neurologic stuff and neuropsych. I know human attention span can be a lot, and even though we just had a little bit of a break, I'm gonna have everyone just stand up and sit down. I know I only have 12 minutes and I'm just taking 30 seconds, but it kind of resets us for a second, and I'm hoping that I get all of your attention. So up, down. I'm Jeannie Doprak. I'm privileged to work at the University of Pittsburgh, which allows me to have learned from concussion from people way smarter than me, including Dr. Mickey Collins and his group. So I'm hoping to share with you some of what I've learned from them today as you're managing concussion in all of your own geographic areas. So the first thing, just to piggyback on what my colleague just said, when you identify someone and they have a concussion, do not return them. I mean, what we know and what we all worry the most about is second impact syndrome. The reality is is that second impact syndrome is actually exceedingly rare, but what is common is delayed recovery. And so if you have someone with a concussion, the CDC's line is it's better to miss one game rather than the whole season. And this resonates with athletes, right? Do you wanna be out the next two quarters or the next two weeks? And they do wrap their head around that, no pun intended. We know from all the evidence that there is a 50% faster recovery if we immediately remove them from play. Two times faster. So you tell an athlete, I can get you back two times faster if you let me know when you have the injury and we remove you. They listen and hear that. So previously we used the cocoon theory, which was we wrapped people up and we put them away. We gave them academic accommodations. We said, don't do screen time, don't go to school, don't do sport. We just want you to stay in a dark room and not do anything and get better. And where that came from was somewhat of this bell-shaped curve. Everything in life is a bell-shaped curve, everything. Like you love ice cream? Well, work at an ice cream parlor. That's too much ice cream, right? But no ice cream, that's not enough ice cream. So the three bears told us all that very early in life. It's too hot, it's too cold, it's just right. There is a sweet spot to everything. And when we first started treating concussion, we went way on the far side of this. We cocooned people. We said, don't do anything. And the reason why is because we had them do too much. And we found out that too much exacerbated symptoms. And so the sweet spot is actually not going far the other way, it's somewhere in the middle. And so what we're learning through really emerging data in the last several years, and if you remember one thing from my 12 minutes, this is it, that early submaximal exercise in aerobic capacity will improve symptoms quicker. Again, early activity. So that means getting them doing some biking, some walking, some swimming, and it's individualized. So when I look at my division one swimmer that at baseline does two workouts on the pool a day and a lift, and maybe even some dry land training, I can get them doing a little bit more. They're also supervised, right? We think about all of our different places that we work. And so if I'm at Pitt, I know the athletic trainer's gonna be there monitoring what they're doing. The strength coach is gonna be looking at their lift. But if I have a high school kid, I may be a bit more prescriptive that I just want them to do a walk around the neighborhood or a bike because they don't have that same amount of attention on them as they're recovering. But early submaximal aerobic activity is going to be important. Early mental activity is also shown to be important. Again, we're coming from a place where just a few years ago we were telling kids to stay home from school. Don't do things, don't do your homework, don't go to class, don't go to the meeting even, right? Don't be at practice. Well, and while I wouldn't sign someone up necessarily for the SATs that week, again, locking them away in a room is not found to be the right thing. We're encouraging people to stick to their schedule, go to class, do the things, maybe do it in shorter durations, give yourself breaks. But again, we're wanting people to get that mental activity because the emerging evidence is is that we're seeing greater improvement and quicker pace. So I've stolen this concept in this slide from Dr. Collins and company because it really summates concussion. And when we're thinking about treatment, the categories that people fall in. And in general, as people have post-concussive symptoms or just concussion symptoms that they're recovering from, we've all seen this. They fall into these categories, vestibular, ocular, cognitive fatigue, post-traumatic migraine, cervical, anxiety, mood. Now on this diagram, they all look exclusive to each other, but in reality, it can be a Venn diagram, right? Because people can not sleep and have a headache and be depressed, right? They can overlap a lot or they can be separated. And we really design our treatment protocols based on what categories people are fitting into. And so here's that same diagram, but now with some of the treatment protocols that we utilize. And if you look at this, exercise is in everyone except ocular. And I think that that was a typo, just so you know. Again, not my slide, Dr. Collins, but in the end, some maximal exercise is gonna be important. But let's go through a few of these categories specifically. So vestibular, when someone's presenting with that dizziness, the vertigo, the balance issues, and again, vertigo spinning like on a ride or just some off balance, like they're on a boat that's rocking, we know looking at the overall collection of data, which we've been doing vestibular therapy for a while, that these very small exercises using eye movements and head movements will restore balance quicker. And in fact, there was a paper published in 2022 where they looked at the body of data and really had very, very strict selection criteria for what they called quality papers and found that overall the vestibular therapy did reduce time to clearance and showed improvement in dizziness and gaze and quality of life. But interestingly, didn't show any effect on balance, which you think it would, but the papers did not show that. So vestibular therapy is certainly something I use in my practice. Please note that you have to write specifically for vestibular therapy. So just sending someone to physical therapy doesn't mean that they get that vestibular therapy. It's really a prescription that's exclusively its own. And so you need to write for vestibular therapy. Cervical therapy, I put after vestibular therapy because I do think the two of those often go hand in hand. And I'll give you a recent example. I take care of football like many of you, but I also take care of a lot of other Olympic sports, including our gymnastics team at Pitt. And in fact, we're hosting NCAA regionals right now as I'm standing on stage at Pitt. And one of our gymnasts was doing something called a Jaeger. If anyone knows gymnastics on bars, her skill was to release the upper bar, do a front tuck and re-grab the upper bar on her way around. Something I could never ever dream of doing in my life. She does it quite well most of the time. A few weeks ago, she missed the bar and fell onto the mat, which doesn't happen uncommonly, just so you know. What the uncommon scenario was, was whoever was supposed to set up the mat didn't position it correctly, causing her to come down in like almost a cobra position with her neck and head, hitting her face and extending her neck. And so, you know, she got up and popped up, had a little bit of neck pain and stiffness, nothing that we needed to board her, but just didn't feel right and kept blinking her eyes at me again and again and again. And we took her to the back and did all the things and I held her. And it turns out she had a whiplash mechanism from that fall and that whip of her head back. And her VOMS, her neurocognitive testing are all normal, but she has like this convergence that's so far out. And she just keeps blinking her eyes and having these ocular symptoms. Treating her with the vestibular therapy and cervical therapy really restored her and got her back much faster. And so in those cases, understand that the presentation may not be what we typically see. And even the testing that we usually use may not lead us to the path of concussion, but this is a concussive mechanism from the whiplash. So again, doing your standard cervical therapy that you would for someone even just in a car accident helps to recovery hasten. So what if someone doesn't, you know, what if we do all the things, we do submaximal exercise, we give them the appropriate amount of time and they're not getting better. And in particular, in the areas of mood, cognitive fatigue and migraine, pharmacologic management can be utilized. My colleague at Pitt, Dr. Kelly Anderson has taught me all I know in this area and is really my go-to person in this. And she always tells me less is more. So start very low when you're using medication and sleep is the most important. And so if we think overall, just in general, if we're not getting good sleep, we're probably not giving our best through the day. And when it comes to concussion, you know, treat sleep first. And so if we look at this very busy chart, it has a lot of the choices that we typically use for the different categories as far as medications. And I'm not gonna go over the whole thing, but I do wanna just give you my favorites in each category and why. So headache prevention, I really like the amitriptyline. I start very low and at bedtime. It generally makes people tired, but they don't get a hangover the next morning from it. But I use the amitriptyline because a lot of times people are having some sleep difficulties. And again, if they're taking it at bedtime, it's giving them that help with their sleep. If we have anxiety or depression, I usually use an SSRI. I take care of mostly college kids. I pick Prozac. My psychiatrists tell me that it has a much longer half-life. And so my super reliable college students who always remember to take their medication, when they forget it, they do not get withdrawal symptoms the same way they would on, for instance, something like Paxil. Paxil actually has a very short half-life. And so nothing against that medication, but it does, when you forget to take it, give you pretty significant symptoms in a short amount of time. As far as sleep goes, I just talked about the amitriptyline, but if it's really exclusively sleep, not any of the other things, I'll try melatonin first. I'm finding more and more people are not responding well to the melatonin, and I'm not sure how much of that is them just knowing it's over the counter and thinking like, oh, this is not, it's like Tylenol versus a prescription medicine. People always say, oh, Tylenol doesn't work. Well, I'm not sure that you just think it doesn't work. And so I'm not sure how much of that is coming from that process. But if it's really exclusively sleep, I actually go to the bottom of this list and use Trazodone, 50 milligrams at bedtime. Again, I feel that this is very well tolerated and doesn't give people that morning hangover that sometimes they'll get from some of the other medications. Lastly, cognitive fatigue. You can see that the ametadine is really our first go-to. Again, keeping in mind that I take care of a population of college students mostly, the stimulants are all banned by the NCAA and need medical exemption. So if you're putting someone on a stimulant for concussion, know that that is not a medical exemption by the NCAA. You really exclusively need to have a diagnosis of ADD or ADHD, and so really be mindful of that when it comes to your drug testing protocols. You know, I don't want to steal fender from the person upcoming, because I know we're going to be talking about return to play, but just as a mention, they have developed a new exit test at my institution that involves some dynamic exercises, zigzag. It involves a cardiovascular challenge and has really been shown through trials to help confirm a safer return to play. And I say safer because I don't know that we're ever 100%, because we're really still relying on the athlete reporting honestly to us how they're feeling. And lastly, again, I think in treatment, it comes to return to play, but we're going to be talking more about that. But I go through really what is a moderate to heavy cardio workout, and then non-contact individual skills, full contact, and then to game. I will say, again, early submaximal activity, right? Like I keep saying that, because I really want you to remember that being the point from this, is that when I get them to the point where they're asymptomatic, they've probably already done a heavy cardio workout. So that also reduces some of that algorithm that you have to return them to play, because you've already put them through the cardio workout and can start right back at an individual skills workout, or even at a full contact practice, because you've done the other things first. So on that note, I am within my timeframe, and I'm going to turn it over to my colleague to continue. Thank you.

Jeannie Doprak

University of Pittsburgh

concussion management

treatment of concussions

athlete safety