Thank you. I don't work at Pitt, but I did go to school there. So I think there's a little bit of a connection. Thank you. I'm going to tie everything up and talk about return to play progression. I'd like to thank Justin Marr on our athletic training staff. He is our in-house concussion guru and helped me prepare the slides. So no disclosures. And then I think before you talk about treatment and return to play, you have to talk about prevention and kind of all that goes into prevention. As Dr. Sills eloquently spoke about this morning, we need to take the head out of the game. And I think the league has done an excellent job, and I'm going to misquote this stat, but I know over the past, you know, 7 to 10 to 12 years, there have been over 50 rule changes related to health and safety in the NFL. And that's really about making the game safer and reducing head impacts and improving player health and safety. Obviously, there's been a movement to top-performing helmets. There's no helmet that's going to be concussion-proof, but I think there are helmets that test better than others. And our friends at BioCorps through NFL research have been able to demonstrate that. And really, what it's about is having conversations with our players and getting them into the top-performing helmets. Understanding and improving style of play and technique obviously comes down to the ground level and working with our coaches, coordinators, and everybody on the football staff. Dr. Sills had mentioned guardian cap usage and there being a 20% reduction when two players are opposing each other, both wearing the guardian cap and reduction in impact. What can we do as athletic trainers, as strength coaches in our rooms? Can we improve neck strength? Can we improve vision training? And then ultimately, as mentioned, early identification leads to better treatment and less recovery time. So understanding and having conversations with our players at the beginning of the year and reducing the stigma around, you know, concussion reporting. And I know from our team and on our field, we've had great success with players reporting and we've had great success with teammates and coaches reporting. And we hope to continue to see that as we get down the road here. Much like everyone else, we use an individualized approach to return to play. And really being able to identify who are those individuals that may have protracted return to play. Those that report later have a history of migraines or learning disabilities or ADHD or concussion history. We tend to use a domain-based approach like everyone else that had just spoken. This infographic was published in BGSM by the AMSSM. And really, we don't treat all knee injuries the same. So why are we trying to bucket concussions as one type of injury? And I think that speaks to being able to individualize care, understanding that every concussion is different from the other. Every player responds to a concussion differently and being able to really assess on an individual basis. We use the vestibular and ocular motor screening as Jeannie described. And really looking at smooth pursuits, looking at horizontal and vertical psychotic motion, looking at convergence and then the vestibular ocular reflex and visual motion sensitivity. Our players get this multiple times serially throughout their recovery. And we're able to tailor a lot of this stuff towards their rehab. And a lot of this stuff actually shows up in some of the concussion rehabilitation programming. While it's beyond the scope of this talk, getting into the VOMS, this is work done by MUCA at the University of Pittsburgh and published as well as with Dr. Collins. So how do we target? So we take a lot of what we see on the VOMS, we take a lot of what we see from the domain-based approach and we really implement it in rehabilitation like you do with any other injury. So being able to work on some of the psychotic motion and some of the VOR and everything while on a balance platform. We'll do some hip turns while they're trying to track a medicine ball and having to move their head to follow the medicine ball. We'll look at Brockstring assessment to look at convergence. We'll implement some lightboard techniques and really having players react. We can do this single leg, we can do this double leg, a lot of different variables there. But really getting them to use their eyes and connect their mind and their body. Late stage we've used some oculus training when players are able to tolerate it and we've had some really good success with this. If you've never tried Richie's Walk the Plank on oculus, it's quite the experience. You feel like you're falling from a five-story building. So that's been a lot of fun to watch. Also some of the creed boxing and there's a lot of really cool stuff you can do here that really stimulates the players and kind of puts them in an environment that's different from what they're used to. We've done some smart or some quick board where they have to react and, you know, track the different dots on the board, reaction time, trying to move their feet, again, trying to connect the mind and body, you know, dual task and really trying to get them integrated. And then, you know, from the cervical perspective, we'll do some biofeedback, we'll do some manual therapy, we'll do some chiropractic care and really it's about designing the program that best fits the profile of your concussion. Just like any other injury, we talk a lot about recovery and no different here. These are really our big five, hydration, making sure they have a good diet, they work a lot with our nutritionist to make sure they're getting the caloric intake they need. Oftentimes these are players that are removed from training, so their requirements may be a little different. We'll look at behavioral health. We're one of the fortunate teams that have an in-house psychologist that's able to work with our players post-concussion and really identify those that may have some difficulties in recovery, whether it's anxiety or some trepidation to return. Exercise obviously is a key component that we've talked about. And then sleep may be the biggest recovery strategy. We tell our players all the time, you know, you could sit in the cold tub, you can do the Normatex, you could hydrate, you could eat and you could do everything great, but if you're not sleeping, it doesn't really matter. And we know that impaired sleep has been associated with increased symptom burden, daytime sleepiness and poor functional outcomes. This is really the foundational component of what we're trying to do from a recovery standpoint. How do we improve sleep? We really educate on improving sleep hygiene, avoiding caffeine and alcohol before bed, trying to maintain a near consistent sleep cycle as you can. A lot of our players wear Whoop and have some wearable tech data that they're able to share with us to really understand what their sleep cycle looks like. And we think there's some value there. Understanding that limited screen time and putting your phones in nighttime mode and some of the blue blocker glasses can really, you know, de-stimulate some of the brain while you're preparing for sleep. Limiting naps, we see this all the time in the NFL. Players will get done with their day around 2 o'clock, 3 o'clock. They'll go home, they'll nap for two and a half hours and then they wonder why they can't get to bed until, you know, 1 o'clock, 2 o'clock in the morning. There's a very big video game culture right now which often takes away from some of the needed sleep. And then cool dark room like a cave, just making sure that there's blackout shades or an eye mask or something to really create a nice dark environment for our players. So with the NFL and the NFL Players Association, they've developed and refined over the past 10 years a return to participation protocol. Again, collectively bargained and really updated annually to include the latest science. And this is available at Play Safe Place or Play Smart Play Safe on the NFL website. Really a five-step protocol. Recovery's variable. There's no time frame on recovery. Every individual is kind of their own recovery baseline. We do symptom inventory daily. And then what's unique about our program is that our players have to see an independent neurotrauma consultant at the time of injury, but also again upon return to play for final clearance. And then they work hand-in-hand with our team physician who ultimately has the final say. So what does this look like? In phase one, you can engage in light activities, ADL, stretching and balance exercises. You can include light aerobic activity. And then we allow our players to go back into meetings and some of the classroom work as long as their symptoms aren't exacerbated and they can tolerate it. When they're able to do this without any increase in symptoms and they do not demonstrate any neurological signs of concussion, we're able to progress them to stage two, which is aerobic exercise. Here we initiate treadmill or some bicycle, some stationary bike work. We'll do some dynamic stretching and balance. And again, we're looking for aggravation of symptoms. We let them attend their meetings and then ultimately we hope that the players at this point are back down to their baseline level of symptoms. So when can they progress? Well, when they have the ability to engage in this exercise without an increase in symptoms or exacerbation, we let them get on to phase three. So phase three, basically we let them do some more football type activities. So exercises that are increased to include sports specific activities. We put them in a red jersey and they usually run off to the side with the medical staff. So they'll run routes on air. The defensive backs will run through the defensive backs route tree. We'll do some offensive line positioning and a lot of the skill work in a non-team setting. They'll be allowed to return back into the weight room in a supervised setting. And then we'll start their neuropsychological testing and what the Giants use, we use a hybrid paper and pencil approach with impact testing as well. And once they're able to do this without any symptom exacerbation, we progress them to stage four, which is basically reintegration of team activity. So we'll let them back into non-contact practice, allow them to run, catch and throw and do everything that they're able to do on the practice field without contact. Again, we'll put them in a red jersey and this simplifies basically don't touch me and all the other players are on board with that. So once they're able to tolerate that without recurrence of symptoms and their neurocognitive testing has returned to baseline, which is important there, we'll let them get back into full team activity. So once their neurocognitive testing is baseline, once they've been able to return non-contact without any issues, we'll let them go back to full contact testing, I'm sorry, full contact activity. If there is a time of year where there may not be full contact, late in the year we don't do a lot of contact, but we'll do some simulated contact where we'll be able to use bags and certain things to jostle them. And then ultimately final clearances with the independent neurotrauma consultant and the team physician. So some of the take home points here is each concussion is unique and should be individually managed. Again, it's graduated and it's a stepwise approach, similar with most injuries. We do utilize the domain based approach as no two concussions are the same, each have their own unique characteristics and should be managed appropriately in that way. And then the NFL has done an awesome job over the past 10 years of really improving the program. So it's about identification, it's about early intervention and treatment. So between the UNC program and the ATC spotters, some of the advances in helmet testing, the medical timeout, the adaptation and the invention of position specific helmets, the medical tents, the guarding caps have all been really positive for our game and positive for our And we just look forward to the future, what it entails, you know, is it biomarkers? Is it pupillometry? What else is out there that could potentially not only enhance recognition, but also enhance treatment and return to play? So I appreciate your time and I look forward to some Q&A. Thank you.

return to play progression

athletes with concussions

prevention

rehabilitation strategies

NFL rule changes