Concussion Leadership Manipalooza 2016

Introduction to the Presentation

Overview of the Event

• The speaker humorously mentions a character in a mask and their excitement about fish, setting a light-hearted tone for the presentation.

• Emphasizes the intention behind the presentations: moving beyond traditional physical therapy practices to address broader healthcare system issues.

Introduction of Dr. Jessica Schwartz

• Dr. Jessica Schwartz is introduced as an expert in concussion management, recognized for her global connections and contributions to multidisciplinary approaches.

• She has received the prestigious Corporate Citizen Award from the Brain Injury Association for her work on concussion certification programs.

Dr. Jessica Schwartz's Background

Personal Experience with Concussion

• Dr. Schwartz expresses her passion for speaking to physical therapists, highlighting their often-overlooked role in medicine.

• Shares her personal story of being injured in a car accident, which led to extensive rehabilitation and shaped her perspective as both a doctor and patient.

Insights into Healthcare System Challenges

• Discusses mismanagement within the global healthcare system based on her experiences during recovery.

• Mentions media coverage that has helped bring attention to physical therapy's role in recovery processes.

Concussion Awareness and Statistics

Common Misconceptions About Concussions

• Plans to cover quick facts about concussions, aiming to debunk myths rather than provide standard conference material.

Leading Causes of Traumatic Brain Injury (TBI)

• Engages audience by asking them to guess common causes of TBI; highlights that falls are actually the leading cause globally.

• Points out demographic shifts expected by 2030, emphasizing increased risk among older adults due to falls.

Prevalence of Concussions in Sports vs. General Population

• Contrasts media focus on sports-related concussions with actual statistics showing higher prevalence rates among non-sporting populations, particularly children and elderly individuals.

What Sports Have the Highest Concussion Rates?

Overview of Concussion Statistics in Sports

• The leading sport associated with concussions is horseback riding, accounting for nearly 45.2% of sports-related concussions, particularly in amateur settings.

• In regions with more farms, such as rural areas, there may be a lack of resources and athletic trainers available to manage concussion risks effectively.

Misinformation Surrounding Concussions

• There is significant misinformation regarding concussions; many believe they only occur from direct blows to the head, which is incorrect.

• The confusion surrounding concussion definitions contributes to the heterogeneity of this injury and has hindered progress in clinical trials related to traumatic brain injury.

Understanding Concussions

• A concussion can result from a bump or jolt to the body, not just the head; even falls that do not involve hitting the head can lead to concussion symptoms.

• Sub-concussive impacts—such as repeated body checks in contact sports—can also cause significant damage without a direct hit to the head.

The Complexity of Brain Injuries

• Brain injuries create an energy crisis within the brain, affecting identity and function; much current data on concussions stems from animal studies rather than human experiences.

• With over 154,000 articles published on concussions, it becomes challenging to discern accurate information amidst widespread misinformation.

Ownership and Education on Concussions

• No single medical specialty "owns" concussion management; various fields including neurology, psychology, speech therapy, and ENT have roles but must collaborate effectively.

• Neurology began formal education on concussions only in 2015; however, many medical schools still lack comprehensive training on this topic across all disciplines.

Concussion and Physical Therapy: A Paradigm Shift

Introduction to Concussion Education

• The speaker references a book from 2006, highlighting the limited coverage of concussions in educational materials, with only one paragraph dedicated to the topic.

• Emphasizes the lack of formal education on concussions within physical therapy (PT), indicating a need for a paradigm shift in PT practices regarding concussion management.

Comparing Concussion and Gait

• The speaker draws parallels between gait analysis and concussion assessment, noting that physical therapists are trained extensively in biomechanics related to gait.

• Questions how similar analytical approaches can be applied to understanding concussions, suggesting that various factors (environmental, muscular, biomechanical) contribute to both conditions.

Understanding Concussion Complexity

• Discusses the abstract nature of concussion symptoms compared to more tangible issues like gait abnormalities; highlights challenges in assessing behavioral and cognitive impacts.

• Quotes Jeff Moore's assertion that "PT is a contact sport," underscoring the active role of physical therapists in managing patient care.

Role of Physical Therapists

• Describes physical therapists as compassionate providers who are integral to patient care; mentions colleagues pushing evidence-based practices forward.

• Highlights the importance of thorough screening by PTs, emphasizing their role as primary access points for patients experiencing concussive symptoms.

Cancer vs. Concussion Management

• Compares cancer treatment advancements with those in concussion management; notes that cancer has benefited from extensive research funding while concussion remains underfunded.

• Points out that "concussion" lacks specificity as a clinical diagnosis, complicating communication among patients, providers, and insurers.

Functional Implications of Concussions

• Stresses that each concussion is unique ("like snowflakes") but shares common attributes leading to significant functional impairments across personal and social domains.

• Advocates for non-invasive treatment approaches within PT settings; emphasizes the absence of effective phase three clinical trials for traumatic brain injury over recent decades.

Importance of Comprehensive Assessment

• Asserts no single test can replace skilled clinical evaluation; stresses comprehensive physical exams are crucial for accurate diagnosis and management.

• Warns against missing critical information during initial assessments which could lead to prolonged dysfunction or mismanagement.

Challenges with Current Concussion Clinics

• Shares experiences from running a concussion clinic; notes many clinics worldwide claim expertise without adhering to established clinical guidelines.

• Mentions ongoing updates every four years by international experts on consensus guidelines for concussion management.

Concussion Management: Insights and Challenges

Evidence-Based Medicine in Concussion Treatment

• There is a lack of evidence-based medicine for concussion, with no randomized controlled trials available. Most knowledge comes from expert consensus and experience.

• The training levels of individuals involved in concussion management vary widely, from personal trainers to physical therapists, highlighting the need for standardized education.

The Burden of Knowledge

• Professionals carry a significant burden of knowledge regarding concussions; understanding leads to better care practices. This responsibility extends beyond the clinical setting into broader societal implications.

• Persistent symptoms can be heartbreaking for patients, emphasizing the complexity of concussion cases that often go beyond simple diagnosis and treatment protocols.

Mismanagement in Concussion Care

• Opening a concussion clinic requires more than just an interest in sports; it necessitates understanding that falls are a leading cause of concussions across demographics.

• Personal experiences reveal mismanagement within concussion clinics, underscoring the importance of proper training and awareness among healthcare providers.

Understanding Pain and Chronic Conditions

• Dr. Lo's concept of "pain neurotag" illustrates how chronic pain affects various brain regions responsible for problem-solving, concentration, and movement cognition. This highlights the multifaceted nature of pain perception in patients with concussions.

• The discussion emphasizes empathy towards patients suffering from chronic pain conditions as they may face emotional challenges alongside physical symptoms due to their injuries.

Societal Implications and Media Influence

• Media portrayals contribute to hyper-vigilance around concussions (e.g., CTE), influencing parents' decisions to withdraw children from sports due to fear rather than informed understanding of risks versus benefits.

• Encouraging safe play while addressing concerns about obesity among children presents a complex challenge for health professionals advocating for active lifestyles amidst rising caution against contact sports.

Comprehensive Patient Assessment

• Effective assessment involves recognizing that symptoms like trouble concentrating are not merely ADHD but indicative of underlying brain injury post-concussion; this distinction is crucial for appropriate treatment strategies.

• A thorough intake process must consider multiple layers of symptoms rather than focusing solely on headaches or balance issues; comprehensive care is essential for recovery from concussive injuries.

Understanding Concussion Management

Current Practices in Concussion Treatment

• The speaker discusses the inadequacies in current medical practices regarding concussion management, emphasizing that thorough intake assessments are often neglected.

• Two case studies illustrate a common prescription of extended rest (14 months) for young patients, highlighting a lack of proper training among some neurologists in concussion care.

• The importance of social interaction is noted as crucial for individuals experiencing chronic pain and persistent concussion symptoms, indicating a need for more comprehensive recovery strategies.

Metabolic Implications of Concussions

• A mismatch in glucose, potassium, and sodium levels during recovery from concussions leads to significant metabolic challenges at the cellular level, resulting in fatigue.

• Fatigue manifests physically; patients may struggle with simple tasks like crossing the street or getting dressed due to energy depletion caused by their condition.

Recovery Expectations and Misconceptions

• The notion that recovery from concussions is linear is challenged; actual recovery can be complex and non-linear, often involving fluctuating symptoms over time.

• Emphasizes the necessity for students to "return to learn" before they can safely return to play sports, linking cognitive function with physical activity readiness.

Understanding Symptoms and Diagnosis

• The speaker questions whether concussion diagnoses can be made solely based on reported symptoms, stressing the need for understanding the mechanism of injury.

• Statistics reveal that a significant percentage (72.1%) of healthy individuals report post-concussive symptoms without any head injury history, complicating diagnosis.

Importance of Holistic Care Approaches

• A biopsychosocial approach is advocated for treating concussion patients; this includes empathetic listening and understanding each patient's unique background and experiences.

• Pre-morbid factors significantly influence outcomes in concussion cases; healthcare providers must consider these factors when assessing prognosis.

Understanding Personality Disorders and Resilience in Concussion Management

Exploring Personality Characteristics

• Discussion on various personality disorders such as narcissistic, dependent, histrionic, and passive-aggressive traits. The speaker humorously notes their prevalence among neighbors in New York.

• Emphasis on resilience as a crucial factor for patients facing tough times. Questions raised about individual resilience and bio-psychosocial vulnerabilities, including ADHD and genetic predispositions.

Mental Health Considerations

• Inquiry into the presence of depression, anxiety, or cognitive diminishment in patients with repetitive head injuries. The term "repetitive head injury" is preferred over "concussion" for clarity.

• Examination of psychological factors affecting recovery: expectations of diagnosis, potential nocebo effects, and stressors from personal circumstances like single parenthood.

Legal and Medical Perspectives

• Discussion on litigation stress impacting patient care; highlights the gap between legal literature and medical understanding regarding concussions.

• Critique of traditional rest prescriptions for concussion management; advocates for a rehabilitative approach rather than prolonged bed rest.

Interactions Between Symptoms

• Overview of how mental health issues (depression, anxiety, PTSD) can mimic or exacerbate concussive symptoms. Importance placed on understanding the mechanism of injury during recovery.

• Recognition that symptoms may develop later in recovery; stresses the need to track patient progress over time despite multiple consultations.

Evidence-Based Treatment Approaches

• Acknowledgment that current treatment protocols are not optimal; calls for improved evidence-based practices in concussion management.

• Criticism of passive medical protocols that fail to address active rehabilitation needs; emphasizes the role of physical therapists in setting short-term goals for better long-term outcomes.

Comprehensive Physical Examination

• Introduction to recent findings advocating comprehensive physical exams tailored to concussion patients; importance highlighted for thorough training in assessment techniques.

• Need for clinical prediction guidelines specific to concussions is emphasized due to existing gaps in definitions and treatment strategies within the field.

Clinical Trajectories and Patient Care

• Reference to Dr. Collins' work at a neuropsychology center treating thousands annually; suggests that clinicians may have overlooked significant patterns relevant to concussion recovery trajectories.

Understanding Vestibular Deficits and Concussion Management

The Complexity of Balance and Headaches

• Balance is influenced by both bottom-up (physiological) and top-down (cognitive) factors, indicating that headaches may not solely stem from physical issues.

• A study from 2013 highlights the importance of understanding baseline conditions in patients to assess their trajectory of disorders effectively.

Importance of Comprehensive Patient History

• Gathering subjective information from caregivers is crucial as patients may lack awareness of their own conditions, necessitating a thorough history-taking approach.

• In emergency situations, clinicians often lack baseline data on patients, complicating diagnosis and treatment decisions.

Multidisciplinary Approach to Healthcare

• Dr. Lorelai Lindgard's research emphasizes that individual confidence does not equate to effective healthcare delivery; a multidisciplinary approach is essential for comprehensive care.

• Treatment must address multiple health issues simultaneously rather than isolating symptoms like headaches or mood disorders; this holistic view is critical for patient recovery.

Communication and Collaboration in Care

• Effective communication among healthcare providers is vital as no single clinician can manage complex cases involving multiple comorbidities prevalent in older populations.

• Patients often experience fragmented care due to a lack of coordinated communication between specialists, leading to distrust in the healthcare system.

Ocular Motor Function and Concussion Outcomes

• A significant percentage (40%) of traumatic brain injuries involve ocular motor deficits, which are crucial for assessing post-concussive syndrome risk. Understanding these deficits goes beyond basic vision acuity tests.

• Early eye movement assessments have been found more predictive of post-concussive syndrome development than traditional neuropsychological testing methods, highlighting the need for specialized evaluations in concussion management.

Understanding Post-Concussive Syndrome and Its Implications

The Importance of Eye Function in Recovery

• Motor function and self-reported health conditions are crucial for recovery; eye exams must be prioritized.

• Visual tracking is significantly impaired in patients with post-concussive syndrome compared to controls, highlighting the need for accurate diagnosis.

• The complexity of understanding these injuries can be overwhelming, emphasizing the necessity for specialized knowledge in concussion management.

Mismanagement and Resources Available

• Patients often face misdiagnosis; access to free resources is essential for proper care. Upcoming guidelines from ZERC will provide updated consensus on treatment.

• The SCAT 2 and SCAT 3 protocols were developed to address gaps in concussion assessment, including neck injuries which were previously overlooked.

Treatment Challenges and Considerations

• Medications may not effectively treat symptoms due to underlying mental health disorders associated with concussions.

• Understanding the role of neck injuries is critical as they can contribute to various symptoms like headaches and cognitive issues.

Accessing Free Educational Materials

• Numerous free resources exist, such as ACE from the CDC, which can aid practitioners in assessing concussions effectively.

• Practitioners should know when to refer patients beyond their expertise, ensuring comprehensive care.

Promoting Consistent Information Sharing

• Many professionals are unaware of available resources; sharing consistent information is vital for effective treatment strategies.

• PTNOW offers excellent clinical summaries that can enhance understanding and application of best practices in physical therapy related to concussions.

Future Directions in Concussion Management

• Collaborative efforts are underway within professional organizations to develop predictive guidelines for concussion management.

• Increased presence of athletic trainers on sidelines is necessary as they play a key role in evaluating concussions during sports events.

Concussion Education and Management Insights

Understanding the Challenges in Concussion Recovery

• The speaker compares football and hockey, emphasizing that while football has a zero-tolerance policy for concussions, hockey allows for more physical contact, complicating recovery processes.

• Emphasizes the importance of patience in understanding patients' experiences; many lack the language to articulate their feelings about their condition.

• Highlights specific symptoms that may not be immediately apparent, such as sexual dysfunction or disorientation while shopping, which are crucial for effective treatment.

The Role of Physiotherapy in Concussion Management

• Argues that physiotherapists are uniquely positioned to provide comprehensive care due to their empathetic approach and rehabilitative programs tailored for concussion education and management.

• Shares a personal philosophy: "I did then what I knew. Now that I know better, I do better," encouraging others to seek guidance in concussion management.

Upcoming Engagements and Contributions

• Invites attendees to connect via email or social media for further discussion on concussion management strategies.

• Mentions upcoming speaking engagements at various conferences focused on traumatic brain injury, including a unique yogurt retreat aimed at women suffering from such injuries.