not talking about concussion, but I don't know if that's ever going to be possible. But I think the panel, we have a wonderful panel, different topics, kind of focusing on treatment, management, and return to play. And so, what I'm teeing off here is, you know, my challenge is, what I've given this talk quite a bit, turning it from a 30-minute talk into a 12-minute talk, so here we roll. But so really, this is kind of the sideline evaluation, you know, overview. This audience knows concussion is a clinical diagnosis. I think also this group knows if you're dinged, you're done. So we've gotten past the idea that, okay, there's varying degrees. In other words, if there's a traumatic event, and the thing I want to point out, and I really feel incredibly strongly about this, because I think it's, in my opinion, it's got a little bit lost in the shuffle. When you're evaluating somebody for a potential head injury, the first question isn't, do they have a concussion? I think the first question that you should have is, is it more than a concussion? And really more along those lines, and work back from that. So you know, this is a slide to say, baseline is really key when you're going to do this. And so without a baseline, a lot of the tools that we're using are not going to be as valuable. This is the pregame meeting that you've heard us talk about this morning. We can go through this quickly, but there's a lot of coordination. And I think, as I mentioned earlier, I think if you're taking care of a high school team, this just needs to happen, not as formally, but just understand who's all there, who's all the players, what's your situation. Now really, I would say most of the evolution has, as Dr. Seals walks into the room, and is, you know, I think if you really look at what we've done, we've become really better at looking at the field. And why is looking at the field important? Because seeing what happens is probably one of the most important things that we have in terms of diagnosing or seeing people for potential concussion. Now the resources that we have at the NFL level with the people all over the place, people in the booth, UNC in the booth, all the people on the sidelines, the video review and that, clearly isn't going to happen at the high school level, rarely is going to happen at the collegiate level. I'm going to make a little plug because I think we need to be educators of people that are on the field. So, do I think coaches can be observers? No, they're too busy. I think the most readily available, and I think the NFL officials have gotten really good at this, and I think campaigns and strategies to educate high school officials is something we ought to think about and should be doing. If you look at the state organizations and how much the officials get, they have to take a bit of a, you know, concussion awareness kind of thing, but it's minimally educational. So I'll just throw that out because I think it's an area that we could be better, who else could be looking at the field better than, or in addition to. So basically, what are we looking for? We're looking for the no-go signs, okay? And really that's, the no-go signs that we have in the NFL is loss of consciousness, confusion, ataxia or amnesia. What I've always said, in my mind, anybody that looks altered would, I think, fit into that category. Evaluation indicated, or the slow to get up and shake grabs head. So those aren't no-go signs, but I think you see something like that happens, that means they need to be evaluated. And again, that's all this is, you know, important on who's, you know, on watching the field. And so I think, main thing, whoever, if you're covering a game, you're watching the field, and that's just really a paying attention. It's paying attention to kind of just anybody acting, you know, the immediate response of the athlete, how they get up, how they get to their feet, how they go to their, you know. And as we'll talk here, you know, this can come from a lot of different angles of who reports this. So what we're looking for, loss of consciousness, the impact seizure, posturing the limbs. I'm going to show you a video of what I, was a real life experience, or I mean, the athlete we had, that I think some of these are crazy obvious and everybody in the stadium can see. I think sometimes they're not like that. Motor coordination balance problems. I'm going to show you what, again, was observed one that I think is a good example of maybe being a bit subtle, disorientation, amnesia, this clutching the head. We had a player that grabbed his head and was mad that he got evaluated, said, don't grab your head then. Because if you grab your head, you're going to get evaluated. So now these are, I don't know if you can play this. So this is, so this is, I'm going to play some examples. So it's a linebacker on the bottom of the screen and he's going to make a tackle. I want you to watch him. And I'm going to run it again from a different angle. And so I saw this, we saw this, I think a couple of us saw this. The 49er saw this, but see how he just kind of crumples back and the 49er comes up there. You can go to the next slide, or I guess I can do that. But so he's somebody at that point in my mind that was, it didn't matter what his evaluation was. That was enough for me. He wasn't going back in the game. I wasn't overly happy about that decision, but I told him watch the tape the next day. As Justin will tell you, one of my favorite lines, do I want you to understand why you're not going back in the game? Yeah. Do I need you to understand why you're not going back in the game? No. Every time I say that, I feel like a parent. So here's another one. This is kind of an example, shakes head, slow to get up. So these, I think, they need to be evaluated. I wouldn't consider that a no-go, but definitely needs to get evaluated. Hard hits are part of the game, but that hard hit and that blow, you kind of go, that needs to be evaluated. So if you could turn this on. So here's another example. This is a slow to get up. So I think anybody that takes a blow like that doesn't pop up. He doesn't look great there, but to me, that's not enough to keep him out probably, but 100% should be evaluated. And you can play, I think they show an instant replay. I think that doctor's in the audience. So when we go to the tape and we see this and we see that degree of head-to-head, that I think is going to mandate an evaluation. Okay, this one's the one that kind of was interesting. So just think, we're on the sidelines on the top of the screen and you're going to see what happens. So this is an example of how you on the sidelines sometimes are in the worst spot. So our vantage point on the side of the sidelines when he lands and does this, and he scored a touchdown, everybody's happy. And you're going to see on a different view, this posturing thing. So I think we think this fencing posture is like a neon sign. It's kind of a neon sign, but only if you can see it. So when he came to the sidelines after scoring and I asked him how, and I could see he laid there, but I couldn't see any of that. And I say, are you all right? And he said, yeah, I'm fine. I said, why'd you lay there? And then he looked at me like enough to know that it's time for me to go look at the video. And he was diagnosed with a concussion. But then when you saw that on the video, because the angle that we had, couldn't see that, but really that didn't really trigger anybody from above, didn't say anything or what have you. It was just kind of that, the thing that made me ask him is he just didn't get up. And so most of the time they like to get up after they score and when he didn't do that, that to me was abnormal. So these triggers can be what we see from the sidelines, what they see from upstairs, what the officials see, they can be other players, it can be other players saying he didn't know the plays, it can be the athlete coming up to us, the individual, and just kind of reporting, I'm not quite right. And I will say, I think in doing this 30 years, it's way, way more likely for somebody to come up and say they don't feel right now than it was 25 years ago. So sideline evaluation, again, is what you observed. I think good questions to start with with them is what happened. Give me history, the Maddox questions I'm going to talk to you about in a sec, and then just reviewing the different signs and symptoms of concussion, headache, fogginess, dizziness, not feeling right. And then it really ends up being this focused neurologic exam, eye tracking I think is a big part of it, balance, cervical spine, evaluation of their speech. And the last point I'm going to make is don't feel pressured to do it quickly. You know, I think that line, my evaluation is not complete, is a good line to have in your back pocket and use it freely because time is on your side. And for us, it's a low threshold to do a screening and then take them to locker room. Mostly it gives me more time and I feel like I get a better evaluation in time. So the Maddox questions, you know, where are we? What quarter is it? It's always good to know who we played last week. It's about 50-50 for me. But hopefully they know or somebody else knows. Justin's laughing. So you know, how good are these questions? The specificity is high, sensitivity varies, and the false positives and false negatives. So it's okay. I mean, I think they're decent screens. We'll tell you a lot of those guys that I just showed you that clearly had a concussion and the next day clearly had a concussion, their Maddox questions were all normal. So locker room evaluation. So anything that's of any real concern, take them back to the locker room or do your, you know, just we do the full NFL SCAT. SCAT 5 is fine. It's basically what we do with the symptom inventory. And then complete neurologic exam at that point. And then if abnormal, no return to play. We make sure and do serial exams, keep them in the locker room, and they all follow up the next day. In fact, everybody that's evaluated follows up the next day. So the SCAT 5, I'm not going to go through it, but it's basically cognitive tests. It's balance tests, eye tracking, memory. And I gotta say this, but we had an individual that was being evaluated and he didn't miss anything. He was 10 out of 10 on his memory, did everything right, and the UNC asked me if he could look at his baseline. Still haven't gotten over that one. It's hard to be under your baseline if you miss nothing, right? I'm not sure you guys got my joke, but the, you know, we're a little after. So that's kind of the quick overview. I mean, as again, it's a clinical diagnosis. I think when we're doing sideline evaluation, it really is, okay, who's, who don't you like? And at that, the way they acted at that point, their exam doesn't matter, okay? That's the take-home point. If they have a no-go sign, they can pass every test known to man, but they're not going back in. And so I really think this field observation is key. If there's ding, they're done. The other thing I'm going to mention and make a big point about is the adolescent brain is different. It's a different, it's the one tissue, if you think about the one tissue in the body that the adolescent heals more slowly than the adult is the brain. And I don't know of any other tissue that would hold that characteristic. Now I think the biggest mistake you can make is tell a high school kid that the stakes are lower so she shouldn't go back in. That, because that's not the way they look at it and it's not the way you should look at it. The biggest thing with that is, you know, you ought to have a higher degree of concern when you're dealing with the adolescent brain. So that's me staying on time. So now we're going to go to treatment. And so I think the one comment that, well, maybe I'll steal Jeannie's thunder, but I think the days of thinking treating concussions as a passive process are over. So I'll turn it over to Dr. Dobrak.

concussions

treatment

baseline testing

diagnosing concussions

sideline evaluations