I'd like to thank our speakers for these excellent presentations today. Is there anyone in the audience that has direct questions that I could start with? Dr. Mormon. Question for Andrew. How long does it take to get those biomarker results? Is that something that an ordinary lab can run or is that? It's a great question. So we participated in a study where we measured these things and it was a research setup where it wasn't, hey, how quickly can we get this information, it was just, can we get this information? So it was days. So the reality of that is that's not very helpful in our world, right? So the practical aspects of this are yet to be sorted out, but I think the reality is it's probably going to have to be these things you can run yourself without having to send them to the lab in order for them to be useful. But I do think there is promise, like I think this will be something we actually use in the future going forward. I don't know if you have any other. Yeah, no, it has been where it's, you want it within like 15 minutes, right, and just, it's been hours. And then the timeframe, almost like troponins and things for heart things, it'll be a similar thing where what's the timeframe when it becomes positive and then goes down. So there's going to be a, it looks like a lot of the ones are going to be a combination of more than one marker. It's going to be three or four and kind of a panel. And then again, what's the, it's going to be like a, hopefully like an eye stat kind of thing where you're just doing it like on the sideline, like maybe a little blood finger prick and then you get that, you know, a readout then is what the goal is. Can I just add that Sniper Camp in Australia has done a lot of work with the validators, the biomarkers, and they're using it to validate what they're actually able to show with their Australia vs. football. And it's taken a day, but it's basically trying to validate what they were able to find on the sideline using the mandatory observatory signs that Andrew alluded to. You know, you can find those, there's like six mandatory observable signs that have been highly correlated with the diagnosis of infection based on data. And so they're doing the work to sort of validate the use of this biomarker, but it takes, he's saying it takes 24 hours. Our study was on the salivary ones too, so at least it's simpler. I have a question for Dr. Lee. When we're arresting our concussed athletes afterwards, we're reducing their athletics and then when they graduate back into the game, we're seeing this increased rate of lower extremity injuries. So it seems like there needs to be a change in how we're doing that rehabilitation. What do you think is going to be the correct balance to strengthen the athletes when they return to sports and reduce their injury risk, but still balance their concussion? So right now a lot of the protocols call for obviously sub-concussive or sub-symptomatic aerobic exercise, but they don't often address some of the strengthening components. And so one of the arguments for lower extremity injury risk is that well, this athlete's been out for four or five weeks, you know, they've missed all their weight sessions, they missed all this stuff, well maybe that's what's putting them at risk for lower extremity injury. And it's possibly a component. It's really hard to tease all that out. But I would say that we're starting to see guidelines on obviously how to do the aerobic component of return to play after a concussion and doing that immediately. And I think we're going to start seeing some guidelines, especially in like our older athletes, about how to get them still doing some of the things that they can tolerate at a sub-symptomatic level. And I think that will help us to integrate them and keep them into like their sport and maybe hopefully decrease some of this risk. Though I think some of it's not just due to like disuse. I think some of it is due to some of the other pathways that we're seeing. But I think we'll start to develop more protocols to be able to do that. And ideally when I'm seeing somebody, depending on the setting that I'm in, I really like to have them doing, even if it's just body weight squats and lunges, whatever it is that they can tolerate while we're addressing some of the vestibular and ocular motor components, then I try and get that started right away if I can. And that would I think be the ideal scenario as well. »» I was going to chime in just to make sure everybody in this group is aware there's good data now that resting people makes their symptoms worse. That exercise is safe. That exercise actually makes you recover quicker from concussion. So your symptoms go away faster. And if you have post-concussion syndrome, it improves post-concussion syndrome. So one of the things that I think we haven't seen yet is what happens now that we realize we can do all these things earlier. Does that help some of the data that she showed you? So if we know this now and we aren't resting people so long, hopefully they won't have as many deficits that you then have to correct in order to get them back. But I think a lot of people are still stuck in this, hey, rest is the right answer. And we know it isn't. It makes you worse. And actually exercise helps you recover quicker, which is again a change from what people were doing. So hopefully that's catching on and people are kind of incorporating that. There's one thing I would tell you to do. It's exercise your kids with concussion. We should be telling them to do this. It's a positive thing. Yes, I do. Can I ask a question too? What is the intensity of the exercise that you would recommend? So it's a great question. The group out of Buffalo is the one who provided all this data that I just alluded to. And they do what's called the Buffalo treadmill concussion test, where you run them on a treadmill until they reach their symptom threshold. What's your heart rate? And then you realize that's what it is. Now, we don't have treadmills everywhere. They did it for bikes. That works as well. But my argument is it probably doesn't matter what you're doing. Strength is probably good too, right? It's what you can tolerate until you reach your symptom threshold, and then you stop or you decrease the intensity. But I tell them I don't care what it is you do. Do something, whether it's aerobic or not. And clearly there's evidence to support doing it. All right. I'll often tell people, especially people who don't have heart rate monitors, things like that, right? A lot of people have the smart watches now that they can do that. My younger athletes or my Medicaid kids, they don't often have access to that. So I'll often tell them, go for a walk. If you start getting a headache, sit down somewhere. If your symptoms go up, you're exerting too much. You want to be right below that level before you feel your symptoms. And it can be as simple as that. It can be if they can tolerate biking, if they can tolerate walking. Some athletes can run and have no symptoms. So finding that level that is their level is helpful. But you don't have to be so exact with the heart rate if you can't be. That's nice if you really need to be, but you don't have to. All right. For Dr. Lee, the study that you showed where the reserves had a higher rate of injury, what age groups were you looking at? That one was high school and college athletes. I know from my experience, I was one of them. A lot of kids mature later physically. And so you've got kids in college, certainly in high school. A few in college, but that's less physically here than the cohorts. That's why they're reserves, because they're overall bikes. Is there any way to tease that out? They didn't look at that. They were too small. Yeah. They didn't look at that in this study. They didn't add in a whole lot of other data, such as their strength, range of motion, et cetera. But that would be another interesting piece of it. I know plenty of starters who are very unathletic when you break down their movement patterns. So I think that there's all that piece to it as well. What are they exposed to before you're doing all of this? Sorry. Can you repeat that one more time? So I think it depends on the setting that you work with and the doctors that you work with. In the collegiate setting where I work, if the doctors identify a vestibular-ocular motor component via the VOMS, which is the primary tool that we use, they'll automatically send them to me and I'll do an evaluation, a more in-depth evaluation of those vestibular-ocular motor components and give them like a home exercise program about those exercises. So it might be that they have issues with looking from one object to another. So there's sarcotic eye movements. And I'll immediately give them some homework based on that and give them some prescription around their symptoms so that they know how to do it to help habituate to those eye movements so that we can get them better in that regard. I don't think that there's a study saying that yet, but I would say that anecdotally I think so. A lot of the athletes will come in complaining about difficulty reading or seeing the board, but I don't know if you guys have seen a study or anything like that. Yeah, I was going to ask what Jeff's experience was. Our experience is that we don't have enough people that do it to send everybody for it. Like we have a limited number of resources where typically it's the ones who have prolonged symptoms that are getting sent for it. But on the college side, we have taken that step to say, hey, listen, if we recognize this early, does this help you sooner if we address it earlier? That data does not exist, but I'd love to see it. But the challenge for us has been the resource. Again, there's just not enough people that do it to say, hey, if you recognize this, everybody should be getting it as soon as you recognize it, not waiting until they don't recover normally to then initiate it. Yeah. That's what a lot of the early data is. They said wait three weeks before you start doing those things. And we were, just like you said, more proactive now. So our therapists have concussion slots that we have available. So if we see one on Monday, they're going to be seen by Thursday to start that rehab. It's just like anything else, right? Swelling, range of motion, anything else. Like, why are you going to wait for it to kind of calm down? Let's try to work on it. Now, some of the kids, though, when they do have those symptoms, they can't do much with it. Because a lot of the treatments are actually you're doing the same movements, but just at a slower pace or something. And so they still don't tolerate it. So you still might have to wait a little bit. But it's like everything. It's just an individualized thing. But I think more and more things, just like with the Buffalo things and exercise, doing things earlier, the things they tolerate, is always better. And so that's what we're going to see with the bombs as well. Yes? The difference is the recommendation was to rest until you're symptom-free before you started. That's the difference. Now we're saying start it immediately. Even though you're not symptom-free, start exercise immediately. That's the difference. I mean, you can argue what's immediate, but sooner than later, right? There's no evidence that doing it even at 24 hours is going to cause detriment. Now, we're not going to tell them to do it if they feel terrible. But sooner than later. That's the change. It used to be wait, wait, wait, wait, wait. You're better. Now you start. Now it's as soon as you feel up to it, let's get you going. Because we know it helps you. Yeah. Again, I know of no data saying what number of hours we're talking about to initiate it. Like, that's a recommendation, but there's no data to say that we have to wait. And I'm not saying to start if you feel bad. I'm just saying the error has been way beyond that. It's been weeks that people have been waiting. Like, not hours, but weeks before they're starting. I'm saying days you need to be starting this. And again, you base it on them, right? So, like she said, like light walks. Like, go walk around the neighborhood. Put sunglasses on. You know, put music to whatever you want to do. You know, you're not going to do something if they have balance deficits. You're not going to tell them to do something that, you know, is a balance. So, if they have a lot of bombs, they're not going to be doing some of those things. But, you know, there's been some things. Do yoga. You know, do some things where you can do it in a cool environment. Do some yoga. You can work on static balance that way. So, there's a lot of things. It's just, again, just get moving. Part of it is, too, is their sleep pattern gets disrupted, right? If you sit around on the couch all day and don't do anything, right, you feel crummy. You think about all the things you're missing. All the things you're not with your team. All these other things that go on when you're just sitting on the couch. Your sleep patterns are disrupted because you're taking naps all day. You know, maybe you're on your phone all day and that's disrupting you. So, that's where, again, doing some light activity has a lot of benefits and you tailor it to whatever their symptoms are. And that's where they were just trying to quantify it with the buffalo thing for a heart rate. But, again, that's not necessarily with that. I have a question for Dr. Blake. Uh-huh. So, you talked a couple of years ago about the second international symposium that happened in Japanese and abroad where it first was discussed as non-manatonic and it's a metabolic problem. So, now you've developed these, you know, rehab ideas to help them get back faster, better, without any restrictions. I'm dealing with the ACL tears and neuromuscular drain and ACL tears. What's the future of therapy in the pre-discussion evaluation program? I think it would have to start to include, like, a full body evaluation, right? So, we do that a lot for our studies for ACLs. We look at things like the Y-balance test, which is supposed to measure neuromuscular control. We look at different strength things. We look at different movement patterns. And I think we're going to start to see that incorporated into our concussion protocols for baseline testing as well. Because how do I know if you're moving differently from the Y-balance after if I don't have your before? So, we'll start to see that in our neuromuscular control. But some of our research that we actually ran these numbers and we didn't see any deficits or changes in our athletes from the Y-balance pre- and post-concussion or post-concussion compared to our healthy controls. But the cervical exam and specific injuries, for example, the fringe, top 14 rugby, you have to be certified to play on the front row because that involves a lot of twerking of the neck. You have to get a certain physical test to be able to be allowed to play there. You can train that, but if you're not qualified, you're not allowed to play there because you're at a high, too high risk for c-spinal concussion. And that's a really cool thing you're kind of alluding to is there's also this difference between clinical recovery and physiologic recovery. So, like Andrew said, imaging isn't kind of prime time yet. It's more research-based. What we're seeing on those scans is that, yeah, there's not everything that's quite normal yet there. And it'd be like if you got an MRI of a knee right after an injury. It's not going to look normal necessarily, but clinically they're doing great. Same thing with brain injury and concussion. So, where's that line where, you know, six months later you got a DTI scan. It was still abnormal. Does that mean you're not letting them play for six months? No. But does that mean anything? And so that's maybe with some of these lower extremity deficits or other things. Is there still something there going on that, again, we need to do more, you know, vigorous return-to-play kind of tasks and everything else to get them back? That might be what's on the horizon as well. Margaret, you may know this data better than me, but the cervical strength data for prevention early on was kind of promising. People thought, well, maybe there's something to this. But my understanding is now that cervical strength training hasn't really shown to pan out for concussion prevention. Am I accurate? That's accurate. I think the biggest thing is if someone's prepared for a blow, then you can have the strongest neck. If you're not prepared for the blow, it doesn't matter. Whereas if they're prepared for the blow, they see it coming, if they're prepared to brace themselves, then that's really helpful. Well, maybe they have to wear a prevention or de-centric exercise before it can be something helpful. You know, that hasn't been studied, I'm sure. This will be our final question. What's your thoughts? I've heard some things that the rather than concussion being the major concern, it's the microconcussions that aren't necessarily symptomatic, which ultimately leads to long-term problems. I was going to say, there's no research on subconcussive hits with lower extremity injuries yet. But there is a ton of research on subconcussive hits in terms of CTE, which could be a whole other day-long discussion. The only thing I'll say is I think it's very hard to comment or really have anything tangible on something that's immeasurable. It's easy to say it, but it's immeasurable. So the reality is we see these strange things where somebody may have this transient neurologic phenomenon that we don't know what it is, but it's hard to measure. So how do you make sense of it if you can't measure it? I think that's the biggest challenge we face. People can talk about it all they want, but until we can measure it, it's very hard to sort of make any correlation at all. I have a hard time even sort of addressing something we can't measure. Final question. And some of the other things we talked about. And so it's hard to say. That said, I have a question I'd like everybody to answer if they can, because I get asked this all the time for everybody else. After a kid's second or third concussion, parents say, how many is too many? And I can't find anything that tells us how many are too many. I had one little girl one time that every time she went back to play soccer, she got a concussion within a week. There's something. Soccer's not her sport. She needs to be playing. What do y'all tell a parent when they ask you that question? I will say from the team physician perspective, you work very closely as a collaborative group, determining the fitness to return to play for a patient or for an athlete. And then you also need to work closely when you have to disqualify somebody from athletics. And it may be due to a concussive disorder. It may be due to a physical disorder. Clearly, if the athlete cannot participate because they have too many of these events, they're going to be disqualified from participation. It's the borderline cases that are more questionable, a severe concussion with prolonged symptoms. Maybe they've had two or three of these episodes. But each time they have it, it's taking them much, much longer to get back. Those are the tougher questions to answer. And I think we need to work together as a group to look at both the qualitative data and the quantitative data, and the athlete's goals to figure out when that return is. But there's never going to be, I think, a hard cutoff. I think that longer return to play and then also less of a blow that causes injury. So everybody's watching and they're coming off the field, they're going, did you get hit? And they're having symptoms. Or the parent's like, well, we didn't even compare to you. You get that big whack. And so those are the kind of other things I say, too. If you're seeing just kind of normal play and you're getting symptoms, and then, again, if they're taking four months every time to get better, I kind of tell them, do you want to go through this every time? So all the aspects you get from sports of teamwork and everything, like find another sport that's maybe less dangerous for you. We unfortunately had a Duke girl that a freshman came in with three concussions in a year, and she was still symptomatic. So we said, well, you shouldn't really play soccer anymore. So I let her find out. She went on the club field hockey team, our neurologist saw her and said, oh, yeah, you can do field hockey. And I'm like, so she came to walk on the field hockey team for a physical? I'm like, what are you doing here for field hockey? I'm like, no, sorry. But she did rowing. So I said, hey, you can row. And she had a blast. So, I mean, again, soccer's kind of a derriere. And you may find that certain athletes are just going to be much more cooperative with that decision making, and some aren't. Right. Absolutely. And parents. But you know during those PPEs who's going to be trouble. They've had three concussions in high school. They've had an ACL reconstruction already. You know, there's something from the physiologic standpoint that they're really maybe not cut out to get to this next level. And we'll see it more and more as people and parents invest more finances into group training, physical rehabilitation. There are kids that probably should not have made it to that level that are going to slowly weed themselves out of the collegiate ranks. I'll offer one other perspective, and that is people talk about two or three, and then you start taking care of college rodeo. Anybody here take care of college rodeo? Fourteen was the one I saw on one of their pre-participation physicals. And you tell these guys they can't do rodeo, that's how they make their money. Right. So if you ask me if there's a magic number, I say there is none. Right. But it's all perspective. Right. I can say I'm not going to sign your form, and he's going to go out on the pro rodeo circuit and ride. Well, listen, everyone, I want to say thank you so much for three fantastic talks. I think we could probably end up talking about this all afternoon, but I think we all came out of it with a lot more information. Two housekeeping announcements, there's going to be a reception in the exhibit area, so please try to attend. That's going to start now. And then if you can fill out your evaluations of the program, that would be super helpful for us on the program committee going forward so we can plan our next year's exchange lectures. All right. Thanks a lot. Thank you very much.

panel discussion

concussions

sports injuries

biomarker results

rehabilitation

subconcussive hits