 Hi, good afternoon, everyone. We'll get started in just a minute. Okay, I think we're gonna go ahead and get started. Good afternoon, everyone. My name is Dr. Harpreet Paul, and I am the academic chair of Pediatrics at Hackensack Meridian School of Medicine and Kehoevnanian Children's Hospital at Jersey Shore University Medical Center. Thank you so much for attending our seminar today. I also want to take a minute to thank our partners, the NJAAP. We have an amazing topic today. It's gonna be an incredible event, and the speakers that you're gonna hear from today are the top neurologists and physiatrists that you're gonna be able to find anywhere. They're gonna be hosting a discussion related to all aspects of concussion, topics such as prevention strategies, testing, rehab, and cutting-edge research. Special thanks to our speakers, Dr. Felicia Glicksman and Dr. Nicole Marcantuono. Dr. Glicksman is a child neurologist, and she's also the director of Pediatric and Adult Concussion Center at Joseph Emsons Ari Children's Hospital. Dr. Nicole Marcantuono is division chief of Pediatric Physiotry at Kehoevnanian Children's Hospital. I wanna thank all of you for taking time out of your busy day to attend today, and just remember that the recording today is gonna be sent to all of you after the presentation. I know our speakers will also keep a little bit of time at the end, around 15 minutes related to questions, so please go ahead and use the chat function for any questions that you may have. You're gonna be in for an exceptional treat, so with that, I'm gonna go ahead and turn this over to Dr. Nicole Marcantuono. Thank you so much, Dr. Paul, and thank you all for joining us today. We're very excited to talk to you all about something near and dear to both of our hearts, and that is concussion. Next slide. A couple of things that we wanna make sure we review with you today are just some basic statistics of concussion and traumatic brain injury in the US. We'll briefly review the biomechanics of a concussion, how it actually occurs within the brain. We want to make sure that everyone here is able to identify the signs and symptoms of concussion and how to effectively diagnose a child or adolescent with concussion. We'll briefly review sideline evaluation for sports-related concussions. We will learn about the treatment and management of concussions, and briefly review some common misconceptions about treatment. Just want to point out, before we go on, that should any questions come up, we just ask that you use the question and answer function on Zoom. Occasionally, we may open the chat box as well, but we will let you know when that opens. Next slide. First and foremost, it is important to point out that a concussion is known as a mild traumatic brain injury. So the CDC made a push in recent years to use the term uncomplicated mild traumatic brain injury to describe a concussion, to differentiate it from a complicated mild traumatic brain injury, where you will see findings on neuroimaging studies. Concussion itself is a syndrome of altered brain function. So it's important to note that it is more of a functional injury and much less so a structural injury to the brain. So we should expect that basic neuroimaging studies like CAT scans should be completely normal. Concussion, obviously, can be caused by a blow to the head. However, you do not directly need to hit the head if there is a strong enough force to the body, that force can get transmitted upwards and cause that brain to shake and twist inside the skull causing that injury. One important caveat is that you do not need to have a loss of consciousness to make the diagnosis of concussion. In fact, most concussions will not have associated loss of consciousness. A CT scan should be normal, as I mentioned before. Therefore, having a normal CT scan does not mean that the individual does not have a concussion. Next slide. So moving on to some statistics. So the most recent from the CDC information was collected from 2006 to 2014. So in 2014, there were almost 3 million TBI-related emergency department visits, hospitalizations and deaths within the United States. And 837,000 of those were among children. TBI was diagnosed in approximately 288,000 hospitalizations which included over 23,000 children. And that was either with TBI alone or in combination with other injuries. And these mild TBI's which include the concussions account for about 75% of the traumatic brain injuries that occur each year. And what we do see is that children age is zero to four and the older adolescents from 15 to 19 years and then the older adults 65 and older are most likely to sustain a TBI. And what some of the data shows is that zero to four age range is mostly accidental trips and falls but to include those also non-accidental traumas and those older adolescents we tend to see those are our ADHD kids at more risk taking behaviors during those years and obviously the older population that are more likely to sustain falls. So the CDC and prevention estimates at about 300,000 concussions are sustained during sports related activity in the United States and more than 62,000 concussions are sustained each year in high school contact sports. And we are seeing an increased incidence of sports related concussion and this is due to the increased number of our young athletes but also due to the increased awareness and reporting of concussions as we're doing today with helping to increase that awareness. What is also seen though again while we're here today is that there is variability in care provider experience and training as well as the explosion of all these reports and studies for sports concussion and mild TBI that has led to the uncertainty and inconsistency in reporting and the management of these injuries. Sorry, I'm going the wrong way so I'm sorry. So overall though an estimated 20% of all adolescents will sustain a concussion and just to put that number into perspective there's 43 million adolescents in the US in 2021. So that's such a high number that again and something that pediatricians, school nurses, ED physicians, everyone's going to definitely see an adolescent at some point with for this reason. So how are these kids getting concussions? A majority of sports related, sorry about the type of so the majority of the sports injuries in these kids are greater than five years of age but approximately 30% were not sports related and that not sports related injuries were higher in the younger ages. So how do we know if it's a concussion or just a simple bump to the head? I think the most important thing to realize is that most symptoms of concussion will begin within minutes or a few hours after the head trauma. There occasionally can be a slight delay in that it takes several hours for concussion symptoms to fully involve. However, typically you will see symptoms or signs of concussion within those first few minutes. One of the most common symptoms that we see is certainly headache. However, a headache is not necessary to make the diagnosis of concussion. In fact, there may be upwards of like at least 15 to 20% of people that don't actually experience significant headaches following concussion. Other things that we commonly see are dizziness, some balance or difficulty with coordination, brief visual changes, as well as nausea. Next slide. The symptoms that we see tend to persist after the first day or so. Most common things are persistent headaches, feelings of lightheadedness or dizziness, poor attention and concentration. Certainly as children are returning to school, we notice more of that memory difficulty. Children tend to be irritable, have very low frustration tolerance. So we will see mood changes start to come out as a result of that. These kids tend to fatigue very easily and that's more of a cognitive fatigue. It's not as much of the physical fatigue that we see early on because these children aren't participating in those sports or physical activities initially. Very common to see light and noise sensitivities and with all of these lingering symptoms, it's important that we identify them so that we can manage these patients moving forward as they transition back into their daily and school activities. Next slide. So what exactly is a concussion? Why are these disturbances happening, causing these symptoms? So we do understand and what we're seeing is that this is actually a functional disturbance and not a structural injury that Dr. Mark Antuanos mentioned earlier. So what happens is that you have the sudden movement or a force that happens to the head that causes the brain to shift within the skull and then additional injury can occur as the brain strikes the skull. This is a very busy slide but it's really to show you all the busy stuff that's actually happening when there is a head injury and so there's microscopic axonal injury which is the stretching or the swelling of the nerve itself and then you get disruption of how the neurofilaments are organized and you have a difficulty with all the processes going down from the cell body down to axon and meeting the nerve on the other side. So what's also seen is that there's decrease cerebral blood flow transiently that can cause these symptoms as well as mitochondrial dysfunction. So increase oxygen demand and as well as increase energy demand at the same time of a decreased supply of energy that is seen throughout all of this, again, this huge neuro metabolic cascade that's occurring when a nerve is injured. So what we see is a peak of dysfunction right at the onset of the injury and then it's going to take time for resolution. And then what happens if there is a second repeated injury before the initial injury has resolved, we can see possibly a prolonged introduction of these symptoms but with increased dysfunction and even longer time to resolution. And what they also see is what risk factors are associated with these prolonged recovery. We always wanna make sure we ask about prior brain injury. If there's any pre-morbid symptoms such as pre-existing headaches, any POT, so Postural Orthostatic Tachycardia Syndrome or orthostasis, as well as pre-existing AMS which is Amplified Musculoskeletal symptoms as well. So pain symptoms. And so these can definitely be exacerbated if they're pre-existing. As well as pre-mortid mood difficulties like anxiety or depression. If there's ongoing psychosocial stressors as well as younger children. In our athletes, there are several standardized assessments that athletic trainers and sometimes even coaches can use on the field when we are talking about sports related concussions. The most common one used is the SCAT or the Sport Concussion Assessment Tool. We are currently up to the sixth version at this point in time. But a lot of folks are still using the SCAT five. It is both on the sideline and off the field assessment that is done by the athletic trainer. It needs to take at least 10 minutes. If done in less than the 10 minute timeframe it can lead to inaccuracies in making the appropriate judgment calls for these patients. So there are 22 different symptoms on this checklist. So those represent all of the symptoms that we can see reported following concussion. It also has an assessment of cognition including delayed recall, some manipulation of digits stating months of the year backwards. It includes a brief neurologic exam. It includes the best, which is the balance error scoring system as well as a coordination assessment. And then finally a professional opinion to make that call. Other assessments that are sometimes used are the standardized assessment of concussion or the SAC, certainly a brief symptom assessment. We already touched on the best as well as evaluations of clinical reaction times looking at gate unbalance as well as the ocular motor screening. Next slide. In the office we also have various tools that can be utilized. So we pay attention to the patient's symptoms and the progression of those symptoms and recovery over time. A lot of the schools and pediatricians offices are using the ACE, the acute concussion evaluation and that can be found on the CDC website. Evaluations include a full neurologic exam including balance evaluation and a visual ocular motor screening assessment. We also do several cognitive assessments, both verbal assessments, recall of information. We can do something called impact testing which is a computerized neurocognitive assessment that is standardized based on age. So you can get an idea of the person's visual memory verbal memory as well as their visual motor speed and reaction time compared to other children or adults their age to get a gauge. This is best utilized when the individual has a baseline meaning that they took this test prior to sustaining the concussion. So you can actually compare the individual to themselves pre and post injury and gauge when that thinking seems to be fully back to normal. We tend to use this in combination with school performance as well. And when we cannot utilize impact testing or if a child has a preexisting difficulties like a learning disability or a significant untreated ADD we also ask our neuropsychology colleagues to get involved and help us with determining when that thinking is back to normal as well as helping to ensure we have all of the right accommodations in school to allow them to be successful as they are recovering. Next slide. One of the more common things that we hear all the time especially when a parent is calling the pediatrician after hours about a head injury is when should I send the child to the emergency room versus what can wait until the next day? Typical red flags of concussion certainly if their GCS is less than 14 if they have any evidence of skull fracture including battle signs bruising behind the ear underneath the eyes, those raccoon eyes we would want to send them in. Any severe headache or specifically progressively worsening headache if the person is at rest should be evaluated any unusual behavior significant confusion, certainly any seizure activity or lethargy would be reasons for evaluation. Should we see any vocality to a neuro exam if they have an unsteady gate just walking down the hall or around their house certainly any ataxia, vomiting once or twice is okay but if they're persistently vomiting those would be reasons that they should be evaluated acutely and possibly have a CT scan to look for a bleep. Next slide. The PCARN algorithm is a criteria that are utilized in pediatric emergency departments to determine whether or not a child is at high risk for having an abnormality on the CT scan. We're not gonna go through this in great detail. I'm sure if there are any emergency providers on they are very familiar with this algorithm already but this is really the slide is really just to demonstrate that much of the time a CT scan would not be recommended and to just briefly review when it would be recommended. So a lot of times too if a child's in the emergency department sometimes we're caught in between do we just observe them for six hours or do that CT scan? Sometimes a provider may leave it up to the parent which one to do but you guys will have access to this algorithm for your review after the talk as well. Next slide. All right, so moving on to the typical air quote typical concussion management. So what should you do if you suspect your patient has a concussion? So important is rest and really it's the recommendation is 24 to 48 hours of brain rest that doesn't necessarily mean bed rest but it should be followed by gradual reintroduction of daily activities followed by any non-contact physical activity. We do recommend treating the symptoms whether they be headaches. In regards to the headaches if they are starting to begin their gradual reintroduction to school we actually don't recommend taking Advil or Tylenol at the beginning of the morning before they go to school to prevent the headaches because we really need to know what is triggering their headaches and worsening it so it shouldn't be used as a prophylactic but it should be used to treat the headaches. You want to be mindful of any mood difficulties that may need treated, any sleep disturbances, cognitive disturbances or any disturbances with the vestibulocular system. We may recommend school accommodations. So if they're having photosensitivity reducing use of screens, recommending blue light blocking glasses, they may need to have a reduced school day or if they are able to attend getting breast breaks throughout the day recommending a reduced workload. Usually what I tell families is when there is a request for this reduced workload is to speaking with the teachers and their guidance counselors that then there's not that expectation to make up what was missed from that reduced workload because that adds added stress and anxiety and can worsen the symptoms also which also goes along with the limited testing. If they do need to have limited testing making sure that there is a plan for an unstressful test environment when they do need to take the test over. Again, use of sunglasses if needed or if they don't need to be some earplugs you may wanna recommend them leaving the classroom early to avoid the quarters with all the kids in there or to get to their next room before the bell goes off. We also recommend what we call submaximal exercise program an aerobic exercise program. And with this they may need physical therapy and using the physical therapist as their guide on how to advance that progression and then eventually sports. When we will discuss the appropriate time to returning to sports with a progressive return to play protocol but this is going to be important that the patient has no symptoms and they're back to normal school and neurocognitive performance and they have a normal exam including balance and the visual ocular motor system as well as they're not being treated for headaches. So they're off medications. So typical recovery in children, half of our patients recover in about two to three weeks. Another big majority, 80% have recovered by four to six weeks and usually 90 to 95% have recovered within eight to 12 weeks. But with all concussions which is including adults majority have resolved way in that shorter period within 10 to 14 days. And I think it's important to tell this to patients depending on when they do present to your office. Sometimes we get them in right away or they're seen right away or they're sent a few weeks down the line. And so setting up that expectation is important but expressing that shared decision-making and the buy-in from the patient as well is going to be important for a speedier recovery. What we also want to make sure that we do address is that a lot of times we see a lot of adolescents right off the bat, the adolescents aren't really eating breakfast but I tell them that that's going to be even more important now as the brain continues to heal. So we want to make sure that they have good nutrition eating breakfast, lunch and dinner, good hydration, avoiding those impact activities, avoiding any symptom exacerbation, again, dressing mood, the school accommodations, the relative cognitive rest and improving sleep. So my patients always laugh at me when I get to the question, what time do you go to bed but what time do you fall asleep and what time do you wake up is really important. And then these students who have confessions they may come home and need a nap and then they're going, they can't sleep at night. And so it's really important to just tell them short nap when you get home, 20, 30 minute power nap but you need to try to stay on a regular sleep schedule. So that way you aren't tired when you try to go to school the next day. So really, discussing that sleep cycle with your patients is really important. From a prognosis standpoint, again, the CDC found that these factors were associated with poor prognosis. So things to take into account is that older age range, Hispanic ethnicity, lower socioeconomic statuses, if they've had a history of intracranial injuries in the past, if they've had any pre-morbid history of mild TBI or increased pre-injury symptoms as we had discussed headaches, mood disturbances, if they have an underlying neurological or psychiatric disorder, if there is any learning difficulty or intellectual disabilities already and if there are family and social stressors. So again, really important to address those at the initial encounter as they can correlate with the poor prognosis. So there's a motto, return to learn before we turn to play. Again, something else that I do tell my patients because the first question is, when can I go back to play? After I filled out their school accommodation so it's important to not allow to return to gamer practice if suspected or they diagnosed a concussion on the day of injury. We need to wait at least a minimum 24 hours. They are not allowed to return to play until they're asymptomatic at rest and off medications. So they can't be on any headache prophylactic medications that we may prescribe or sleep supplements. And you have to make sure that they are completely asymptomatic. I tell them that there's not a defined set timeframe but they need to be symptom-free at minimum that week as well as off that medications. And we review the progressive stepwise approach to return to play and again, return to school first. In New Jersey, since we're talking to New Jerseyans, a student athlete who sustains a concussion or other head injury is ineligible to return to competition or practice until he or she returns to regular school activities and is no longer experiencing symptoms of the injury when conducting those activities. So this is actually part of New Jersey legislation. I tell families that I'm not doing this to be the mean old doctor. We're here to protect our student athletes and our patients and we need to make sure that they're safe to return. And moving on to prevention. We wanna teach that athletes, it's not smart to play with a concussion. Schools and teams should have a concussion contract. State legislation and prevention programs are in place in order to help educate the coaches, the athletes, the parents. And we really do ask that the parents do participate in these programs because there's so many different eyes on the field. And if a parent or other spectator sees somebody get hit and nobody sees them fall and get up and hold onto their head and walk on steadily or try to shake it off, we all need to be advocating just let somebody know that perhaps they need to pull that player and assess them and make sure that they're okay. But this should go also, the athletes should advocate for this as well as well as the coaches. And also very important to just even monitoring the health of these athletes, making sure that they are conditioned and well enough to even go out onto the field and play. So we're gonna move on to case review. Dr. Marca Antuano is going to take over. Thank you. All right, so we are hoping to engage you guys a little bit more at this point. We're gonna go over two cases and just ask kind of your opinion on what you would do in your office as well or when assessing them at school or sideline. So our first case study is Lucy. She is a 17 year old who is a junior. She is very driven. You got straight A's, very involved at school. She's a member of the National Honors Society, choir and yearbook committee. She's also on the varsity soccer team. The basketball team runs track. So she is a year round athlete as well. Pretty typical social history. She lives at home with both of her parents, two sisters. They have a dog as well. As we mentioned, she's a very good student but her parents have gotten her a tutor for the upcoming PSATs and are already starting to look at colleges. Next slide. So this morning, Lucy was at school heading to her calculus class and she accidentally got elbowed in the head by another student while walking down the hallway. In turn, this caused her to lose her balance and fall backwards, striking the back of her head against the locker. Right away, she noticed a mild headache and dizziness. Her friends that were with her said she seemed a little bit dazed for a couple seconds. She definitely didn't vomit or lose consciousness but her friend took her down to the nurses office to be checked out. When the nurse heard about what happened, she recommended that Lucy be evaluated by her pediatrician. Next slide. So if we can just kind of open a polar chat here. She shows up in a pediatrician's office. She lets them know what happened, that she has a mild headache and feels dazed. So at this point, would you all suspect a concussion? I think we should have enough people that voted by now. Can we close that up and see, are we able to see our results there? Perfect, so 99% of people said yes. We would suspect a concussion and Dr. Glitzman and I both agree with you there. Definitely sounds like it. She has the mechanism of the injury happening. She had that direct hit to her head. Those immediate symptoms and signs of a concussion. So the important thing is when she's in your office that you're getting a good history. Like we mentioned, you're asking what happened? Did she have any sort of alteration in her mental status? If she did lose consciousness, how long was it? Was it just a couple seconds or was she out for five or 10 minutes before coming to? Certainly there are many symptoms that can support that diagnosis, just as Lucy had the headache and dizziness. You may also hear about ringing in the ears or even a brief like muting of hearing, vision changes, nausea, vomiting. The important thing to also find out are has she ever had any concussions before? If this isn't her first concussion, it certainly may take longer to recover from it. And we know that with each subsequent concussion you get, though we are expecting full recovery in between, that it becomes a lot easier to get that next one. So it takes slightly less force to give a concussion with a direct impact to the head. We also know that once you have three concussions, we take a bigger jump in risk to that fourth concussion and what we are and that's why there are folks in the country that manage concussions that will say, if you have three concussions, we don't want you going back or you'll hear athletes say, oh, don't tell them you had your third concussion because they won't let you play anymore. And while there definitely is risk to that, there are other factors that may help us to decide should this teenager or child go back to playing the sport that they've had three concussions in or do we really need to recommend that they pull and they look towards those much lower risk sports activities. Other things that are important to note on history, is there any history of mood disorder or other mental illnesses? Are they currently ill or have any other chronic diseases that may play a role in what their recovery patterns look like and also certainly considering any alcohol or substance use certainly where they under the influence of anything at the time of their injury, but also making sure to review with them that while they are recovering, it is even more important that they do not use these substances because they will be much more affected by it while that brain is healing. Next slide. So when evaluating the child in the office, you kind of wanna do your general exam, do they look otherwise well? Do you see any outward signs of trauma, any bruising, bumps to the head? Certainly you should feel their head around where they were injured, make sure we're not feeling any step offs or other signs that there may be a skull fracture there, checking their cognitive status, even briefly and just conversation. Are they alert and oriented? Do they seem confused? Are they repeating things? You want to do a motor exam? Are they moving all their extremities equally? Does their strength look symmetric side to side? Are you seeing any weakness on their exam? Certainly, are you seeing any abnormalities in their reflexes or their sensation on sensory testing? Looking at the cranial nerves, making sure that the eye movements are intact, that the pupils are responding appropriately to light, that the face looks symmetric. We mentioned that we utilize the VOMS and I know someone had asked what that is or for us to expand on that. So that is our visual ocular motor response. It consists of several eye movements, not only performing the movements, but also asking the patient if they experience any symptoms while doing it. So that would include smooth pursuits, vertical and horizontal saccades, our vestibulocular reflex, both horizontal and vertical, optokinetic response, as well as convergence testing. We're also making sure we do a balance assessment, looking at just their gait, how are they walking, and checking their balance. We typically will check several balance measures. We will check the rhombus, so standing with feet together, closing eyes, doing a single leg stance with eyes open and closed, as well as tandem stance and tandem gait as well. Next slide. Here we just wanted to point out that on the CDC website, there is a lot of good information on concussion, how to treat them, as well as various screening tools available that you can utilize in your office as well. Next slide. Coming back to Lucy again, as all of you agreed, a concussion is very likely. Lucy came to school, was feeling well. She had no history of any risk factors for prolonged injury or prolonged recovery, I'm sorry, or anything else that could explain her symptoms. The timeline of head trauma preceding symptoms definitely fits the bill, and she had those common symptoms to support her diagnosis. Next slide. So what management would you recommend at this point? So we're just gonna open up the chat very briefly, just throw in some answers, and I'll read them off. I see rest, treat the symptoms, school accommodation, rest limit screens, brain rest 24, 48 hours, no sports, Tylenol, modifications in school, no gym sports, limited timeframe. Ooh, everyone's typing so fast. Inform teachers. Yes, absolutely. That's all headache resolves, breaks as needed, let the teachers know, return to learn before we turn to play. Wonderful, it sounds like everybody's been listening very well. So briefly agree with all of you guys, limit that screen time, including phone. I tell my kids, you know, typically for most people, a little bit of TV is okay, particularly those shows where you really don't have to pay attention, you know, cooking network, sitcoms, things where if you walk away from a 30 minute show for 15 minutes, you can still understand what's going on, but we definitely wanna stay off the Instagrams and the TikToks and Facebooks and constantly going back and forth with our friends chatting. Hope I'm seeing some nice other good answers, temporary 504 plan in there. So typically if a patient is still pretty symptomatic, like we mentioned, you wanna arrest them for at least a day, maybe two at the most. I always make sure to tell my patients, like we never really wanna brain-rest more than a week at the absolute most, like we don't want them missing more time from school than that, but typically we would recommend just a day or two and then gradually transitioning them back, definitely making sure we have lots of accommodations in place, like some of you are mentioning here in the chat limiting screen time, so printing out work for them, using enlarged fonts on any reading assignments, sometimes limiting the school day or having rest breaks in there, possibly a 504 plan. Someone mentioned sending them to physical therapy and while there is definitely very good literature for early submaximal aerobic activity to help speed up recovery, there are many kids that are pretty mild, straightforward concussions that won't need that, but certainly if you felt that they should be sent right away, that would be great. I would say if you're referring them to PT right away, you might also wanna think about sending them to the concussion specialist right away as well. Next slide. Are we gonna, we have another poll I think for this one, so Lucy's headache worsens overnight, she vomits once and seems more irritable, she's brought back to her pediatrician for that follow-up visit. When assessed her neuro exam is normal, so what should we recommend now? Should she stay home to rest, go to school, go to the emergency room or be referred to a concussion specialist as an outpatient. All right, we'll give you a couple more seconds if you haven't answered yet, let's close the poll. Okay, so I think we're kind of split, most people are saying center to a specialist, some are saying go to the emergency room, some saying go home to rest. I think that all answers can be correct actually in this case, depending on the situation, so certainly if she was home resting, not doing anything and the headache acutely worsened and she vomited and seemed more irritable, we would be concerned that there might be an epidural bleed going on or some other bleed that we should scan her for, but if you find out that right before the symptoms started, she was running around with her friends through the mall, on a weekend and that's what caused the symptoms, we have a reason behind it, so we would recommend that she scale back and rest. I know that we are starting to run short on time, so briefly we'll go over, there are several red flags, reasons you would definitely want to center to the emergency room to get evaluated as are listed out here on our slide. So those red flags were like we talked, the increasing headaches, vomiting, and the change in mood, the more irritability going on. Next slide. I think we kind of touched on this, when we're going to the ER, if we're worried that there's a more serious injury, there's a abnormality on their neuro exam that is focal or other concerns based on those PCARN criteria, and again, the emergency room and CAT scan should be used alone to diagnose the concussion. Next slide. Go ahead. We did have a second case. I think we could run through this quickly and leave some time for the Q&A. You agree, everybody? Yeah, I think we can, I think you can go through quickly. All right, so John is the captain of the varsity soccer team. During a game yesterday, he went up for a header at the same time as another player and they hit heads. He noticed brief dizziness and blurry vision, but continued playing for 15 more minutes until the game ended. He went home, fell asleep earlier than usual. When he woke up in the morning, he had a frontal headache and dizziness. He went to school where his symptoms were sent and texted his parents to pick him up early. In the car, he then reported what happened in the game and his parents brought him to the pediatrician for evaluation. At the pediatrician, his exam is normal except for a positive Romberg. So what would you recommend as next step for management? We were gonna open up the chat for you guys to kind of throw in there, but in the interest of time, we'll just move forward and just noting that he did have some sway on his Romberg. So essentially, and again, I think everybody's been answering correctly recently, right? So it is recommended that John should stay home at brain rest for 24 to 48 hours. And after that brief period of rest, John can return to school, potentially with that accommodations in place. And at this point also the pediatrician recommends that he can have medication as needed for headache. And the thing I wanna just mention here is there's a conversation always about should we be giving acetaminophen versus ibuprofen? And the real thought about not using ibuprofen is that if there is a concern for a bleed, that it could worsen bleed. But honestly, if you're not really thinking that there is a bleed and it's really just post-concussive headache, it is okay for them to take ibuprofen. So the pediatrician reevaluates a week later and he's been doing well. So now we're going to jump into what can we recommend for the return to play guidelines? So this is a five step graduated, five step return to play. So it's all separated by 24 hours. So the first day light aerobic activity, so go for a walk around the block. The next day, if he doesn't have any symptoms return, he can go for his jog or a little more of a run. And again, if no symptom return the next day, he can increase that activity. So sports specific drills without any contact. The fourth step could be practice yellow shirted and then the following with full contact and then competition. So this is part of the Department of Education's recommendations that they have for the safety training program. And they each school district must have a written policy concerning their prevention and treatment of sports related concussions and head injuries and they must follow the return to play recommendations. So in order to be cleared for return to play, they need to have a normal neurologic exam. They need to be symptom free. I tell the patients, this is an invisible injury. They're not sitting here, limping or cast on. So they need to be honest that they don't have any more symptoms. We have to take into consideration the history, the length of recovery and those previous concussions. I also go into what kind of concussions that they had and how long they've had their symptoms after each concussion, but also, let's say they fell off the swing when they were three and then they got a concussion when they were 10 playing soccer and another one when they were 15, you have to take all that timeframe into consideration as well. They need to be off medications. I did see a question in the Q and A in terms of, if we can utilize the help of the athletic trainer, absolutely the athletic trainer can complete these steps if there is an athletic trainer. Sometimes I will have the physical therapist to help provide with input as well. So there really is no red and green if there is loss of consciousness or yes or no loss of consciousness, but typically one week if there's no loss of consciousness and at two weeks, again, what other symptoms were going on along with those loss of consciousness? How long was the loss of consciousness? If there was a bleed or a contusion, that's going to increase the length of time for return to play. And again, has fully returned to learn with no academic limitations. I see a couple of questions in here that I want to make sure we have to address. So one from school nurse that they see many patients that return the day after a concussion with notes from the doctor, should they be encouraging that they rest? I would say it depends. If they have very minimal symptoms and they're able to make it through the day, it's probably okay for them to be there the next day, but just keeping an eye on them, making sure that we're not seeing those symptoms get worse over time. If they are still very symptomatic, they still have a constant headache that is a five out of 10 or more, they're dizzy, they feel nauseous, they're tired, then yes, you should recommend that they miss school, at least a day to try to rest and recover. Another one, if two students run into each other and bump their head, but one has a small bump, no other symptoms, do you need to keep them out of gym or recess on that day? Probably not, especially if the little bump you see is up in that frontal area, but I would, again, keep a close eye on things. Certainly if you had the choice to do a lower risk activity, I mean, that would be preferred. It's hard to make a blanket statement on that one, but most of the time, as long as they're asymptomatic and that one's looks good, that should be okay. Someone asked about young kids who are nonverbal autistic or other neurodivergent kids, how do you evaluate them? Basically the same way, doing the best you can within their abilities. So for our nonverbal kids, certainly it's going to be more challenging to assess their cognitive status and ask them, to remember words or tell us the months of the year backwards, but this is where we're really looking to families, to teachers, or if they have one-on-ones in school to tell us what are you noticing going on? So it's important to have that open dialogue between the medical team and the educational side of things. And I know if Dr. Glickman and myself are always, always happy to talk directly to school nurses, to teachers, administrators, anyone who has questions about what we should be doing to manage or to help manage our patients and have them be successful. The way that I also answered that is just, not even just the autistic kids, but any younger child who can't speak yet is, is there any change from their baseline mental status? And is there any change from their baseline motor exam? But a patient with hypotonia may take longer to recover if there was a concussion, just because they're already hypotonic and maybe a little unsteady to begin with. They may definitely improve with more physical therapy. They may have physical therapy for a different reason, but they may need to kind of change their goals in physical therapy for a little bit, just based on a concussion symptom. Julia DeBellis asks, why is the Hispanic Ethnicity Associate with the poor prognosis? That's really interesting question. I know this was all based from the CDC and the CDC studies, and I don't know if that just was based on their population, but good question. I'd have to look into that answer. And then the last one I think is important, right? School seems like a big factor. What do you do in the summertime when kids are still participating in sports? That is always a little more challenging. I would say that in the summertime, it's even more important to make sure you have some kind of neurocognitive assessment that is being utilized, whether it's neuropsychology doing testing, impact testing. There are some other baseline tests that are out there that are sometimes utilized at the schools that do have a cognitive component as well, like the Sway. So I would make sure that we have something. Sorry. Oh, that's okay, I'm just trying to make sure to clarify patients should be symptom-free before even starting return to play protocol. Not necessarily entirely symptom-free, it's just that the symptoms need to be relatively mild and that the physical activity isn't exacerbating those factors and you may take a bit of a slower progression just depending on things. So the last two slides, sorry, was again just to show you the different various forms that are available on the CDC website for coaches, for parents, for healthcare professionals, nurses. So you can download everything and it's all for free. And just some information, the Brain Injury Alliance of New Jersey is also good resource as well for fact sheets. And I'm in the interest of time, this is our contact information. Again, if you guys wanna send patients our way or to speak to us, we're always reachable. There was a question in the chat, I did just wanna address was, what's the best time, I think there was an ED, an ED a physician of, when's the best time to refer? There's always, you could always refer depending on the situation, obviously, they should always follow up with their pediatrician as well as referral to concussion center, to a neurologist. I just always worry personally, and I know me and Dr. Marcantuana have talked about this before, is we have a patient who waited a week to see us or even two weeks to see us and they've been out of school because they were told no school until seen by somebody. And so I think that's really why it's important, like the pediatrician, that the kid may feel better by the next day and can go back to school, but if they're not, then they can definitely be, should be seen by a specialist as well. I like this one, I have a student that's had five concussions and was taken out of contact sports for the rest of school life, will that ever be lifted or is that for life? So the risk of re-injury doesn't really change over time, each time you have a concussion, that risk does continue to go up. And some of that, again, with multiple concussions, some of it is certainly a judgment call. If a child had three concussions, but they were all extremely mild, they were symptom-free by 10 days post-injury and they were able to progress back to the return to play by three weeks, post-injury or four weeks post-injury, that may look like a different conversation than a child who has had, we'll say the same number, three concussions, but took nine months to recover from the first one, a year to recover from the second one and six months from the third one and they all happened playing football, that's going to be a different conversation. Now we have like that one, we probably would say that contact sports are not a good idea when we talk about risk benefits. Yes. So Dr. Marcantuno and Dr. Glicksman, being at time, I just wanna take a moment to thank you both so much for speaking today and giving the education on this really important topic to so many different providers and experts who work with patients. You can continue to see, share your screen, Dr. Glicksman and Dr. Marcantuno, I just wanna let folks know if they need to head off now, that's totally fine. And if you have the time to answer a few more questions, I know there's a few more Q and A. So feel free to reshare your screen, Dr. Glicksman, in case people wanna grab your content information. What would you recommend for kids adolescents who do not have an athletic trainer to guide return to play? Do they follow up with the PMD weekly to guide level of play, not necessarily. Some of that, I typically give kids the return to play protocols, at least the non-contact stages. I let them progress that on their own and talk about how to do that. I also have some like sport specific months that I utilize depending on what the child is participating in, but certainly before they are going to those non, I'm sorry, those contact stages of return to play, they need to be feeling 100% back to full baseline school performance. They need to have a completely normal exam, including balance and the VOMS testing as well. So if you're a primary care doctor and you're talking about managing that on your own without a specialist, please make sure you check those other assessments as well, because I have seen patients in my clinic who have gone back too soon and have very clear abnormalities on their visual tracking on exam. So that can not only slow recovery, but put them at risk for more severe brain injuries, as well as orthopedic injuries as well. So I also like to tell patients that, if there's no hard fast, you're gonna get better in this time and you're gonna feel better here and this is what you're gonna do. It's an art and there was a question of, what if the patient's symptoms continue after two days of period? Do you keep them out of school longer? You worry about a student playing up symptoms to avoid school. So again, it's an art, you know your patient well, but the other thing is studies have shown that keeping them out longer from school, they tend to have the longer recovery, whether it's because that social integration is just important for mood as well, but also the fact that at least they can understand what's going on a little bit at school and not miss things in audit. So I'm actually a firm believer as even just treating headaches and chronic headaches is that I don't provide blanket letters that please excuse if they have a headache. They need to call and let me know, right? But what time of day are you getting your headaches, right? And so if the patient needs to sleep in and waking up is really kind of causing them to get headaches, let them sleep in and let them go to school from 10 to two, right? So maybe just do half days for a little bit with auditing, no homework, no tasks. So, you know, that's the really important thing of, you know, as I say, we're all part of the team speaking with the school and really trying to get them into school as much as possible in order to avoid falling behind and then getting stressed over trying to catch up. So, you know, everybody's gonna be a little bit different but I've had to dig out patients who have been homeschooled for four months and I know that this is going to be a chore to get them back because four months of being homeschooled, something's going on a psychological level that they can't go back to school. Like there's something else going on. And then that kind of goes in to what Kate Backer was saying is that as of August 2023, it's a six step return to play. Yes, step one, they added return to school. So I think that that was a nice important addition. Just putting into print of the return to learn before return to play is a very important step. So thank you for sharing that. Um, we answered that and that. What about a case about a blessing who has some behavior, mental health substance use pathology like you might see in the juvenile justice setting? It's a very good question. I actually have a patient who vaping marijuana was a very big, big, big problem with underlying oppositional defiance disorder. And it actually took a lot, a lot of interdisciplinary participation between me and the psychiatrist and really interplaying what's causing what and actually really getting him into a smoking sensation program was really important also. And again, there's so many different underlying things that are causing worsening symptoms to really try to pick the one that's really affecting him the most. And that's really the approach that we had to take with him that for him it was the marijuana, but also he actually did have nicotine as well. And then he came out that he was just smoking so, so much. So we actually got him into rehab for that. And then eventually everything else started to kind of get better. So, you know, picking that battles this time is really tough. If a child bumps into other students or something in the classroom and has a small bump and no symptoms that is recommended that the student doesn't participate in recess on that day. You know, that's a vague, you know, there's not gonna be the best answer, right? If you, if they're in the school setting, the school's probably gonna just sit them out and just call the parent just to sit them out and make sure that they're okay for the day. You know, I would say in a school setting, from a nursing standpoint, it's better to err on the side of caution. But if the kid is completely fine, otherwise I wouldn't call that a concussion. Do we have a step, I'm sorry, Dr. Glickman, do we have a stepwise approach to return to school to give families? Some schools do well with vague guidance, but others need more specifics. Like, yes, we do have some and certainly I would check also the CDC heads up website for some of that information as well, but we try to get very specific things and how we progress. And currently down here at Jersey Shore through our concussion program, I don't know if Dr. Glickman, you may already have it, but we're working on just some information for like concussion in the classroom and providing the teachers and school nurses just like more information on how to manage that and why we do what we do as far as the accommodations go. So somebody wanted me, sorry, in the chat. I think this is the same person because it's coming up as anonymous. This messaging is so different than years ago when my son concussed frequently as a snowboarder and we were told not to let him rest and to get him back on the snow immediately. He died at the age of 30, but I often wonder how the field got this so wrong back then. I think the answer to this really has evolved out of coming out of the national football league, all of their research that's been going on on the NFL player's brains and seeing the effects of chronic traumatic encephalopathy. I know we didn't talk about that takes that's a whole other ballgame, but going back to the NFL players they really saw that they weren't being up front with their head injuries. They were shaking it off and getting back to play. It was not cool to sit out because you didn't feel good. And so, going back and interviewing those that they could really showed that just the increased number of hits, even subconcussive hits with the linebackers really have increased the risks of mood disorders, Alzheimer's, Parkinsonism, epilepsy in the older population. And so, starting younger with proper practices and decreasing the amount of headers at certain ages and how many you can do in younger age groups and in practice versus play is really trying to prevent the chronic traumatic encephalopathy and the neurological disorders that they were seeing in those patients. So I think that that's why there's been that change has really just been because of so much focus on the NFL. Yeah, I think a big thing just to add there is that I don't know how many years ago we're referring to here that this happened, but we know that 30, 40 years ago people didn't really care about the concussions. We didn't really realize that they were causing injuries to the brain, right? You kind of still hear the terms like, oh, it's not a concussion, you just got your bell rung. But we know that that is actually a concussion. And some of it would be older advice, right? If your child has a concussion, don't let them go to sleep because if there is a slow epidural bleed going on, you may miss that. They may sleep through those presenting symptoms. So perhaps this was where some of the information about don't rest came from. But I don't know about sending them back to sport because that seems to be more in the past, like prior to the last 20 years or so. So thank you for that. We had one more question. So I thought this will be our last question in the chat. It's not in the Q&A on the chat from April, which said, with any hit to the head, is it necessary to use the SCAT six or is it a judgment call? I already answered that. Okay, yeah. Ben, we're solid. If there's any other closing notes that you guys would like to say at this point, let me know. No, I think just in closing, I just wanted to thank everyone again for being here for our talk today. We are definitely available. If you have any students or patients that you think need a specialist, please reach out to us. We're more than happy to see them. If any other questions come up or if you're interested in having any more talks for your office or schools, definitely let our team here know and we can try to make some arrangements for that. Yeah, no, thank you so much for staying on this long. We really appreciate the enthusiasm. Thanks everyone. The recording will be sent out after today's presentation and I appreciate everyone joining. So thank you again to our speakers and our attendees. Have a great day. Thank you. Thank you.