that are in the brain. There's miles and miles of them.

John Horton:

A lot of them. Whatever the number is.

Dr. Rick Figler:

What's that?

John Horton:

A lot of them. Whatever the number is, it's high.

Dr. Rick Figler:

Yeah. So if there's 90 billion of these, there's a lot of them, so we can impart a little bit of damage that we can probably heal. But all these trillions of connections that are going around the brain get disrupted, and these are all connected by axons. And we think that these axons, which are the wires that send signals from one cell to the other, think about it like a phone wire or your charging cord, if there's a break in that, then it doesn't conduct as quick. When it's insulated, it conducts quicker. And we think that some of these stretch injuries that happens to the axons and allow the axons to leak, those are what need to get fixed in the immediacy.

So we think that when some of those stretch injuries happen... And they happen in different parts of the brain, for sure, where there's more axons, there's more interconnections. Think about it like if you ring a rag, the outside of the rag's not going to get as tight as the middle of the rag. So the center of the brain, we think, takes a little bit of the brunt of some of these injuries more so than the periphery. And it affects function, and it affects function on a lot of different levels, whether that's sleep, whether that's emotional, whether that's cognitive, behavioral, whatever it is, it affects all those different functions of the brain.So typically, like I said, the brain starts to heal itself right away, and it does a pretty good job, as long as we don't get in the way of that and we nurture it appropriately along that recovery pattern. So that's what happens in the brain.

We also think that there's a secondary injury that we see a lot. About 40% to 50% of people that suffer a concussive injury also suffer some neck pain. So they'll complain about neck symptoms after their injury too, because if you think about when the head gets hit, the neck is going to snap back, and the muscles are controlling that motion going back. And a lot of times, there's a strain of those muscles that we see a lot in clinic and that we've done a lot to identify, because a lot of those persistent symptoms after their concussion are related to their neck discomfort.

John Horton:

You just talked about the head going back, and I know when you watch things and you hear people talk about concussions, is there a difference if your head snaps back, like what we see a lot with football players when they go back, they get tackled and their head hits the turf, or if it's on the side? Does it make a difference where that impact's coming from, given how your brain's kind of floating around in there?

Dr. Rick Figler:

We think there is. There were some studies, and I wouldn't say they've all been validated. But when you think about just the skull itself and you get hit in one spot, that energy's going to get imparted someplace else. So if I hit my head here, the energy's going this way. If I hit my head here, the energy's going that way. If I get twisted, it's going to get hit and twisted around as well.

John Horton:

It goes with the force. However you get hit, your brain's going to... You get hit in the back of the head, it goes to the front.

Dr. Rick Figler:

It's all about vectors. It's all about physics. It's all about vectors. So we think that when that brain gets jostled around a little bit, there's some predictability models about where you get hit, how you get hit, the force you get hit by, the head goes back. I truly, truly believe that the neck has a lot to do with that too, and the neck will absorb some of that blow too. So if I were to tell you, "Hey, listen, I'm going to hit you," you're going to tense up and get ready for that hit. If you don't see me coming and I hit you, there's going to be a lot more motion of your head and your neck going back as well.

So we do think that neck strength and neck stability helps a lot when it comes to absorbing some of that force. Some of the worst concussions that we've seen, when I say worst concussions, I'm talking about length of recovery, not necessarily severity, but length of recovery, come from the sucker punches, so to speak. The kid that's playing soccer that turns around and the ball's getting cleared behind them, and next thing you know, that ball doesn't clear, they get hit in the head and the head goes forward.

John Horton:

Is that when you hit in the side? Is the side worse or is going front-back worse?

Dr. Rick Figler:

Well, there's a bunch of different mechanisms. So a lot of the football players get conditioned to do this. Soccer players get conditioned to hit in the front of their head. So those neck muscles are really in tune with that. But let's say somebody falls backwards, when you fall backwards, you put your hands down. A lot of times, you don't know when you're going to hit and your head's going to snap back, whether it's the back and then a forward motion that goes on with that too. So there's different things that are happening to those neck muscles that are trying to stabilize the brain when that happens.

Other kids, volleyball players, they're putting their hands up and they're expecting to block the ball like this and they get hit in the head. The analogy is similar to if you're walking down a flight of stairs and you think there's another step and there's not another step, and your body is expecting one thing and there's another thing that's happening, your body has to adapt to that. And sometimes it's a twisted ankle, sometimes you catch yourself. But if you don't have that anticipatory ability to absorb that blow, we think that that's when some of those worse injuries happen, especially around the cervical region, the neck region.

John Horton:

So Dr. Wichman, when you're on the sidelines working with young athletes, how often are you seeing concussions happen on the field of play?

Dr. Lauren Wichman:

We definitely see these injuries throughout the season, not only at the youth and high school levels, but also at college and professional. Certain sports, it definitely happens more frequently, I would say. We've touched on some of them already, football, soccer. But any contact sport, hockey, wrestling, any sport with projectiles, lacrosse, you've got a lot of different sports that have mechanisms that allow these concussions to happen more frequently.

John Horton:

I know we had mentioned soccer too, which isn't one you normally think of. But, I mean, heading that ball, that's a pretty big force on your head.

Dr. Lauren Wichman:

No doubt about it. As somebody who did unfortunately experience a concussion during my college soccer career, when you're going up for a header, you can hit the ball, but also the other player's head. And as Dr. Figler was talking about, not necessarily anticipating that the other player's head is coming into your line of aim, that can lead to a pretty gruesome mechanism for a concussion.

Dr. Rick Figler:

We were talking about those vectors earlier, John, and the physics, so that's another one that we see, is they go up in the box and they go to head the ball, and then they get jostled, and they think that the ball's going to hit them here, but it doesn't, it hits them here, and the neck muscles are in tune to think that it's going to hit it right here, but then the neck goes back and twists, and that's... A lot of times, we see those concussions happen too.

John Horton:

Yeah. It sounds like it's those unexpected forces that hit you, where you can't brace, and then your brain just kind of bounces around in its little home there.

Dr. Lauren Wichman:

You can even see it too, right? It's player to player, player to ball, player to surface. We'll see it in basketball or volleyball, where players are hitting their head on the court. Definitely a lot of different pieces at play here from a mechanism standpoint. It can happen to anybody.

John Horton:

And that's what's so fascinating with this. When we were talking ahead of time, I think we went over how if you break a bone or even you sprain an ankle, you do something like that, there are some pretty obvious physical signs that you see that let you know, hey, something's wrong. With a concussion, there doesn't seem to be that same thing. It's not going to pop up on an X-ray or something like that, or you're not going to have that real obvious sign that when you just look at somebody, to know. And I know we talked about there is an extensive checklist that you go over to determine whether somebody may have suffered this sort of brain injury. Dr. Figler, can you walk us through the steps that happen there?

Dr. Rick Figler:

Yeah. So when we're suspicious of it, we can do some sideline testing, and we'll ask them how they feel, which is a really horrible question, because the answer that we always get is, "I'm fine. I'm fine." So then, we go into some details, and you could see it. I've been on the sidelines long enough, Dr. Wichman has as well, that you can kind of see it in their eyes, when their eyes are kind of glossed over. To that point, we've developed some diagnostic tests that we can do on the sidelines, where we track eye movements, and we move their necks and see if they can focus on objects at times. And a lot of times, that will increase their symptoms, which tells us, I don't want to say definitively, but with pretty good confidence that it's a concussion.

One of the things that we've been saying for years and years and years is when in doubt, sit them up. So if they're coming over, by Ohio law, actually, if they're coming over and they have a concussion, and most laws across the country, by the way, if you suspect a concussion at the high school level, they're not going back in. It's very difficult to disprove a concussion because it really happens in evolution. Sometimes those symptoms don't come on right away. They may come on worse in the next half hour or 45 minutes or hour, or even the next day. So the general rule is if you're evaluating them, they should pretty much be ruled out. There's a difference, there's variabilities at the professional level. I would say in a collegiate level, if we're pretty confident that it's more neck than it is head, then we might be able to clear them to go back out there. But that's with some pretty extensive testing and making sure that we're confident in the fact that they don't have a concussion.

John Horton:

Yeah. I think you said there was like 27 symptoms that you guys run through with that checklist to see whether or not somebody may have sustained a concussion.

Dr. Rick Figler:

Yeah. So they're kind of clustered into physical symptoms, emotional symptoms, sleep symptoms, cognitive symptoms, like do you have a headache? Do you have neck pain? Do you have dizziness? Do you have lightheadedness? Eyes hurting? Are they more emotional? I've had kids come off the sidelines crying, and can't tell me why they're crying, because they just got hit in the head. Fatigue, difficulty focusing, difficulty concentrating, eye pain. So there's a host of symptoms that...

And then, we monitor those over the course of their recovery. And if you took 127, it's a scale of zero to six, zero being nothing, six being severe, and when they come over and they have a symptom score right off the bat of 144, there's two things I look for, is, one, okay, let's shut them down obviously right now. But two, what's their symptom score the next day? Because that trajectory usually goes like this. So if they have 144 here and they have 20 the next day, that's a really good sign. If they have 144 on day one and 137 on day two and their symptoms are going down like this, that trajectory suggests that they may take a little bit longer to heal. And the literature supports that as well.

John Horton:

In the moment though, when an athlete comes to the sidelines, concussions can be severe, obviously, and those seem like they stand out, but if they're really mild, which can bring concerns, how hard is it to detect? Are you worried that things might just slip past you?

Dr. Lauren Wichman:

I definitely think, as Dr. Figler said, that they can be challenging if they are on the more mild side, which lends to what he said in terms of if we feel like there is at all a suspicion for a potential concussion, we have to pull them out, because those 27 symptoms on the checklist can develop over a course of 24 hours or even longer. And one of the big challenges, especially in somebody who may have had more than one concussion in their history, is those concussions can present differently. They may have one concussion that has a lot more of those headache-type symptoms, but then another one that is a little bit more focused on difficulty concentrating or difficulty with some of those managing emotions or sleep. All of those clusters can be different in everybody, which makes it even more challenging to recognize.

John Horton:

Well, and even as you're going through that list, you can see how difficult it would be to assess that in the moment. I mean, you're in that little blue medical tent or whatever it is, and you're trying to make this call in an instant. It's got to be tough. Dr. Figler, I've got to be honest, I've been laughing about your proposal to invent something called the concussionator since we talked the last time. I think we really need one.

Dr. Rick Figler:

Yeah. It would be great. And I think that eventually, we're going to get to the point where there's these biomarkers that are released from the brain when the brain is injured that we know happen, these little proteins that when there's trauma, they get released into the cerebral spinal fluid and then into the bloodstream. We'll get there at some point. But it would be great to, almost like Star Trek, just wave something around their eyes, and then next thing you know, they have a concussion. I actually think the eye stuff will come faster than the biomarkers, because the biomarkers are fraught with potential misses. I don't think the eyes will miss much. Because I can ask you to jump high, if your ankle's broken, you can't jump as high. I can ask you to move your eyes fast, but if you can't move your eyes fast because you have a concussion, that's a concussion, or you're drunk, right? And if they're drunk on the sidelines, we've got a whole nother problem.

John Horton:

That would be an issue. What you're saying about the eyes though makes total sense, because you do see it in them. You see so much in the eyes, like you said, that glassy look. I'd imagine the pupils even get a little more dilated?

Dr. Rick Figler:

They do, and it's pretty impressive. We'll come out... Because you lose some of that regulatory control, that autonomic control of your eyes, and that's why we think a lot of people get sensitivity to light, because it's almost like you're just opening up the blinds and all this light's coming in. You can't control that anymore. So there's some pupillary response stuff that they're looking at as well, where if I shine a light in your eye, your eyes should be able to close pretty quickly. And then, sometimes there's a lag when that happens, so they're closing much slower when it comes to somebody who just suffered a concussion. And that gets better over the course of time, but we've got to monitor that as well. But that's where the concussionometer idea comes in.

Dr. Lauren Wichman:

And I tell people too, especially with the eyes, it's so important that we do monitor that as we're recovering, because eye movements are really important in sport too. You need to make sure that you can move quickly to be able to track the ball, to be able to perform your best. So that's a really important piece in the recovery too.

John Horton:

Now, since you brought up recovery, let's move to that step here, because obviously we know that concussions happen, we know that your brain is suffering an injury. So now, you've been pulled out of the game, and now you've got to work on healing and getting better. So let's walk through that process that starts, because I know it's a little involved when you do have a concussion, and as I understand, there's kind of six stages of concussion recovery. So Dr. Figler, if you want to get us going on step one.

Dr. Rick Figler:

Yeah. So the first one is basically, obviously, we're removing them from the field, from the play. There are times when we'll have athletes stay on the sidelines because their symptoms are pretty mild, but we want to get a good assessment in the locker room. So that first step is relative rest. And we could border online strict rest for the first 24, 48 hours or so to see how those symptoms are coming about. We get in the way of recovery, I think, more than we should sometimes by doing too much to some of these athletes, or the athletes doing too much. Again, it goes to the same thing I was talking about before, where we pull them off quicker, they get better faster. They take another hit, now they have two injuries that are trying to heal themselves all at once, and those two injuries may be more than what the brain can actually handle at the time.

So the first step is relative rest, and then we try to get them to do some light exercise. We know based on... Well, actually, let me go back. What we try to do is minimize the amount of brain function that they're using. So we try to get them to stay off their screens for a little bit, not completely. But the general rule that I tell people in clinic all the time is if you start to do something that starts to bother you, just pull back.

John Horton:

Stop. Yeah.

Dr. Rick Figler:

Yeah.

John Horton:

Listen to your body, which we say all the time.

Dr. Rick Figler:

Right. I mean, if you sprained your ankle and you were walking on it and you couldn't walk, I wouldn't tell you to keep walking. I mean, you've just got to back off, right? So we let them go to their symptoms, and then pull back a little bit.

John Horton:

On the relative rest thing, and we're in this first step, I know there's something that we've all heard over time ,that there should be no sleeping, that if you're worried if somebody has a concussion, you've got to keep them awake. Is that kind of a fallacy, one of those old things that's just kind of hung around?

Dr. Rick Figler:

So we think that sleep is one of the best recovery tools when it comes to concussion. Now, sleep without the ability to wake up, so being unconscious, different story. But we advise the moms to check on their kids, but not to go in and poke them with a stick every 20 minutes while they're sleeping because we want to make sure that they're resting appropriately. Think about the last time you didn't get a good night's sleep. How did you feel the next day? The brain recovers when it sleeps.

There's something called the glymphatic system. So the glymphatic system is... The brain has a filtration system that works 90% when we're sleeping and only 10% when we're awake. That's filtering out all this crud that's in our brain, similar to our liver getting through toxins, but it filters out all that stuff, and when we're sleeping, it does a much better job. If we don't sleep well, it doesn't do a good job. And it's really vital in that moment. There are studies that show that people that have poor sleep after concussions, whether that's inability to fall asleep, inability to stay asleep, not sleeping too much, but inability to rest, they have a longer recovery.

John Horton:

And just to clarify too, when we're talking about going to sleep, this is hours later, after you've been assessed, things like that. If you come off the field and want to take a nap on the sidelines, you've got some bigger issues there, that's not what we're looking at.

Dr. Rick Figler:

Yeah. And that's actually one of the red flags that we look for. If somebody cannot keep their eyes open, they're going to the emergency room because that could be a brain bleed, and that's one of the things that comes in from that mild sports concussion to a traumatic brain injury.

Dr. Lauren Wichman:

And during that period of relative rest, if our athletes are having symptoms like headache, one of the most common things I would think of is, okay, if you have a headache, take an Advil to be able to help curb some of those symptoms. What are your recommendations to parents during that relative rest period when it comes to medicines to be able to help improve some of those symptoms?

Dr. Rick Figler:

Yeah. It's a great question, because we get it all the time and we think that everybody knows the answer. I think it's because we've been doing it so long, we just think everybody knows the answer. So there's a relative risk when you put somebody on an aspirin or an anti-inflammatory that they could potentially increase their risk of bleeding, so we tell them to avoid those at all costs. If they needed to take medicine, we want them to take Tylenol in the first 24, 48 hours. We think after 48 hours, it's probably safe to take Advil or Motrin, because that does, quote, unquote, "thin the blood" a little bit.

But we want to make sure that when they take the medicine, it's not to go do something, because what we find is they take medicine, they go out, they do something, and next thing you know, the medicine wears off and everything gets worse. So the idea is that if you're going to rest, like I tell people, before sleep, all means. If you have a headache before you're going to bed, pain and sleep do not get along together. So if you can take care of that pain by taking the medicine before you go to bed, absolutely wonderful. That way, you have less of a headache, you're going to sleep a little bit better, so that's a smart thing to do.

We also have been using a lot of anti-inflammatory gel on a lot of kids for their neck discomfort, because it's relatively superficial and it's not as absorbed, so it shouldn't affect their ability to mask their symptoms, so to speak, with the medication.

John Horton:

You had mentioned light earlier too and how that can really bother people after they've had a concussion. Another old tale, I guess, you used to hear was staying in a dark room. Do you have to turn all the lights out, or can you just be in a normal setting and just... I guess, as you can tolerate it?

Dr. Rick Figler:

Yeah. We've come full circle on that one. So we started preaching this years ago, where this relative rest, getting more activity is more important. Cocooning is completely out of style, so we don't want to cocoon kids. So I tell patients and parents all the time, the stagnant brain becomes more stagnant and the overactive brain becomes more symptomatic. We're really searching for Goldilocks. We want you to be able to do what you can without aggravating your symptoms, and that's going to win the game. We want stimulation, but we don't want too much.

So I kind of equate it to a dial. So if you turn something up and it's too loud, you turn it down, you can tolerate that, wonderful. If that gets too loud, you turn it down another notch, and you keep doing that based on your symptoms. And we think that does a lot better than just saying, "Don't do anything." Again, I equate it to how we used to treat some knee injuries in the past. So when somebody tore their MCL, we put them in a cast and we'd take them out in six weeks. And then, when you take the cast off, they have a raisin for a leg, and now you've got to rehab that for six weeks more, and so they're out for that longer period of time. So we've got to stimulate what we can stimulate, and not overstimulate what we don't want to overstimulate.

John Horton:

And when you're talking about that relative rest, then you can go do small things, like if you want to take a slow walk around the block, if you're okay doing it, that's all stuff you can do. You just don't want to do anything where you're pushing it, you're getting your heart rate up, that your body is really getting revved.

Dr. Rick Figler:

Yeah, 100%.

Dr. Lauren Wichman:

And I think this period of time can be really challenging for athletes too, right? Because we're pulling them out of sport, which is one of their prime social activities with all of their friends, and having to remove them from that can be really challenging. You pair that with taking away their phone, which is one of the more common ways that they communicate, they're at a complete loss. And a lot of times, what I'll recommend athletes do is if they aren't feeling well enough to be able to go and sit on the sideline at a practice or a game, at least checking in with their friends at the beginning, checking in with coaches, staying involved, as involved as they can, that keeps them really engaged.

And if they are going to use their phone, I completely agree with Dr. Figler, trying to minimize screens as much as possible. The TikTok, the video games absolutely has to go, especially if you think about it, all that scrolling and all the moving across the screen can really affect the eyes, which can slow recovery. But if you're going to send a text or two to stay involved with your friends, I think that that's okay. And then, one of the other things too that I always talk to athletes about that we don't always think about is driving. Many times, athletes have driven to practice, driven to school, and we have to eliminate that, especially during this relative rest period, but also throughout recovery, because with a concussion, you don't have that reaction time that is critical to make sure that you're safe on the road. So that's something that comes back later.

Dr. Rick Figler:

Yeah, those are great points. A couple of follow-ups. We have a reaction time test that we do in the office, where there's a dowel rod attached to a hockey puck. It's been around for years and years and years. But we basically drop the hockey puck, and the athlete has to catch the stick. And we can tell, based on how fast they are, whether or not they should be driving, because the last person I want behind me on the freeway is a kid who's got a concussion who can't press on the brake if I have to slam on my brakes.

And then, the other thing is, what you mentioned before, is these are social interactions for kids. This is their identity, and when we take that identity away from them as being an athlete, and now not an athlete for that period of time, and wondering when am I going to go back? The predictability models for what we used to determine grading of concussions, a lot of it was based on whether or not somebody was getting better within a week or within two to four weeks, so it was retrospective. I think now, we know that it's a day-to-day activity. Are they going to get back to school within the week to 10 days that we expect them to? Are they going to get back to sport within the three to four weeks that we expect them to or sooner? And that takes away a lot of what their plans were.

And a lot of it's riding on it. They don't want to let their teammates down. They don't want to let their coaches down. They don't want to lose the opportunity to maybe go play in college. They don't want to lose their starting position. I mean, there's a lot of emotions that are involved with this as well, and it's rough. It's difficult to handle that. And then, what she mentioned before, taking away all that socialization with their phones, we tell them, "Text your phone. You can text, it's fine. But just make it short, use voice-to-text, and then put it down and just chill after that."

John Horton:

Well, and I think those are all great points, because I think we've always gone with this, it's nothing. And it sounds like you want to have the brain working a little bit and doing some things, you just don't want to overstimulate it. So maybe keep your Snapchat streak alive and shoot something up. Maybe you can do Wordle. But you don't need to be scrolling for an hour looking at those videos just popping up over and over and over again.

Dr. Rick Figler:

And that scrolling that you mentioned, the eyes moving up and down, then they become more symptomatic, they get nauseous. They can't figure out why they're getting nauseous because we don't even think about it. When we're scrolling, we're just watching that stuff go up and down. But you get a concussion, you think about that a lot. We've had people have to use blinders so they can go into this little square so they can actually look at words just in a square and eventually get it out over the course of time as they can recover.

John Horton:

How long does this relative rest stage last? Are we talking just like a day, two, or is it just dependent on each person and the severity of the concussion?

Dr. Rick Figler:

Yeah. I think it's more dependent upon how they're doing from a symptom standpoint. And the relative rest, like she mentioned before, Dr. Wichman, everyone has a different time point and a different threshold where their symptoms start to come on. So we talk a lot about this sub-symptomatic threshold level, where once they reach their threshold, they back down. And that's the same with walking. So if somebody is going for a walk and they start to get symptoms, and they start to increase in intensity, and then they back down to a lower intensity and they feel better, wonderful.

I tell kids all the time, "You reach that intensity, you get a symptom, you back down to here, you feel fine, I'm fine with you being there. That's fine. But I don't want you down here either, and I definitely don't want you up here." So the threshold is really important, and the timeframe varies. It really varies for people. Their relative rest stage can last a day. They could be itching to go back the following day because their symptoms were mild and they cleared real quick, or they could last several weeks.

Dr. Lauren Wichman:

And one of the things that I think is really important to talk about during this relative rest period before we dive into that return to sport is return to school for a lot of these athletes. These are student athletes. So a big piece is I always say getting into the classroom before we even consider getting onto the field. Dr. Figler, what are some of the tips and guidance that you give student athletes regarding school?

Dr. Rick Figler:

Yeah. So it's kind of a similar thing. We don't want them to fall behind, because what happens is when they fall behind, they get more stressed, and when they get more stressed, again, stress and concussions are not going to go along very well. So we tell them when they're going back to school that they need to be able to read something beforehand, because if they can't read a paragraph without getting symptoms, they're not going to be able to control the environment in school and do what they need to. And the environment in school is not... They can't call timeouts in the middle of class and say, "All right. It's nap time. I'm going to sleep."

But they can potentially go to school... And I tell them to pick the easier subjects first. So we don't tell them, "You have to go to a half day or a quarter day or a full day." You go to the classes that you think you can manage because they may not be as obtrusive or challenging to your brain, or even environmentally. You might go to a science room and it's full of windows and the light bothers them, but they go to their computer class and then the computer screen bothers them. So they have to figure out what they can manage during that time. If they go to class and they start to get symptoms, a lot of times, just closing their eyes and taking that visual out of it so they can just sit there and listen might help them out. They can put their head down. If not, then they go to the nurse's office, they rest, they recover, and then they go back to classes.

So sometimes, they'll go to their easy class. They have a super hard class the next time, they'll skip it, and then they'll go to the next class. If they can't do that, then we tell them, "Listen, it's easier to pace yourself at home than to pace yourself at school." Because it's really hard to pace yourself at school when everything's getting thrown at you. So maybe they stay home if the environment is conducive to that and they can work on what they can work on, so they're trying not to fall behind. And communication for this is key with the school nurse, with their teachers, letting them know what's going on so they can feed them information and feed them what they can to try to keep up, because the stress that happens when these kids fall two, three weeks behind...

And we see kids sometimes, for whatever reason, two to three weeks after, and they have not gone to school, and they were ready to go to school after day two. And now, they have to make up all this work, and they feel like they're completely ostracized from their class. They can't catch up, it's new math problems. And they get really stressed and they get really far behind, and it takes a toll, for sure, because you mentioned, it's student athlete, student's first.

John Horton:

How often does it last that long? Because I've got to say, when I think of a concussion, I think, oh, you have a day or so maybe where you have to do this relative rest. You're talking weeks. I mean, is that that common, where it takes that long for your brain to get back to the point where you can ramp up activities?

Dr. Rick Figler:

I think a lot of it depends on the severity. There are some other things that I think play into it. I mentioned sleep before, pain. So if they are having significant neck pain and those headaches are getting in the way, and then they get more tense, and then the headaches get even worse, and they'll complain about all these frontal headaches.

I think it's more common, and I hate to say it, but I'm in a specialized clinic, so to speak, so I see this a lot more often because I see kids coming in for how to get out of this rut. I think a lot of them clear a lot faster than what we think. But I think the more complicated ones are just that, they're more complicated and they tend to last longer. Learning disabilities can play into that too. Kids trying to push through symptoms, definitely. And I tell kids all the time, "You push through symptoms, it's going to push back and it's going to take longer for you to heal."

John Horton:

Yeah. All right. Well, I feel like we spent a lot of time in that relative rest stage, but I think that's the key one, because it sounds like if you mess up that first step, nothing's going to go right after it. So you really want to take your time at the beginning and make sure that your brain gets the rest it needs, and can start advancing forward and letting you move on.

Dr. Rick Figler:

John, it's a really vital time for the recovery process, because as much as we know about the brain and how it heals itself, we don't know everything. But what we do know is that people, it takes them longer to heal when you irritate something. And again, you get a cut, you're not trying to make a cut bigger. It's not going to stop bleeding if you make it bigger. You're trying to hold it so it stops bleeding right away, and that's what we're trying to do in that immediacy. A lot of times, we go back to the basics too. When kids come in with a concussion, symptoms have been lasting several weeks, we just go back to the basics, and a lot of times, that works. That gets them back to where they need to be, because they've been trying to push through so hard because they're so far behind.

Dr. Lauren Wichman:

And there are a couple of tools too that we can use when maybe we're transitioning back to school or transitioning back to getting out and maybe need to dampen some of that input that is overstimulating. One of the things that I tell a lot of my student athletes is when you're trying to go back to school, you may be able to tolerate a classroom, but the loud environment of the cafeteria or during transition from class to class could be too much. So not even hesitating to throw in a pair of foam earplugs to try to dampen that sound, or sunglasses or a hat if it's really bright outside when you're going on your slow walk can be really helpful. We don't want people taking medicine to get through the school day because that's going to mask symptoms, and like we said, that's going to prolong things, just like Dr. Figler said, from a we're pushing through symptoms standpoint. But I think once we've transitioned off of needing those tools, and once we're back to the classroom without any issues, that's when we can consider that return-to-sport protocol.

Dr. Rick Figler:

And the other thing that we tell them all the time, if nothing else, just holding your hand above your head like this, because if they can't wear hats in school, they can't wear sunglasses, it blocks off a lot of that ambient light that's above them that's pouring down on them that we never think about. And again, until you get a concussion, you think about it a lot.

John Horton:

All right. So once you get to the point then where you're walking around in your daily routine, you're going to class, you're doing your full schedule, you're not hurting from all these other forces, like you said, the lights and things like that, where you're just back to that normal baseline. It sounds like step two then, you go to light aerobic activity?

Dr. Rick Figler:

We actually... Yeah.

John Horton:

Yeah. What does that mean? Because I think with most athletes, you want to jump from relative rest still and getting right back to it. What is that light aerobic activity step?

Dr. Rick Figler:

So we want that, actually, to start earlier. We don't want them to have to go back to school and then start that. We want them to do it as quickly as they can, and the studies suggest that if we do that earlier on, I think the pathophysiology of it is that they're flushing their brain out and they're getting their heart rate up. We all feel better... Most of us feel better when we exercise, right? But it flushes the brain out, similar to what we're doing when we're sleeping, and we think that that helps with the healing process. So it is based on the exertional level that they can maintain or they can start off with, and they can advance it every day.

So the general rule of thumb is we go light, moderate, high-intensity exercise, and if we can do that three days in a row, wonderful. But if they can only... We want them to get on a bike, go for a walk at a decent intensity, get their heart rate up a little bit. But if they notice their heart rate gets up or their symptoms come on, again, they go down to the next level of intensity and they stay there for that next 20 minutes, if it happened after 10. And then, we want them to push it a little bit further the next day, and a little bit more the next day. The sports-specific stuff is going to come later. It's a stepwise fashion. We can't get here without going from here to here to here to here to here to here to get to there.

And a lot of times, they will try to push it too hard, and next thing you know, they're stuck at a certain level, and that's okay. Then we reevaluate them and see what's going on during that time. It could be their neck's bothering them. It could be there's something else going on. But a lot of times, when they start to progress, they start to feel better, and the more that we keep them dormant, the longer it takes for them to heal.

John Horton:

So you said light, moderate, heavy, and it sounds like you want to spend at least one day at each one of those levels before going to the next one?

Dr. Rick Figler:

Yep. I would say that's the standard protocol. But there are times when we need multiple days in each of those steps, because it might be light-minus, light, light-plus for those three days, and then gradually getting them up to... And again, it depends on severity. It depends on the timing of the season too. I'm not going to push somebody as fast as they may want me to in the middle of summer because there's no games going on. We're preparing for the season and getting them better. But I'm not going to tell them to do nothing either, because I want them to stimulate themselves to make sure that they're getting that blood flow, getting that brain working again, and making sure that they're getting back to their sport, because again, it is, after all, their identification, and we want to get them as quickly, but as safely as possible back to where they need to get.

John Horton:

Especially with that light aerobic step, I take it you want to do things too that are not going to jostle your head?

Dr. Rick Figler:

Right.

John Horton:

I know you mentioned an exercise bike. That's something you can do, you're stationary. What are some other things that might be in that first light aerobic activity step?

Dr. Rick Figler:

It's walking. Elliptical might be an option for them as well. And by the way, when I say bike, I'm talking about stationary bike. We'll make sure we're not doing e-bikes or down the road or anything like that, increasing their risk. Light walking. And we tell them, "Don't walk around the neighborhood, walk by your house and keep going back and forth, if because you get symptoms, you don't want to be here and you have to go all the way back if you're symptomatic." And then, it's a great point about the jostling, because there's a lot of people that are proponents of heavy treadmill work when this happens, and I've seen way too many people start to jostle their neck and have worsening symptoms right away, because again, the neck is involved about 50% of the time with these injuries.

John Horton:

So you take that step there, you go to moderate. What does moderate mean? Dr. Wichman, you're dealing with your athletes, what are you telling them to do at that step?

Dr. Lauren Wichman:

I would say too, and I want to give a huge shout-out to our athletic training teammates here, because they are hugely, hugely helpful on progressing through these steps. A lot of times, they will give the athletes specifically what they want them to do to try to minimize some of the confusion that can happen. And also, which I think is really, really key, monitor symptoms before and after the exercise happens, because if our symptoms are significantly spiking, we may say, "Okay. Maybe we do need to back off a little bit on the intensity and try again tomorrow." So huge plug to them. I would say that the moderate activity is probably somewhat similar to the light activity. We're not getting into intense sprinting, we're not getting into jumping or anything like that, but we're just sticking with some of those similar activities, but taking it up a step.

John Horton:

And then, that next step, the heavier activity, a little bit more stuff. I think the key there is it's heavy, but non-contact, right? So if you're on a team, whatever, this is where you're off on the side doing some drills and making sure you don't get hit, your head doesn't get knocked, something like that.

Dr. Rick Figler:

Yeah. That's the sprinting, that's the cutting, that's the up-downs, doing HIIT workouts, or high-intensity workouts, where maybe they're doing jumping jacks, and then they're doing pushups, and then they're doing bear crawls. There's been some pretty inventive athletic trainers over the course of time that have built some of these protocols. But pushing the athlete to get their heart rate up. So when you think about your rate of perceived exertion, we want them up at the point where they're having a hard time catching their breath, we want them at that high intensity, but to your point, no contact. We want them to... And this is, obviously, after they've been cleared to progress to that next level. But we want to make sure that they're not aggravating anything while they're trying to push themselves cardiovascularly.

And then, sports-specific stuff can come into that as well, kicking a ball around on the ground, playing catch, getting their ocular system involved, doing dual tasking, things where they're having a conversation and they're walking, they're having a conversation and they're exercising, because we think that they need to get involved in the sports-specific stuff as well. But again, like you mentioned, no contact at this phase.

John Horton:

So that's where you can maybe do a drill. If you're playing soccer, you can do some dribbling or whatever, but you're not going to be out there running a practice?

Dr. Rick Figler:

Right. And it gives them a taste of getting back to what they want to do.

John Horton:

All right. So then, once you clear that, now we've gone through these steps, how do you know it's okay to get back to practice full-contact stuff to take that next step forward?

Dr. Rick Figler:

Yeah. So ideally before they go back to full contact, if we've had any baseline testing, and we could talk about baseline testing in a lot of different varieties, but we want them to feel back to their normal self. One of the questions that we always pose to the athlete is, "How much do you feel back to your normal self percentage-wise? So if you're 80%, what's that 20%?" And if they say, "Well, it's because I haven't played yet," or, "Because I haven't caught up on my homework," that's different than saying, "Well, because I still have a headache when I do this and my eye's still bothering me."

So once they get to the point where we can make sure that their symptom scores are basically zero... If they're not zero, we have to explain why they're not zero. Again, because maybe it's because they have trouble focusing, but they also have ADD, so I would never expect that score to be zero because it's always going to be one or two. So if those baseline scores go back to where they are, then we can progress them. There are some neuropsych testing that we do as well. The clinic, years ago, we developed an app to check some of their visual motor speed, their reaction time, and their processing speed, so they can do that and we can compare that to their baseline and make sure that they're where they are.

And I think athletes have been relatively honest about this over the course of the years, is are you back to where you need to be? Are you back to normal? Can we get you back into contact activities? And they'll go through lifting sessions as well to get their heart rate up. But before that contact, I want to make sure that they're back to where they need to be normally. And that contact, by the way, is controlled. That's not game. That's a controlled practice where they're hitting their teammates, because we know that, based on numbers, concussions are going to happen a lot more frequently in competition than they are in practice.

John Horton:

Yeah. You just mentioned lifting, and I want to make sure we touch on that, because we didn't as we were going through those steps. Lifting is one of those things I don't think people think of as being like we're going to jostle things around. But there are concerns, if you're trying to lift a bunch of weight, as far as the amount of pressure it puts on your brain, right?

Dr. Rick Figler:

Yeah. And we see that pretty frequently, especially with kids that have some autonomic dysfunction, which is something that we see post-injury that can delay recovery as well, and that basically is the way that the brain and the heart communicate with each other to increase their heart rate when it needs to. But when they're straining and if they're getting symptoms, that's never a really good sign. So we want to get them back to that strain level that they were at before to make sure it doesn't produce any symptoms. And by the way, one of the reasons why we take them through that stepwise fashion is just to test them at each of those levels, one, to make sure that they can handle it, but two, to make sure that the symptoms aren't getting worse. But we're really making sure that they can go to that next level based on this activity level, so it's a test. Every one is a test and a step to get back to where they need to be.

John Horton:

So with lifting, light aerobic, I take it you probably wouldn't be doing much lifting at all?

Dr. Rick Figler:

No.

John Horton:

Moderate, maybe you're just-

Dr. Rick Figler:

A little bit.

John Horton:

... lower weights, lower reps? And then, obviously-

Dr. Rick Figler:

No strain.

John Horton:

Yeah.

Dr. Lauren Wichman:

Yeah.

John Horton:

Okay.

Dr. Lauren Wichman:

Machine-based.

Dr. Rick Figler:

Simple.

Dr. Lauren Wichman:

Yeah.

John Horton:

It sounds like the key is not to push stuff.

Dr. Rick Figler:

Correct.

John Horton:

Yeah. And then, obviously, once you get through the practice, the full-contact thing, then if you go through that with no issues, you're game-ready again?

Dr. Rick Figler:

Yes. And everyone has bated breath when we release them, but we check all the boxes, dot all the I's and cross all the T's before they get back out there. There's always pressure because of games. And I hate to say it, but when you think about why some of these rules were put into place, if you think about a football injury happening on a Friday night, and then they start to recover Saturday, Sunday, they have enough days to get to that next Friday game if they clear everything. So that's kind of why that was made. I'm not saying it's the right thing or the wrong thing, but that's kind of why it was made, because there are kids that can get back that fast.

The ones that we don't want to miss are the ones that are going to take longer, that need a little bit more TLC to get them back to where they need to be. We have a lot of kids that come in with cumulative injuries over the course of time, that when you truly ask them... They come in and they've had five concussions, and you say, "All right. Tell me about the first one, second one, third one." The question we ask, "Did you fully recover from that? Were there residual symptoms?" A lot of times, they retrospectively look back and like, "Yeah, I've had headaches." We had a kid in clinic not too long ago that she's had a headache, she's been taking Motrin every day since soccer season, October last year, and it's August.

John Horton:

Wow. Yeah.

Dr. Rick Figler:

Yeah. She-

John Horton:

That's not good. Yeah.

Dr. Rick Figler:

No, and she never told her parents, but the good news for her is that academically, 100% fine. Sleep, emotionally, 100% fine. It's all in her neck. So we've been treating her neck, and she'll be fine. I have confidence that she'll be absolutely fine. But she didn't understand why she was having headaches. She'd never had headaches before, but every day since then, she's had a headache.

Dr. Lauren Wichman:

When you're getting back to competition and you're thinking, okay, especially in somebody like the cases that you see a lot in your clinic, Dr. Figler, with multiple concussions, I think one of the rumors that goes around is if you've hit a certain number of concussions, you can no longer participate in your sports. When people have come in and said that to you, what is generally your response and guidance for them?

Dr. Rick Figler:

So it's not a three strikes and you're out, right? The three concussion rule was from Dr. Augustus Thorndike, who was a Harvard sports... He's considered one of the grandfathers of sports medicine. In the 1950s, he came up with this arbitrary rule based on his experience that if you have three concussions, you probably shouldn't play anymore. So we even bring it up after the second concussion in almost all of our visits, that that's not a rule, because you cannot have an absolute number of concussions and say that if one kid has a concussion and the symptoms last for two days for the first concussion, four days for the second one, and five days for the third one, you cannot compare that to somebody who took three months to recover from their first one, six months to recover from their second one, and four months recovery from their third one. Those are two totally different scenarios.

John Horton:

Severity matters, is what you're saying.

Dr. Rick Figler:

Yeah. It's severity and it's recovery. I think it's a very hard and fast rule that we've tried to debunk over the course of the years, and I think we've been successful with it, because when kids... And the problem is then there's a fear of reporting, and if you have that fear of reporting, then the kid who has that third concussion and may be even more symptomatic says, "I'm not going to say anything because I don't want to be disallowed from playing sports anymore." I mean, it's a great question and it's a great topic to touch on, because yeah, it's not three strikes, you're out. It's have each concussion evaluated and make sure that you're safe to go back to play.

John Horton:

Well, I feel like this is a nice pivot point to talk about the long-term outlook. Everything we've been talking about now is getting that athlete back on the field so you're ready for the next game and things like that. Eventually, seasons end, people aren't playing games forever, and you have to look at how your brain is going to be working when you're 50 or 60 and things like that. We hear all the time about how concussions are linked to dementia. We hear about CTE all the time, this long-term damage that accumulates. Where does that fit into the picture here, Dr. Figler?

Dr. Rick Figler:

CTE in and of itself is a pathological diagnosis that is only, right now, only be able to diagnosed at death, so with autopsy. So similar to the conversations about ankle sprains, severity, there are people that sprain their ankle, they go back right out and play. There are people that sprain their ankle, they have a fracture, and they're out for three months. The severity definitely matters, we think, and the accumulation over the course of time matters as well.

So when we have these injuries... We talked about the protein buildup as well. So they did a study, it was several years ago, where they took boxers and they compared them to non-boxers. They did a pre-match lumbar tap, where they take their cerebral spinal fluid, which is the fluid that's floating around your brain, they took that out and they looked at the protein levels of it before the match and then looked at it after the match, and there was a significant amount of protein deposition in that fluid after their match. They didn't need to get knocked out. They didn't need to get diagnosed with a concussion. We just know that the head trauma caused that.

So what that tells us, as well as this pathophysiology of these neurotransmitters getting irritated, the billions of neurons and the trillions of connections that are in there getting irritated, is these proteins are released, and there's an accumulation of those that happen, that most of those get cleared up. But these tau proteins that you see in the literature, you hear about with CTE, are these little tangles that happen. They're all in there, but sometimes they get tangled up and they can't get removed, either because they're too big or there's just way too many of them. So then, the brain kind of walls them off a little bit, and we think that those protein depositions are what build up over the course of time, secondary to accumulation.

So amateur athletes, less likely to have dementia and ALS and neurodegenerative diseases over the course of time. Professional athletes, soccer, football, more likely to have it because of, we think, the repetitive head trauma. So that's something that we worry about, but I wouldn't say that we worry about it in our context of these kids getting one or two concussions, because a lot of these things are fixable because our body does a great job of fixing it. But we also think that if you're a professional athlete, you're making millions of dollars and you're getting hit, and we know that linemen are very bad at... They're higher risk for those problems, but they also don't admit what's going on every time that they get hit, and they have these because-I'm-supposed-to-feel-that-way attitudes about I don't feel right, I have a headache after every game. And those might be sub-concussive injuries that are accumulating over the course of time.

John Horton:

I thought I've read research though that said even one concussion, your risk of dementia jumps a little bit, and I'd imagine with every one after that, it ticks up a little bit more. Is this buildup a natural thing, and we're all dealing with stuff every day with what happens to our bodies?

Dr. Rick Figler:

We are. And I think that it depends, again, on the severity, how much protein is there, and what we do to clear those proteins out initially. There will be, I'm sure, in probably hopefully our lifetimes, a medication that will help clear those proteins out a little bit better. We don't have anything right now. But the protein deposition, we think, has a lot to do with it. But the treatment, I think, has a lot more to do with it now than what it did before. We don't see a lot of 14-year-old kids with dementia, right?

John Horton:

Not going to hit right away.

Dr. Rick Figler:

Right. But you're right. A lot of things that we do throughout the course of our lifetime shape how we are going to be later on down the road. That could be processed food, that could be lack of activity, that could be diabetes, smoking, hypertension, all those different factors that come in. I think one of the things that we've missed along the way with treating a lot of these athletes that have gone on is the awareness of what's going on with them and the lack of treatment that we might have for them because we don't address the issues that are building up over the course of time.

Why are you having those chronic headaches? Is it your neck? Why are you having depression? Is it from the concussions? Is there stuff that we can do to help that out? And there's a lot of socioeconomic issues that can go on with that as well, as far as people getting the appropriate treatment at the right time. It's a scary thing when you get a concussion for everybody, the kid, the parents, the coaches, everybody involved. But I think we do a much better job of hopefully preventing injury in the future than what we did years and years ago, which was how many fingers do I have? Four? Close enough. Okay. Get back out there. It just doesn't work that way anymore.

John Horton:

Yeah. So when you're having these discussions, it seems like this is where doing those recovery steps right really come into play. Dr. Wichman, when you're talking to your 17-year-old athlete, they're not thinking about how they're going to feel when they're 50. They're thinking about getting into the next game. How do you lay this out for them that says, "Listen, how you do the next week could make a big difference for you years later"?

Dr. Lauren Wichman:

I completely agree with where you're coming from, in terms of sometimes it's very easy, in an athlete mindset, to be so passionate and want to do everything you can for your team, to want to just focus on the short term. And that's where I think it is helpful for us to be able to try to remind athletes about the long term, telling them, '"It's important. You only have one brain, and that brain is one of the most important organs in your body for not only right now in school, in sports, but long, long term. And by treating the recovery process with a concussion the right way, we're doing everything we can to maintain the health of that brain." And I think when you remind people about truly what we're talking about here, it can set the stage for hopefully a more successful recovery.

John Horton:

Yeah. I feel like we're kind of winding down here, and I want to make sure we touch on prevention. And I know so many of these concussions just happen in the course of an activity. I mean, there's nothing you can really do about it, it's part of the game you're playing. Are there things you can do to protect yourself a little bit more or maybe improve your odds?

Dr. Rick Figler:

So we've been doing that over the course of years, and I think that we're doing a better job of collecting data and research that has our common sensical ideas about this to ring true. The biggest thing, I think, that's happened over the course of time has been the policy changes that we've seen at different levels. The NFL change their kickoffs for a reason, collect data, and then make a change because the kickoffs are causing a lot of the concussions. I'll be honest, I don't know why it hasn't trickled down to multiple leagues at the collegiate level, as well as the high school level, but that's a whole nother discussion.

We know that there are some neuromuscular training things that you can do several times a week, like balance exercises, neck strengthening exercises that have been shown to decrease the risk of concussion over the course of years or course of the season. We've seen that mouth guards in hockey, just wearing a mouth guard across the whole board decreases your risk of concussion by 28%.

John Horton:

Wow.

Dr. Rick Figler:

Rules changes in hockey-

John Horton:

That's pretty significant.

Dr. Rick Figler:

That's huge. But hockey, 68% decrease in concussions with no checking in the adolescent period, so they decrease the concussions by 68%. You could still get hit by a stick and hit your head on the ice. But checking was a major reason why these kids, who had underdeveloped necks and weaker necks, were getting these concussions earlier on.

Other rule changes that we've seen. There was a study that was done in Florida, and this hasn't trickled across nationally yet, but when you think about women's lacrosse, men have to wear a helmet. Men or women do not have to wear a helmet, and I've argued this for years and years and years, that why is that the case? I mean, the ball's flying around, the sticks are flying around, and part of it is because there are rules that allow stick-to-stick contact in lacrosse, but not body checking or anything like that. So there was a study that was done in Florida that showed that they instituted a helmet law in 2018, and when they compared their concussion rate to other states, there was a 74% increase of concussions in states that didn't wear helmets compared to Florida. That's huge.

So the other thing, I think, is collisions in football, so we've minimized the amount of contact that happens in football practices. So by minimizing that, we've seen the decrease in concussions in football practices, which is great, because athletic exposures are just that, and when kids are getting hit, they can get a concussion. Other things that happen are just implementing these strategies about awareness and making sure that we're recognizing these things earlier so we can implement the appropriate protocols for getting these kids off when they need to get off once they get hit in the head.

John Horton:

The equipment is such a big thing. And you think about those Guardian Caps you see now on NFL players, and they look kind of funky, I've got to be honest, when you see them on the field now. I wonder if in 10 years, everybody's going to have them on.

Dr. Lauren Wichman:

What do you tell parents, Dr. Figler, who are asking you about the latest new product that's on the market for a specific sport to prevent concussion?

Dr. Rick Figler:

Yeah. So the Guardian Cap's one of them, because we get that a lot of time during the course of the year. I think it's a great idea. I don't think that the literature to this point, aside from some of the NFL data that they've collected, that they've seen a decrease in contact with those athletes, the linemen that are wearing them, that has not been published. But the published data that has been shown in the high school areas where they put them on, dissimilar to what they did with the lacrosse helmets, it has not shown that there's been a significant decrease in concussion.

So for kids that want to prevent concussions, there are helmets. You have to make sure that regardless of what helmet you use, and you can go to... Virginia Tech has a website, along with the NFL, that lists the helmets that they think are the best in the lab and on the field that decrease the risk of concussion. Technology has come an awful long way when it comes to that. But the helmet needs to fit well. It needs to be in good repair. You need to use it correctly. You shouldn't be leading with your head. So those changes of showing a kid how to hit somebody else, not leading with their head is a big benefactor in decreasing concussions.

The headgear that came out with soccer, you were playing when that headgear came out, didn't show any decrease in concussions. If you're going to say what are the two things, I would say neuromuscular activities, so balance, coordination, and then the other one is neck strength, because I really, really believe in neck strength. One of our retired neurologists, Dr. Rothner, he came and shadowed me in my clinic, which I was very surprised by, and we were having really good conversations about what he saw in concussions over the course of the years, and he made a point. He said, he goes, "I see more symptoms in tall, thin people than I do in short, stout people." And it makes sense, because if this is somebody's neck and it's only going to go this far because their neck is really strong and it's able to control some of that, versus the whiplash-type injury that might happen with somebody who has a long, thin neck, they get more symptoms. And we do see a correlation with neck strength, not size, but neck strength and coordination with a decrease in concussion.

So if you have your kids do that, that might show a difference in the number of concussions they get throughout their playing career, might.

John Horton:

I'll have to work that in. Arm day, leg day, neck day.

Dr. Rick Figler:

And it's funny, because I have these conversations with girls all the time too, and I'm like, "No, no, no. I don't want your neck to get this wide. I just want it to be stronger. That's all we have to work on. It could be the same size. It's fine."

John Horton:

Well, I guess to wrap things up here then, Dr. Figler, Dr. Wichman, what do you want people to take away from this discussion on concussions, as far as maybe the seriousness of it, what they need to do, how important it is to really address symptoms right away?

Dr. Lauren Wichman:

I think some of the biggest takeaways are some of the pearls that hopefully we shared for everybody, especially during that relative rest period. The reminders that, okay, it is okay for everybody to go to sleep the night after the injury happens, not taking medicines to mask symptoms to be able to go do activities, that is not conducive to brain healing. Limiting screens extracurricularly from a TikTok and a video game perspective, but staying engaged with your teammates and being a part of the team is critically important. So sending off a text message or stopping by practice to say hi to everybody is really, really important.

Dr. Rick Figler:

I would echo those. To me, it's awareness, it's education, it's realizing that if you get hit in the head and you have symptoms, it's okay to pull yourself off the field and get better. If you tweaked your knee and you were worried about whether you tore something in your knee because your knee was hurting, you'd pull yourself out. And get evaluated for concussions, getting evaluated by somebody who knows what they're talking about. We see a lot of kids in our concussion clinic that I don't want to say were mismanaged, but probably didn't get the ideal care right after their injury that we could have maybe made a dent earlier on.

And we don't know. We don't have a magic formula, other than what we talked about today, to take care of concussions. But we're developing things that we think that we could probably institute a little bit faster, especially with the neck, because the neck is just one of those things that we see with these persistent symptoms after a concussion. And for everybody, I want to be able to separate this out, because we're doing a better job of it, but again, there's two injuries. There's one to the brain that affects the cognition and the ability for the brain to function. And then, the other one is, a lot of times, to the neck or emotionally or behaviorally or sleep disturbance or autonomic dysfunction that we touched on. We have to address those underlying persistent symptoms after the concussion.

So when we talk about... There's two different nomenclatures, persistent post-concussive symptoms and persistent symptoms after concussion. But we're really trying to do away with post-concussive syndrome, because a syndrome sounds really daunting, syndromes are bad. But these are just symptoms, and these symptoms that we can identify and then treat individually, we've been pretty successful at getting a lot of our athletes back to their function where they want to be, whether that's as a student or as a student athlete.

John Horton:

Yeah. Well, I have to say, I think this discussion we've had today shows how far we've come in the last 10, 20 years on concussion care, and how much more serious of an issue it's viewed as, and not just glossed over to get kids back out there on the field. So Dr. Figler, I really appreciate you coming in here, sharing all this information, and hopefully we'll have you back on at some point, we can talk about the concussionator and how it's really improved everything as far as the diagnosing.

Dr. Rick Figler:

Let's hope. Let's hope. Thank you, John. Appreciate it.

Dr. Lauren Wichman:

Thanks for coming, Dr. Figler. We really appreciate the discussion today.

John Horton:

Dr. Wichman, that conversation ended up being as info-packed as we had hoped coming in. And there's just so much to wrap your head around, but I think it all starts with the importance of if you suffer a concussion, if your kid suffers a concussion, you really have to follow this plan to make sure you can minimize any sort of complications.

Dr. Lauren Wichman:

100%. I think we heard so many different pieces to the recovery process and what's involved, but I think first and foremost, one of the most important things Dr. Figler emphasized is that if there is at all a concern for a potential concussion, we need to take it seriously. So athletes aren't letting their team down, letting their coaches down, letting themselves down by taking a step back, pulling themselves out for an evaluation. One could argue that by doing that, you're actually helping your team, and you're helping yourself in the short term and the long term by doing that so you can recover faster and get back on the field.

John Horton:

The hard part with that is athletes are so programmed to just fight through everything, you've got to grit it out and just power through it. It doesn't work that way when you're talking about a brain injury.

Dr. Lauren Wichman:

Particularly a concussion, which is so challenging to sometimes diagnose. Some of those symptoms can be in that gray area, where it's not as obvious as a sprained ankle that's bruised and swollen, you're walking on crutches so all your teammates can see, oh yeah, obviously this is something that's going on here. Those symptoms are the only way your body is telling you something's not right, and that symptom list can be long and vary concussion-to-concussion.

John Horton:

Right. And it sounds like the key is you have to be honest with yourself as you're getting back into your routine. If you start feeling some issues, you're having headaches, you're having pains, you need to dial it down a little bit and make sure that you give your body time to do the full recovery that it needs.

Dr. Lauren Wichman:

Not only initially, but also, just like you said, John, throughout that recovery process. If we're noticing some of those symptoms, headache, neck pain, difficulty concentrating, sensitivity to light or sound start to creep back up, we've just progressed too quickly. It doesn't mean we're going back to square one, but we just need to take a step back and give it a little bit more time before we're ready to progress to the next phase.

John Horton:

It's like when you play chutes and ladders, sometimes you go down a little bit, then you work your way back up. The key is though, eventually, you'll get back to your activity, things improve, but it just takes a little bit of time.

Dr. Lauren Wichman:

Once we're at that 100%, then we can feel confident going back to competition. And so that's where the guidance of our sports medicine team there, we're happy to help people get to that point.

John Horton:

Well, we definitely had some good guidance thrown our way today, and I think hopefully it'll benefit a lot of people as they're navigating what to do here. So if you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, play hard and be well.

Outro:

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