#78 - Concussion Guidelines for Return-to-Play with Dr. Mike Olson, Part 2

Hi guys, welcome to another episode of The Factor Podcast. I'm your host, Jessica Riddle. Today we wrap up the second part of our series on concussion and return to play with Dr. Michael Olson. In our last episode, we were introduced to the concept of crafting individualized concussion management plans and discussed the importance of ensuring every member of the healthcare team is in agreement on the best path forward for optimal patient recovery. In today's episode, we will be discussing the finer details of RTP, or return-to-play protocols, and how to manage the delicate balance between healing and returning to daily activities. Dr. Olson highlights the differences and special considerations in working with elite-level athletes versus recreational or youth athletes, and he will also discuss the important role that hormones and blood pressure can have in recovery from a TBI. Finally, 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. So grab something to take notes with and be sure to hit the save button. This is one you'll definitely want to listen to more than once. Let's dive in.

Now we're going to get into, oh, real quick here. This is my, this is what I give the athletes here. Again, my form's slightly outdated in that technically now this complete rest is 24 to 48 hours. This is considered step 1. So that's why you see step 5 is return to play, whereas now they list this as step 6. But same thing, and it just outlines it. And anytime an athlete of mine has sustained a concussion, I give them this form and we just walk through it with them. And their coach is going to get one, mom and dad's going to get one, and the school administration is going to get this form so that they— we're all on the same page and following the Some barriers to recovery. Okay. Could there be genetic barriers, age differences? Really what we're seeing is a couple barriers are neurodevelopmental factors, such as like ADHD, family history of migraines or other mental health problems, as these can be substantially altered or changed. But our biggest barrier is having, or the biggest risk factor is if we've had a previous concussion or a brain injury. A lot of times we're going to see those individuals have a little bit harder time progressing through and returning to their normal state. Severity of a person's initial symptoms on the first day after injury is the strongest predictor. So what that means is if you diagnose them with concussion, but their symptoms are on the fence, like, you know, I don't know if it is, this is, if it is, it's very mild. You maybe have a 2 out of 10 headache, and you also don't know, is that just from like Your skull hurts from the hit type of thing, or again, they have all the signs and symptoms of concussion. That's going to tell us a lot how fast they're going to recover. So you can use those as pretty good predictive indicators as you start to manage this. And factors aiding recovery is there's more and more literature out cardiovascular exercise, which is why after that 24 to 48 hours, we want to start getting them up and getting them moving a little bit, get that metabolic rate increased. And I'm also seeing more and more literature on B12, and specifically a lot of times I'm seeing more providers just give them the whole B complex to aid in their recovery. But there is indication that B12 is going to help improve our nerve neuronal repair and restore our nerve function. But again, rest, primary treatment in that 24 to 48 hours, and then move into rehabilitation specific to dysfunction. That's going to be completely different. I'll be talking about concussion management at the upcoming TCC convention. We're going to gear a little bit more into some of that rehabilitation standpoint. So if you're interested, tune into that, that's going to be good. But there's, there's 3 types of post-concussion, and that's cervicogenic, physiologic, and vestibular ocular. So from a cervicogenic standpoint, chiropractors, if they're looking into rehabbing it, fit in well there. If they're falling into vestibular ocular, they may need to see a rehab specialist. They may need to Work with, uh, like a behavioral optometrist and do more things along those lines. But all of those things help aid in recovery, and depending on what type of care that athlete's getting from a rehab standpoint, it's going to definitely help improve their recovery. Elite versus non-elite athletes, guys, concussion doesn't matter, shouldn't matter if you're 12 and on the Sandlot team or if you're Tom Brady. Concussions need to be managed the same. The only spot where they differ is depending on how fast or slow an athlete is recovering. But there's not a different set of rules for an elite versus a non-elite athlete. And there is, there's a few different guidelines depending on if you're a child or adolescent or an adult. And something that you, as you read through the consensus statements, you can look at and see. Let's move into this return to school here quickly. And the return to school guidelines, and what you could also modify to return to work, are new with just the recent consensus in sport update, that 5th edition. Never really used to have these guidelines out there, and there's not a step-by-step progression with these like there is with sport. Again, but the more you manage concussions, the easier this is going to get. And so typically, I, I manage our football team the most. Typically, concussion during the game, on a Friday night game, I have them rest Saturday, Sunday. Typically what they'll do with me, for me then, is then I'll send them to a half day on school on Monday and then follow up with me right after that half day and we see where they're at. If they, if they had struggled with that half day of school, a whole back farther, maybe give them a couple more days of rest from school. But it's kind of the same thing. You want to gradually reintroduce things. And this chart does a good job of stage 1 is we're looking at do some things at home, okay, that are going to be similar to what they're doing at school. Maybe that's just trying to like read or text some friends or do a couple math problems and see. And if that goes fine, then yeah, let's get them back to school. Things that you're going to have to limit initially is the amount of homework they're doing, the amount of reading, the difficulty of cognitive levels, and again, returning them to school part-time first prior to returning them to full-time activity or full-time school. So it is also important with schools is that if you're going to start managing these concussions and your school doesn't have a program, that one be established Okay, schools should have a return to school policy, or you should help them create one. So if you're sending Johnny back to school, you're informing the teacher, "Hey, he needs to be doing this. He might need to be allowed to wear sunglasses at school. He might need to be allowed to sit in front of the classroom so he doesn't have to strain his eyes. She might need to take more breaks or be allowed to." be dismissed to her next class a little bit sooner so she can avoid noisy halls. They might need to set up an excused absence policy. So all of these things are things that schools need to consider when they're working with athletes and, and groups that are trying to manage these concussions. Obviously, I think all of our teachers need to be familiar, like, some things that we're looking for for concussion. The athlete, the parent, the school nurse, the principal, the teachers need to That, and especially those that really know that child, are they having difficulty paying attention? Are they having problems remembering things? Are they needing more time than usual? Are their grades dropping a little bit? Do they not seem like their normal self? Are they irritable, emotional? Are they falling asleep in class? So these are all things that we need to educate our schools on and teachers on and making sure that they're paying attention to so that they can report that. to the physician who might be managing this individual as well. Obviously, as you're probably aware, concussions can affect our athletes' ability to learn. And thus, thus adhering to a well-thought-out plan of the return to school is going to be important, but it's also going to be unique to each student. Twyla might be able to go back on that Monday and do just fine for a half day, where John said, hey, a half day is still too much. In most cases, concussions won't significantly limit, but again, there's always these cases where that concussion is severe and it will. So again, read— it's just important to read through those contestant statements and, and get a good general understanding of how these return to school guidelines— and again, you might have to alter it to return to work guidelines— how, how they work and things that we need to be cognizant of. And pay attention to. When are they ready to return to school? Well, that's going to be your call, essentially. That's— and that's their ability to problem solve, to think, to stay awake, to sleep. Again, go back to that line graph I drew. It just— it doesn't just pertain to physical things. It's a physical cognitive checklist. As the days progress outward, They should be able to cognitively start to do more and more as well. A lot of times with my cognitive rehabilitation, I'm printing out 3rd grade multiplication tables or math charts and having them do some of those at— during the day. If they're pretty symptom-free, I'll have them fly through the— through a couple sheets in my office to say, hey, how did you— how did you do with those? Did that give you a headache? Did that strain your eyes at all? Paying attention to that. And also, if you're using any type of neurocognitive test, That's going to tell you a lot. I have a baseline for all of my athletes before the start of every season, and so I will put them through post-injury tests when they start to be pretty asymptomatic, and I can see where they line up from a standpoint of post-injury compared to their baseline. And I want to get them back to baseline before, obviously, their return to play physically and before I remove all limitations from school. Can understanding concussion symptoms help identify with a specific student's individual needs? Absolutely. If you're dealing with an individual who has cervicogenic post-concussion syndrome, the way you're treating and managing them from a rehabilitative standpoint and a cognitive standpoint is completely different than if you're dealing with someone with vestibular ocular. Okay, that cervicogenic patient might not They might not have any problems seeing the chalkboard. They might not have any, any problems with like their balance, things like that. And so I might allow them, hey, yeah, you can sleep, you can sit in the back of the room. I'm not worried about eye strain with you. Whereas that vestibular ocular, they're sensitive to bright lights. And again, I might need them to wear glasses, or they might need to sit closer. Or if they have a computer class, I might say you're only in class for 20 minutes with, with the computer because I don't, I wanna avoid that strain. So understanding what areas of the brain are affected with concussion is gonna vastly help you continue to manage this, these individual symptoms.

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But essentially, this is a breakdown of, of the limitations that I give my, my kids when they go back to school. And you also gotta be cognizant is if they're not an athlete, but they have gym class. In gym, they got to follow those same return to play, essentially return to gym guidelines. But I have a form that I developed that is a checklist, essentially, of how these kids go back to school. So here, this top example deals with testing. If there's some important tests, I might have that conversation with that student. Hey, I don't mind if John takes the test, but right now he just needs to do it open book. Can he take the test broken down in a couple days, like give him the first page this day, the second page the next day, and so forth? And again, broken down, right, stages. We want this— this is the first slide here, but we want stage 1, these just daily activities, to be done at home, okay, so that we know if it's going to be safe to get them back into school and start with that 5 to 15 increment, 5 to 15 minutes. Stage 2, some easy light school activities, allow a little bit of the homework, allow a little bit of reading, their cognitive activities outside of the classroom. But they, they still might be at school only part-time during this stage, and we're just trying to build up that tolerance to cognitive work, right? We're trying to, as days progress out, we're trying to move up along that symptom line. Again, back to school, reintroducing more schoolwork and just classroom activity, the noise levels. If they're in band or choir, you might have hold them from that for a week sometimes, depending on the band setup, and still building up that tolerance level until we can get them to return into school full-time and back to normal academic activities. And then ideally, they might have to play some catch-up. And so is it safe when, and is it safe for them to do their normal stuff and play catch-up? Those are all some things to think about and consider. Again, I'll be at TCC and then Factor Southeast Sports Education has, I believe it was an 8-hour module, Jess, if you can correct me, that I put together that kind of deals with that whole entire bubble on our, on that second slide of mine and explains and goes through the entire concussion management procedures that I work with and where individuals can get involved. But I can open up the floor to any questions here now if anyone has any.

Awesome. Thank you so much, Dr. Olson. And as he mentioned, we do have a full 8-hour online on-demand course on our course online learning website. I'll put that in the chat so that you guys— a link to that so you can check it out if you're interested in learning more. We'll also follow up via email to let you guys know a little bit more about that. Again, there's only so much that we can cover cover in this 1-hour format when it comes to a big topic such as concussion. And Dr. Olson gives some really great in-depth directives on post-concussion care and of course helping patients with their recovery from that, from a rehab standpoint in that online course. That being said, we have had a few questions that have come in from our live audience. Very early on, you were talking a little bit about What do you think, and I know obviously this is your opinion, not based on research because they haven't come up with a definitive conclusion yet, but why do you think we've seen this increase in concussion in recent years?

Yeah, I think if I'm gonna go, if we're gonna use fourfold, I'm gonna go give a 3-to-1 ratio. So I talked to a lot of older athletes that may have played sports back in the '70s, the '80s, my dad being one of them, and he He's just like, man, I probably had several concussions going through football, but half the time you're just told to get back in there. So that being said, I think we have so much more knowledge now, oodles, oodles more. And so of that fourfold, I would say at least 3 of it is we are recognizing concussions faster. Okay, so a lot of these concussions back in the '70s, '80s, early '90s, probably going missed, probably not being Dealt with at all or even reported as a concussion. However, that one fold, I do think, like, bigger, faster, stronger, right? Our athletes are getting bigger, they're faster, they're stronger, collisions are harder, and probably substantially more compared to, again, '70s, '80s, '90s. But with that being said, our protective equipment gets better too.

Okay.

And our practices are better at how we're managing these. So me personally, don't think it's that drastic change in the sport as much as it is our awareness to recognize and manage these. But I think there's a little bit of both, definitely just heavier on the recognition standpoint.

No, I can absolutely see that. And I know even within kind of the general public's knowledge and understanding of concussion, I think parents on the whole are probably way more cognizant of the brain health for their kids now since major movies have come out about it, since the NFL has had the major news stories that they've had about CTE and the long-term effects of concussion. So I can certainly see how a lot of that factors into public awareness, which in turn, a lot of times parents might be the ones kind of looking at that for their kids a little bit more than their young athletes who are just trying to get back in the game.

Absolutely.

Now, kind of going along that same line, you mentioned that a lot of times you'll have those conversations, especially with parents, when you're dealing with an underage athlete, someone that their parents are typically the ones bringing them in. Do you find that most of the time having those conversations with parents is a really effective way to make sure that their young athlete is recovering? recovering on an appropriate timeline? Do you often get a little bit of pushback from the athletes themselves because they want things to hurry up and get better faster? How do you have those conversations with the athletes so that they understand that this is a process and that recovery takes time?

Absolutely. And I'm very blessed and fortunate to be practicing in such a small, rural, remote area. So I believe that aids to the betterment of the athletes simply because a lot of these athletes, their parents are my friends now. And over the 12 years of doing this, you start to be recognized as, you know, the concussion guru. And so when I first started, yeah, I had a little bit more pushback 12 years ago. Oh, are you sure he's got one? Or, you know what, I— And it also goes to the level of our team used to be better 12 years ago. We were competing for state a couple. So you have those athletes that they're not going to miss a game. But I think, again, in these past 10 to 12 years, the amount of concussion laws that's come out, and now you're almost having athletes more worried for themselves than you used to. Like, hey, I had a little headache, or what do you think? And I go back in and I think we're finding more and more athletes with concussion wanting to play and err on the side of caution or err on the safe side. And the more people I can get involved in, again, during a football game, if it happens, mom and dad come over and I sit and I talk with the parent and mom and dad about this, what's going on at the end of the game. If the coach wasn't able to come over during the game, we discuss it. A lot of the teachers, I have their number and I can send them a message, hey, So, if someone's got a concussion, here's what we got to do. What's your weekly schedule look like? How can we get this individual back to school safely? And so, the more education— I mean, the biggest part to concussion management is education. And if you can tell that athlete what to expect, that's going to calm down any nerves or fears. That helps, especially if mom and dad know, so then they're not, you know, on the athlete and making them more nervous. The more people you You can get to understand this, the better. And every year I give a concussion management talk to our school at the beginning of the year. And so teachers are on board, the parents are on board, everyone, everyone just has a good awareness. And I would say, I don't want to say we're a role model for, for a program, but I, I do think it is. It has taken 12 years, but I think we have a really good, good program here. And parents fully understand and And the teachers fully understand how to operate this. It's made, it's made my job easier.

No, absolutely. I can, I can see that. And I know that along those same lines, it's really important when you are dealing with an athlete that has coaches involved and athletic trainers involved and maybe their medical doctor involved and other, other members of their healthcare team that you communicate regularly with them about their care. What are some kind of tips or best practices that you utilize in your office to communicate with those other members that are overseeing that young athlete as members of their healthcare team?

I would— I'm trying to think of tips here. If I would have to say it was allowing myself to establish like, hey, this is like Manny's concussion expert, concussion guru. Research and almost trial and error in getting those concussion patients. And if your first concussion patient you have, you might not want to be the primary guy that manages it. You might just want to be a part of the team. But then after that, if you stick to the internationally accepted guidelines and and essentially Minnesota has adopted the national accepted guidelines, so I can go right on my Minnesota State High School League and print off this that same stepwise. Progression and use those forms. And if I'm evaluating this, but that athlete's also— they chose to see their medical doctor first and he wants to do it, then they come to me for symptom management, I'll write those guidelines out and say, hey, here's what I'm finding, here's our state guidelines, he should be on step 1 or on step 4. Hey, I see like you didn't hold him from school, I think he's not quite ready for That, that, and, and I'm the one that administers all the, the neurocognitive baselines. So most of the time now, it's like if there can cause— nurse will just say, you just gotta, you know, go follow up with Dr. Olson. He's gonna progress you through it. But it's, I, I think it's just, it takes time to develop and it's, and the biggest, the biggest help is you, if you're gonna manage it, establishing yourself as the expert in it.

No, absolutely. And I think that's, that's key again, just kind of keeping everyone in the loop, letting them know that what's going on with the athlete and how they're doing. As you mentioned before, I mean, there's so much coming out still in the research. They're still updating things regularly, which I think it's, it's nice that the medical community is now really paying attention to this and has this as a high priority, especially when it comes to sports and athletics and It seems like we're just kind of scratching the surface on our understanding of the brain and long-term effects of concussion. So if you could kind of speak a little bit to some of the long-term effects of concussion that you've seen with patients. Obviously, there's the recovery period where we know we're going to have specific symptoms, but have you had any cases where even years after the fact Or after having multiple concussions over time, you're seeing patients that have symptoms that just become chronic throughout the rest of their life? Or what are those things that you're seeing that make you ask that question in that initial exam with a patient? Have you ever had a concussion in the past? Have you had one in recent years or multiples, et cetera?

Okay. A couple answers to this question as well. I've only been in practice again for For 12 years. In my 12 years here, I've had 2 that have had multiple concussions, and unfortunately one was multiple concussions within 5 minutes. So he fell into the second impact syndrome. He essentially was— got knocked over in gym class, hit his head, and then as he was walking out of gym class, someone threw a basketball from one end of the floor to the other, hit him in the head, and then he fell. Fell over the ground and his head hitting the ground again. He was top of his class student. He was, I believe, 6th grade at the time and just really took a turn from the— from the— for the worst and struggled with school and mother's name and things like that. And his recovery was a long, a long time. He had to get pulled out of school and go into homeschooling. And with all that just came— he was a different individual. And so I think this individual is learning how to adjust to someone that he wasn't used to And with that middle school age friends and bullying and picking on each other, I think came some social issues. These other two individuals that I spoke about with that previous concussion was the biggest thing is like depression, right? They they can't provide for their friends and their family or their kids like they were so used to doing. It's such a light switch change. Right? It's like boom, here's your injury, and all of a sudden you can't do this. And those are the biggest things that I see with patients that I know very well before they get the concussion. And again, small town, I'm fortunate for a lot of my athletes. Like, I know these athletes, and so I have an easier time managing concussions because I know this individual is normal. Whereas my worst fear is trying to manage a concussion. I have no clue who this individual is. It's the first time I see him as post-concussion. I don't know what They look like, how they talk, how they act, and what their normal is. So that being said, the concussions I've managed, I'm just getting to the, to the point now where it's like some of my early ones would be, yeah, have they fallen into any long-term deficits? Now from just a regular provider side of things, like, do I get patients that come in and say, yeah, I've had multiple concussions when I was a kid and now I have like I've, after my third concussion, I've had chronic headaches and chronic neck pain. Yeah, I see that. A couple of patients I can think of, quicker to get angered, a little bit more higher anxiety. I never used to be anxious or agitated. And I think, I think that agitates. I get irritated more. And both of them would probably say, I don't know if that's related to pain and/or just brain dysfunction. But I think those are kind of the top things that I can think of that come to mind.

Wonderful. Thank you so much. And thank you so much for this presentation today. Again, thank you so much, Dr. Olson, for tackling this very big topic for us today. You provided a lot of great information that I think our providers will be able to take into practice immediately. Thank you so much, everyone. We're signing off for today. Thank you, Dr. Olson.

Yes. Thank you guys for having me.

That's it for today's episode. Be sure to tune in for episode 79, where we kick off a brand new series on harnessing the science of HRV, or heart rate variability, for enhanced patient care with Dr. David Hopper. You won't want to miss it. Episode 79 drops in 2 weeks. If you're more of a visual learner or want to see the full presentation slide deck from today's training, Be sure to visit the link in our show notes to watch the full recorded replay of this webinar. You can also scroll through our show notes to find a link to our newly launched Factor Podcast website, factorpodcast.com, as well as links to all of the special offers from our sponsors. We'll see you next time.

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