#77 - Concussion Guidelines for Return-to-Play with Dr. Mike Olson, Part 1

Hi guys, welcome to another episode of The Factor Podcast. I'm your host, Jessica Riddle. Today we kick off a brand new training with Dr. Mike Olson titled Concussion Management. How to use graded return to sport and return to school guidelines. Concussion management and post-concussion care are multifaceted and highly individualized. One person may have a fairly easy recovery and little long-term effects from a head injury, whereas another person with an almost identical brain trauma can be permanently disabled. The scientific community has made incredible advances in the last decade in our understanding of the short- and long-term effects of concussion, But there's still a number of mysteries when it comes to the physiological, neurological, mental, and emotional inner workings of the human brain. In part 1 of this fascinating 2-part series, you'll learn from Dr. Mike Olson. He's a nationally and internationally certified chiropractic sports physician, and he heads up the Concussion Management Program at Big Fork Valley Hospital in Minnesota. He will walk us through the internationally recognized return to sport guidelines And provide us with a step-by-step approach to managing concussion throughout every phase of the healing process. So if you treat anyone with a brain, which I would venture to guess all of you do, then this 2-episode series is one you'll want to bookmark to listen to more than once. Click the save button, grab something to take notes with, and settle in. Let's get started.

Thank you, Jess. Well, welcome everyone. As Jess mentioned, we are going to be spending some time today talking about concussion management and how to properly manage those athletes that may come through your office. But first, I just want to draw a little bit of attention to this concussion management. I would say 10 years ago, there was probably a lot more hype than there is now. I think some of that hype has calmed down, but I think that's Because we as practitioners have have done a better job at recognizing concussion and understanding the importance, and what we're doing to treat it, to monitor it, to how we're holding our athletes up out from play, or if they have a concussion, we know they're they're not supposed to go back to school right away or go back or go back to work. But a lot of that hype stemmed around. The fact that there's a significant risk to individuals who may have sustained multiple concussions. Concussion studies suggest long-term cognitive deficits. And furthermore, there's this overhead— overlying risk of second impact syndrome. And that's basically getting a second concussion while you're still recovering from the first one. And what we're seeing with this is, as we're recovering from our initial concussion, our brain is sometimes a little bit more susceptible to changes in that blood pressure. And when we sustain a concussion, we kind of see like this catecholamine release or catecholamine surge essentially from that second impact to the head. And that can cause vascular congestion, cerebral edema. It can increase our intracranial pressure, which then could lead to coma or heaven forbid death. But that's kind of where a lot of this hype stemmed from. A few quick facts about concussion. We now know it's a— we do know and we have for a while that it's a traumatic brain injury. There's a It can occur from a sports injury. It can occur from a fall. Usually they're not life-threatening, but they, but they are serious, and we need to take concussions serious. So with that in mind, I'm hoping that this, this presentation is going to allow you to realize the seriousness of, of concussions and, and understand the importance of recognizing the signs, the symptoms, and the importance of following a proper return to Leading causes: falls, motor vehicle accidents, again, playing sports, unintentionally being struck by any object. The CDC in the US is estimating that there's probably anywhere from 1.6 to 3.8 million just sport-related concussions each year. 300,000 of them are from football, and they're thinking at least 1 out of every 10 athletes sustain a concussion on a yearly basis. From a sports standpoint, brain injuries alone cause more death than any other type of sports injury. And football brain injuries account for 65 to 95% of all fatalities. Now, you'll also see that we're seeing 1.6 to 3.8 million concussions a year, but 5 in 10 of these go unreported. That's a fairly high number. Boys are a little bit more— football accounted for more than half of all concussions of this study. And over the past 11 years, the rate of concussion has increased over fourfold. Now, it's that common question, well, are we having more concussions, or are we recognizing them better? I'm not sure if we know that answer in its entirety, but I will say that Most of us are more educated in concussion management, and there's definitely a component where we are recognizing them earlier, faster, and dealing with them more appropriately. So I do think that's part of the mix, but we're not sure. Literature hasn't pointed to the exact increase of of why it's been fourfold. A few other more facts, and this is almost this just. Page right here is almost more of like how are we diagnosing these? So concussions used to be diagnosed on a grade one, two, or three scale. Now, in in the office, when you diagnose a concussion in your assessment, you're going to say patient sustained a concussion on whatever date this they sustained it. From there, you look to see if there's any consciousness that was lost. So if if there was no loss of consciousness, you'd You'd indicate patient had sustained a concussion on this date, no loss of consciousness. And then after that, we look to categorize any amnesia. Do they have anterograde amnesia or do they have retrograde? There's 3 components to a proper diagnosis of concussion, and that's when and if it was sustained, and then was there loss of consciousness, and was there any amnesia? And specifically, you want to know anterograde or retrograde amnesia. With that, some truths. Most people do recover from concussion quickly, somewhere in that 10 to 13 day period. We used to say 7 to 10 days. We are kind of expanding that date a little bit now. Some symptoms may last longer though, months. Recovery may be slower as we age. Remember, concussion is a metabolic injury, so the younger you are, typically the higher metabolism you have, the easier you are, you know, heal from these. And those who have sustained a concussion are at increased risk of sustaining another one. And generally, we'll find that the recovery period for your second concussion is a little bit longer. Symptoms kind of fall into 4 different categories, from our physical side of things to the emotional, to sleep disturbances, and then to our ability to think and remember things. So physically, headaches, neck pain, Blurry vision, ringing in the ears. Emotional standpoint, a lot of times you might see some irritability, some anxiety, nervousness, a depressed state of being. From that cognitive side of things, patients may have a hard time remembering recent events. They may have a hard time doing schoolwork or work, especially if their work takes a lot of cognitive function. And then Some individuals are going to be extremely fatigued and sleep all the time, and then others might feel fatigued, but they almost have a sense of insomnia where they're not sleeping at all. A few things that you absolutely need to do if you, if you have sustained a concussion, that being you need to get, get in and see a doctor. And I put a slight hesitation here because you really should be doing some research, or the, or the parent should be doing some research. And getting in to see someone that— seeing a doctor that understands concussion. There's so many times, and it's even better in the institution I work, but ER is not the place to manage a concussion. Now, you get a bad concussion on the field and your symptoms progress and you need to be triaged at the ER, great. You know, go in, be looked at, make sure we're ruling out any red flags. If you need to do a CT, To rule out any skull fracture, things like that, great. But don't let that ER visit be your end-all be-all for the management process. And what I mean by that is a lot of times an athlete will go into the ER, yep, I had a concussion. I was told just to kind of watch and rest, and then I'll get better. Well, if they're playing a sport, especially anywhere in the US, they're going to need to follow this return-to-play protocol that I'm going to go to. And the ER doc's not going to walk walk them through that. So, and furthermore, even if you're not playing a sport and you get this, it's so important to just be followed up with someone that knows about concussion after you've been in the ER. Important to note, if you're taking any blood thinners, obviously with concussion, it could be at a risk of brain bleed. So you don't want to thin your blood anymore. Make sure there's a thorough exam that's done. And then you want to avoid driving. You want to avoid any drug use. You want to avoid any alcohol use. Let, let the physicians know what type of meds you're on and so forth. Again, you may need advanced imaging. You may need to perform some neurocognitive tests. You may need to assess your learning and your memory skills. You may need to assess your ability to concentrate, pay attention, your reaction speed, problem-solving ability. You're probably going to be sent home with instructions that's going to be important to follow. So, There's some needs and there's some possibilities of things that you're going to have to do depending on where you're falling at from the symptom scale and what you're trying to get back to in, in your normal activities of daily living. These are some really good position statements to go on and take note of these. A lot of these position statements overlap. A lot of them kind of read and sound the same, same. But if you're brand new to this, reading at least half of these going to give you a good understanding of concussion. And then as you read them, you're going to, you're going to know where to look, look for more information and, and where to go from there. So I, I think we have done a good job here in the US at, at focusing on concussion management and putting some good literature together.

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I'll introduce myself here real quick. My name is Dr. Mike Olson. I am a Palmer College of Chiropractic graduate, graduated in 2011, and started practice at Big Fork Valley Hospital as the hospital's first chiropractor. We had an overlying need of sideline care in this rural town, and so I started working with our football team. I have a strong interest in peripheral nerve entrapments. I have a couple courses through Factor through with peripheral nerve entrapment. Have a concussion, another concussion class through Factor as well. What else? A little bit more about myself. Adjunct faculty currently for Palmer College of Chiropractic and recently just started a new role here at our facility, kind of managing our entire rehab staff, our fitness center, and my own chiropractic department. There you have it. That's myself. Let's continue on with this presentation. With Module 1, what we're going to do is we're going to have a thorough understanding of this return to sport strategy and the steps associated with it, and then kind of briefly discuss any similarities or differences, whether you might be an elite athlete or adolescent or more an adult. Go on, use these position statements. The nice thing I like about that is all these position All of these position statements follow this internationally accepted return to play guidelines. So these guidelines that I'm going to go through are going to be associated with all of these position statements here. And the biggest one is there's this consensus concussion and sport group, CISG, and every 4 years they come out with an updated consensus. And we're on the 5th one right now. The 6th one's in the works of getting published. With COVID there's a little bit of a A delay and a setback, but we should see that sixth one come out. So, and as soon as that comes out, I will. I'll go through it. There might be some things that I even need to update and change with with how I run my policies. But obviously, they're supported by some pretty big big players in the world of sports management. And these are our steps here that we're going to go over six steps. There's a goal for each step, and there's certain activities that we need to do in each. steps with regards to returning to play. But as we go through this, we need a general understanding of what is concussion recovery. Recovery is clinically defined as a functional return to normal activities. So school, sport, work, life, essentially. It encompasses a full resolution of our symptoms that we may have. And for most injured athletes, we do know that cognitive deficits, balance, and physical symptoms improve rapidly within that first 2 weeks of injury. Studies published before 2005 concluded most athletes recover within 10 days. However, now a lot of these studies post-2005 are suggesting a little bit longer than 10 days. And so that's those— what we see with those bottom 2 statements there. This is a graph I use for a lot of my patients as well. And where concussion recovery gets hard is that Elite varsity athlete that wants to get back to play and that he knows the rules and he's got to tell you he's going to— he's feeling fine and he's ready to go. And it's also, it's also hard for that 50-year-old individual, individual who still works their, their tail off and is constantly busy, whether that be providing for their family, taking care of their kids and so forth. And they're used to living a very busy life. And as we recover on this bottom of the graph here, we have days. So typically, as the number of days progress, the amount of activity we can do increases. And this line here represents our threshold level. If we go above that line, then we have symptoms. If we stay below that line, we are symptom-free. And the goal for concussion is to, as the days progress, we always want to stay subthreshold, or we always want to stay below this line. If we ever go over this line, typically we have a So for that person that's doing everything, one day they may, they may feel great. And then what you typically see is the next day they're raring to go, hey, I had a good day, I can do a lot. And they do a lot that day. And 4 or 5 o'clock comes around and they're wiped, they have a headache, they're nauseous, their balance is off, they can't think, they can't function. Well, guess what? You just went over this line and you're gonna set yourself back a little bit farther. Now, first phase really talks about rest and 20 years ago, rest was key. Oh, you got a concussion, lay down, rest. How long? Just keep resting. Well, that's— rest is good now, and, and, but we're not looking at 2 weeks of rest or even a full week of rest of just laying down. That initial rest period needs to be about 24 to 48 hours. And then because we know this is a metabolic injury, there's more and more literature stating that After that 24 to 48-hour period, trying to get back and doing a little thing. So just like a slow walk or a really slow stationary bike, just something to kind of get our metabolism going. Still avoiding any rigorous activity, but again, doing some light activities that keep us below that threshold line. So currently we don't have an exact amount or duration of prescribed rest. Also because it's gonna vary for individuals. But as I said, this 24 to 48 hour period, if you wanna rest for 20 hours of, of both of those days, great, that's fine. Then after that, let's, let's try to start doing a little bit of things. And the study by Letty here discussed about the negative consequences of prolonged rest, and obviously that can cause metabolic disturbances.

Mm-hmm.

Can cause or can put you into a state of ongoing fatigue, can become physically deconditioned, and we can go into a, like, a reactive depression type of thing. So again, rest also doesn't mean keeping yourself or your child in a dark room. You can rest and do 5 to 10 minute increments of computer use or TV use or You know, light studying. It's just kind of letting our brain shut down essentially and start to use it in small bits. So again, the first days after the concussion, you're not going to be as active. And so your rest is going to be more. But by upping your activity level, you can see the subthreshold that helps us increase the outcome of recovery by increasing the amount of activity we can do to stay If we just rested nonstop, this line likely is going to be a lot flatter. As mentioned, we don't have a proper timeframe. Again, it's key to that 24 to 48 hours. Let's move into this, this next step here. As we go through these steps, and keep in mind that as we're progressing through the steps with athletes and as we return to play, each step has to be a minimum of 24 hours. And then I like to use heart rate activity and duration of exercise increments as I progress my athletes through those. And so I'll kind of show you what those look like as we, as we go through here. Step 1 is that symptom-limited activity, okay, 24 to 48 hours, and then basically start working into some really easy, easy things. After that, step 2 is now we want to start walking We want to start doing some stationary cycling. Keep in mind, this is no resistance training, and the goal here is to increase the heart rate. Well, why are we increasing our heart rate? Well, because increasing our heart rate is going to help us up our metabolism a little bit. And so typically with that, we're looking at something that's going to get the heart up to 100 to 140 beats per minute. Again, as I mentioned, that's just walking, stationary cycling, swimming. Typically when I think of swimming, that's a little bit different. Harder than walking, but I mean, maybe you're just treading water for a little bit, or maybe you're doing really slow laps. And, and again, 15 to 20 minutes, 10 to 20 minutes. And if you want to start even a little bit less than 20, depending on how high your— how bad your symptoms are, that's fine. It's just we're trying to test the waters here and not overdo it so that we know if we can progress the next day. But I have a A 15-year-old athlete who the area of did they sustain a concussion was gray, which you're gonna see at some point. Sometimes it's, it's hard to, to say, oh yeah, you, you for sure had a concussion, or maybe, maybe you did. We're not really sure, but we're gonna, we're gonna follow these guidelines and we're gonna play it safe. Well, they're probably gonna be able to tail the line here closer to 20 minutes. But if I have a 50-year-old individual that was horseback riding, They're not really an athlete and they got bucked from the horse and hit their head and they're still just miserable, but I got to get them out of just this rest stage and do just a little bit. This duration of exercise might be 10 minutes. And globally, we want about a 30 to 40% max exertion right here. Step 3, we're going to get a little bit more sport-specific. So light sprinting or some jogging now, some skating drills. Remember, we're still in non-contact, so no head impact. The goal here is to add various forms of movement with my progressions being somewhere between that 120 to 160 beats per minute. That's again, that moderate run, skating, dribbling. You do a little bit of lightweight training, thinking on more repetitions versus maxing out. I'm progressing that time typically up to the 30, 40-minute range, and my exertion level is going to be around that 50% max exertion rate. We do fine with that for a day, then I guess, well, I get to progress on to the next step. Okay, and again, this is still non-contact. We're looking at still sports-specific training drills that are just getting harder, with the goal is to involve a little coordination with this too. So when we think of concussion, our coordination can, can get thrown off and our reaction time. So this is looking at increasing those a little bit. Our heart rate, we're starting to get up there with some of these individuals around 180 beats per minute. This is 60 to 80% of our exertion levels. Possibly they're working out for an hour. Here we got full sprinting. If they're doing fine, we can get them back up onto their typical normal weight training. Again, non-contact though, okay, and very heavily sports-specific. So after that, if they do fine there, That's when I have them back in my office. We clear them, and now they need to have a full contact practice before they go back to a game. So if they've gotten to step 4, they come back into my office, I go through my exam. At this point, they should be pretty symptom-free, so I'm going to go through my impact test or any type of neurocognitive assessment along with my musculoskeletal and neuro exam. And if that all looks good, okay, and they're progressing through school fine, then I sign a form, say, all right, tomorrow you're doing a full-contact practice. And now we're looking at participating at practice at normal levels and looking at just restoring that cognitive and sport-related confidence. And then I also want to follow up with the coaches. Hey, how'd Joe look in practice today? Okay, so Duration, we're looking at that full practice. I want to see somewhere at least up to 80%. And again, we're starting to max out that heart rate here. And after that, you've already medically cleared them. And if practice goes fine, great. They're going to be, they're going to be ready to go for game. If I clear someone for practice, my rule is, is I want to talk to mom or dad, the athlete and/or the coach. And then I do a second clearance. For our program. That's not necessarily how you have to do it. I'm just working with high school athletes, so I want to be open and communicative with all individuals involved. So then if practice goes fine, then I send another thing, hey, they're cleared to go for game time now. And obviously game time, we're looking at a complete and normal return to function and that normal game— gameplay. So that's kind of that step-by-step Plan. Now, if it's full, it used to be if, if you failed a certain step, so let's say you went through step 4, non-contact training drills, and by at the end of the— if you had symptoms, it used to be take the day off and then start back at step 4. Well, those 5th International Guidelines now say if step 4 brought on the symptoms, you should actually jump back to step 3. And start from there again after you take a day off. So keep that in mind too. I brought you through the steps, but if you start to fail any of these steps, wait 24 hours and start at the one, one previous. I also like to look at, as I, as I get an athlete onto this program, I ask them, what's our game time? So I'm going to use an example here. If they get a concussion on a Friday night and their next football game's on the following Friday, we basically have— they can't have any setbacks if they want to play again in a week, right? This is a week-long process. If they have one setback, then essentially we have another 2 weeks before the game. And so in that case, if it's longer than a week, a lot of times I might tell an athlete, we're going to do step 2 for 2 days, step 3 for 2 days, step 4 for 2 days. So if you get a good idea of— of the length of their games or the duration apart, we can— you can kind of tailor this plan a little bit too to be more beneficial to the athlete as well. And there's always a— we call it our MEA game in Minnesota where it's on a Tuesday or Wednesday night, and then that following week it's not till a Friday. Not that I ever want a concussion, but if I'm going to get one, that's a nice time for a kid to get one because then they don't have to rush through the program. We have a week and a half for them to progress through it. And it's, in my opinion, it's a little bit less pressure on the kids, especially if they're that elite athlete and they don't want to miss a game.

That's it for today's training. Be sure to tune in for part 2, where we'll talk more about the differences in working with elite versus recreational and youth athletes. Dr. Olson will also elaborate more on the role that hormones and blood pressure can play in concussion symptoms and recovery, and he will guide us through the RTP formula, his structured approach for getting athletes back in the game safely, focusing on gradual increases in activity and constant monitoring. You won't want to miss it. Episode 78 drops in 2 weeks. Be sure to check out our show notes for a link to the brand new Factor Podcast website that just launched today. Where you can access highlights, content, and of course replays from all of our past episodes. You can also click on the Send Us a Voice Message button on any page and give us your feedback, or click on the Reviews tab and shoot us a quick note. We would absolutely love to hear from you. As always, you can also find a link to the recorded webinar replay in our show notes, along with other goodies, promotions, and offers provided by our sponsors. We'll see you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R-store.com to find out more information about all that we have to offer. We have a variety of online offerings as well as our hands-on Factor Rehab System course. Scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.