#77 - Concussion Guidelines for Return-to-Play with Dr. Mike Olson, Part 1

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Hi guys, Welcome to another episode
of The Factor podcast. I'm your host
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Jessica Riddle. Today we kick off
a brand new training with doctor Mike Olsen
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titled Concussion Management How to use graded
Return to Sport and Return to School guidelines.
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Concussion management and post concussion care are
multifaceted and highly individualized. One person
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may have a fairly easy recovery and
little long term effects from a head injury,
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whereas another person with an almost identical
brain trauma can be permanently disabled.
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The scientific community has made incredible advances
in the last decade in our understanding of
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the short and long term effects of
concussion, but there's still a number of
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mysteries when it comes to the physiological, neurological, mental, and emotional inner
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workings of the human brain. In
Part one of this fascinating two part series,
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you'll learn from doctor Michaelson. He's
a nationally and internationally certified chiropractic sports
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physician and he heads up the concussion
Management program at Big Fork Valley Hospital in
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Minnesota. He will walk us through
the internationally recognized return to Sport guidelines and
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provide us with a step by step
approach to managing concussion throughout every phase of
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the healing process. So if you
treat anyone with a brain, which I
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would venture to guess all of you
do, then this two episode series is
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one you'll want a bookmark to listen
to more than once. Click the save
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button, grab something to take notes
with, and settle in. Let's get
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started. Thank you, jes Well, welcome everyone. As just mentioned,
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we are going to be spending some
time today talking about concussion management and how
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to properly manage those athletes that may
come through your office. But first I
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just want to draw a little bit
of attention to this concussion management. I
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would say ten years ago, there's
probably a lot more hype than there is
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now. I think some of that
hype is calmed down, but I think
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that's because we as practitioners have done
a better job at recognizing concussion and understanding
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the importance and what we're doing to
treat it, to monitor it, to
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how we're holding our athletes up out
from play or they have a concussion.
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We know they're not supposed to go
back to school right away or or go
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back to work. But a lot
of that hype stemmed around the fact that
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there's a significant risk to individuals who
may have sustained multiple concussions. Concussion studies
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suggest long term cognitive deficits, and
furthermore, there's this over overlying risk of
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second impacts there. But that's basically
getting a second concussion while you're still recovering
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from the from the first one.
And what we're seeing with this is as
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we're recovering from our initial concussion,
our brain and sometimes a little bit more
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susceptible to changes in that blood pressure
and it makes to stay a concussion.
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We kind of see like this catacholamine
release where catacholamine surge essentially from that second
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impact to the head, and that
can cause vascular congestion, cerebral edema,
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it can increase our intracranial pressure,
which then could lead to coma or heaven
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forbid death. But that's kind of
where a lot of this hype stemmed from
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a few quick facts about concussion.
We now know what we do know,
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and we have for a while that's
a traumatic brain injury. There's a period
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of time where some of our leading
researchers wanted to just get away from the
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term concussion in general and just basically
call it a traumatic brain injury. We
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haven't been able to ditch the word
concussion, but I think a lot of
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this newer research, we no longer
are calling it, I got my bell
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wrung, I got a dinger or
something like that. And obviously, as
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many of you are probably where it's
caused by a bump or blow or jolt
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to the head. It can occur
from a sports injury, it can occur
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from a fall. Usually they're not
life threatening, but they are serious,
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and we need to take concussions serious. So with that in mind, I'm
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hoping that this presentation is going to
allow you to realize the seriousness of concussions
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and understand the importance of recognizing the
signs, the symptoms, and the importance
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of following our proper return to play
guidelines. Leading causes falls, motor vehicle
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accidents, again playing sports, unintentionally
being struck by any object. The CDC
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in the US is estimating that there's
probably anywhere from one point six to three
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point eight millions just sport related concussions
each year, three hundred thousand of them
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are from football, and they're thinking
at least one of every ten athletes sustain
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a concussion on a yearly basis.
From a sports standpoint, brain injuries alone
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cause more death than any other type
of sports injury, and football brain injuries
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account for sixty five to ninety five
percent of all fatalities. Now you also
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see that we're seeing one point sixty
three point eight million concussions a year,
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but five and ten of these go
on reported. That's a fairly high number.
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Boys are a little bit more.
Football accounted for more than half while
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concussions of this study, and over
the past eleven years, the rate of
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concussion has increased over fourfold. Now
it's that common question, well, are
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we having more concussions or are we
recognizing them better. I'm not sure if
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we know that answer in its entirety, but I will say that most of
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us are more educated in concussion management, and there's definitely a component where we
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are recognizing them earlier, faster in
dealing with them more appropriately. So I
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do think that's part of the mix, but we're not sure. Literature hasn't
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pointed to the exact increase of why
it's been fourfold. A few other more
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facts, This is almost this page
right here is almost more like how are
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we diagnosing me? So concussions used
to be diagnosed in a grade one,
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two or three scale. Now in
the office, when you diagnose the concussion
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in your assessment, you're going to
say, patients sustain a concussion on whatever
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date is they sustained it. From
there, you look to see if there's
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any consciousness that was lost. So
if there was no loss of consciousness,
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you'd indicate patient sustained concussion on the
state no loss of consciousness. And then
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after that we look to categorize any
amnesia. Do they have andrograde amnesia or
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do they have retrograde There's three components
to a proper diagnosis of concussion, and
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that's when and if it was sustained, and then was their loss of consciousness
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and was there any amnesia, and
specifically you want to know anthro grade or
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retrograde amnesia. With that some truths. Most people do recover from concussion quickly,
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somewhere in that ten to thirteen day
period. The use of say seven
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to ten days, we are kind
of expanding that date a little bit.
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Now. Some symptoms may last longer
though months. Recovery may be slower as
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we age. Remember concussions of metaballg
intury, so the younger you are typically
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the higher metabolism you have, the
easier are you're going to heal from these,
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and those who have sustained concussion are
an increased risk of sustaining another one,
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and generally we'll find that the recovery
period for your second concussion is a
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little bit longer. Symptoms kind of
fall into four different categories, from our
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physical side of things to the emotional
to sleep disturbances, and then her ability
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to think and remember things. So
physically headaches, neck pain, blurry vision,
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bringing in the ears emotional standpoint,
a lot of times you might see
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some irritability, some anxiety, nervousness, the depressed state of being. From
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that cognitive side of things, patients
may have a hard time remembering recent events.
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They may have a hard time doing
school work or work, especially if
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their work takes a lot of cognitive
function. And then some individuals are going
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to be extremely fatigued and sleep all
the time. And then others might feel
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fatigued but they're almost have a sense
of insomnia or they're not sleeping at all.
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A few things that you absolutely need
to do if you have sustained concussion,
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and that being you need to get
in and see a doctor and I
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put a slight hesitation here because you
really should be doing some research or or
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the parents should be doing some research
and getting in to see someone that seeing
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a doctor that understands concussion. There's
so many times, and it's even better
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in the institution I work. But
er is not the place to manage a
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concussion. Now, you get a
bad concussion on the field and the symptoms
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progress and you need to be triage. You have the ER, great,
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you know, go in, be
looked at, make sure we're ruling out
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any red flags if you need to
do a ct rule out any skull fracture
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things like that. Great, but
don't don't let that ar visit be your
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end. I'll be all for the
management process. And what I mean by
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that is a lot of times as
an athlete of going to the ER.
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Yet I had a concussion, I
was told just to kind of watch them,
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watch them rest, and that I'll
get better. Well, if they're
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playing a sport, especially anywhere in
the US, they're going to need to
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follow this return to play protocol that
I'm going to go to the ER.
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Doc's not going to walk walk them
through that. So and furthermore, even
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if you're not playing. As you
get this, it's so important to just
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be follow up with someone that knows
about concussion after you've been in the er.
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Important to note if you're taking any
blood thinners. Obviously with concussion it
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could be at a better risk of
brain bleeds, so you don't want to
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thin your blood anymore. Make sure
there's a thorough exam that's done, and
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then you want to avoid driving.
You won't to avoid any drug use.
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You don't avoid any alcohol use.
Let the physicians know what type of meds
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you're on, and so forth.
Again, you may need advanced the imaging.
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You may need to perform some neurocognitive
tests. You may need to assess
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your learning and your memory skills.
You may need to assess your ability to
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concentrate, pay attention, your reaction
speed, problem solving ability. You're probably
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going to be sent home with instruction
that's going to be important to follow.
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So some needs and there's some possibilities
of things that you're going to have to
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do, depending on where you're following
out from the symptom scale and what you're
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trying to get back to in your
normal life activities of daily living. These
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are some really good position statements.
To go on and take note of these.
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A lot of these position statements overlap, a lot of them kind of
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read and tell them the same same. But if you're brand new that's reading
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at least half of these is going
to give you a good understanding of concussion.
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And then as you read them,
you're going to you're going to know
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where to look look for more information
and where to go from there. So
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I think we have done a good
job here in the US at AT focusing
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on concussion management and putting some good
literature together. If earning a certification is
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on your ce plan this year,
then you're in luck. Southeast Professional Education
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Group just launched four new certifications on
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your certification in dry needling, functional
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performance with immediate access to get starts
learning right away. To learn more and
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get started, click the new certifications
link in our show notes or visit online
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dot Sports Hyphenseminars dot com today.
Oh and one more thing. If you
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have no idea what a CE plan
is or why you should have one,
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don't stress. We've got you covered. Simply check out episodes twenty six and
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twenty seven, where doctor Tom Teeter
explains what the rehab continuum is and lays
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out a plan for developing and expanding
a strong clinical skill set through CE courses.
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Now back to the show. I'll
introduce myself here real quick. My
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name is doctor Michaelson. I am
a Palmer College Carobrector graduate graduate in twenty
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eleven and start a practice at Big
Fork Valley Hospital as the hospitals first CARO
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director. We had an overlying need
of sidelined care in this rural talent,
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and so I started working with our
football team and what that came the need
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for to put together basically a concussion
management program that we could use between our
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school and hospital. So I spent
a lot of time in just a lot
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of years trying to work at home
in this program and continue to continue to
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improve it. And so I've had
a lot of I've had a good twelve
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years of concussion management. I have
a strong interest in sports medicine. I
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have a strong interest in perferal nerve
or treatments. I had a couple of
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courses through Factor. Through with perferal
nerve or treatment, have a concussion and
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another concussion class Factor as well.
I want was a little bit more about
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myself adjunct faculty currently for Palmer College
or chiropractic and recently just started a new
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role here at our facility kind of
managing our entire rehab staff, our FATA
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center, and my own chiropractic department. There you have it, us myself.
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Let's continue on with this presentation with
Module one. What we're going to
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do is we're going to have a
thorough understanding of this return to sports strategy
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and the steps associator with it,
and then kind of briefly discuss any similar
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user difference as whether you might be
an elite athlete or adolescent or more an
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adult. Go on, use these
position statements. The nice thing I like
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about that is all these position statements
follow this internationally accepted Return to Play guidelines.
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So these guideanes that I'm going to
go through are going to be an
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associator with all of these position statements
here. And the biggest one is there's
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this consensus Concussion and Sport Group CISGREE
and every four years they come out with
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an outdated consensus and we're on the
fifth one right now. The sixth ones
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in the works of getting published with
COVID. There's a little bit of a
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delay and a set back, but
we should see that six one come out,
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so and as soon as that comes
out, I will I'll go through
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it. There might be some things
that I even need to update and change
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with how I run my policies,
but obviously they supported by some pretty big,
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big players in the world of sports
management. And these are our steps
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here that we're going to go over
six steps. There's a goal for each
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step, and there's certain activities that
we need to do in each steps with
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regards to returning to play. But
as we go through this, we need
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a general understanding of what is concussion
recovery. Recovery is clinically defined as a
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functional return to normal activities so school, sport, work life. Essentially,
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it encompasses a full resolution of our
symptoms that we may have, and for
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most injured athletes do know cognitive deficits, balance and physical symptoms improved rapidly within
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that first two weeks of injury.
Studies published before two thousand and five compluted
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both as athletes recover within ten days. However, now a lot of these
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studies post two thousand and five are
suggesting a little bit longer than ten days,
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and so it vessels what we see
to those bottom two statements there.
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This is a graph I use for
a lot of my patients as well.
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And where concussion recovery gets hard is
that elite varsity athlete that wants to get
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back to play and that he knows
the rules and he's got to tell you
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he's going to he's feeling fine and
he's ready to go. And it's also
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it's also hard for that fifty year
old individual individual who still works their their
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tail off and is constantly busy,
whether that be providing for their family,
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taking care of their kids, and
so forth, and they're used to living
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a very busy life. And as
we recover on this bottom of the graph
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here we have days. So typically
as the number of days progress, the
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amount of activity we can do increases, and this line here represents our threshold
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level. If we go above that
line, then we have symptoms. If
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we stay below that line, we
are a symptom free. And the goal
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for concussion is to as a day's
progress, we always want to stay sub
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threshold, or we always want to
stay below this line. If we ever
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go over this line, typically we
have a setback. So for that person
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that's doing everything, one day,
they may feel great, and then what
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you typically see is the next day
there we're into go ay, I had
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a good day, I can do
a lot, and I do a lot
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that day, and four or five
o'clock comes around and they're white, they
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have a headache, they're nauseous,
their balances off, they can't think,
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they can't function. Well, guess
what, you just went over this line
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and you're going to set yourself back
a little bit farther. Then, first
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phase really talks about rest, and
twenty years ago, rest was key.
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Oh you got a concussion, laid
down, rest, I just keep resting.
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Well, that's the rest is good
now, but we're not looking at
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two weeks of rest or even a
full week of rest of just laying down.
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That initial rest period needs to be
about twenty four to forty eight hours,
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and then because we know this is
a metabolic injury, there's more and
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more literatre stating after that twenty four
to forty eight hour period trying to get
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back and doing a little thing.
So it's just like a slow walk or
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a really slow stationary flight, just
something to kind of get out of metabolism
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going still avoiding any rigorous activity,
but again doing some light activities that keep
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us below that threshold line. So
currently we don't have an exact amount of
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duration of prescribed rest, and it's
also because it's going to vary for individuals.
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But as I said, this twenty
four to forty eight hour period,
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if you want to rest for twenty
hours of both of those days, great,
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that's fine. Then after that let's
try to start doing a little bit
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of things. And the study by
Letti here discussed about the negative consequences of
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prolonged rest, and obviously that can
cause metabolic disturbances, can cause it can
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put you into data on board fatigue, can become physically deconditioned, and we
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can go into a like a react
depression type of thing. So again,
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rest also doesn't mean keeping yourself or
your child in a dark room. You
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can rest and do five to ten
minute increments of computer use or TV use
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or you know, light studying.
It's just just kind of letting our brain
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shut down essentially and start to use
it in small, small bits. So
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again, the first days after the
concussion, you're not going to be as
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active and so your rest is going
to be more But by upping your activity
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level. You can see the subtreat
threshold that helps us increase the outcome of
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recovery by increasing the amount of activity
can do to stay below our threshold.
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If we just rest and down stop, this line like is going to be
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a lot flatter. As mentioned,
we don't have a proper time frame against
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key to that twenty four forty eight
hours. Let's move into this next step
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here as we go through these steps, and keep in mind that as we're
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progressing through the steps with athletes and
as we can play, each step has
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to be a minimum of twenty four
hours. And then I like to use
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heart rate, activity and duration of
exercise increments as I progress my athletes through
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those, and so I'll kind of
show you what those look like as as
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we go through here. Step one
is that SENTI limited activity okay at twenty
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four to forty eight hours, and
then basically start working into some really easy
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easy things after that. Step two
is now we want to start walking,
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we want to start doing some stationary
cycling. Keep in mind this is no
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resistance training, and the goal here
is to increase the heart rate. Well,
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why are we increasing our heart rate? Well, because increasing our heart
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rate is going to help us apartment
metabolism a little bit. And so typically
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with that, we're looking at something
that's going to get the heart up to
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one hundred to one hundred and forty
beats per minute. Again, as I
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00:21:02.839 --> 00:21:07.680
mentioned, that's just walking, stationary
cycling. Swimming typically what I think of
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swimming as a little bit differ harder
than walking. But I mean maybe you're
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just tread and water for a little
bit, or maybe you're doing really slow
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laps and again fifteen to twenty minutes, ten to twenty minutes, and if
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you want to start even a little
bit less than twenty, depending on how
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higher how bad your symptoms are,
that's fine. It's just we're trying to
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00:21:29.839 --> 00:21:33.039
test the waters here and not overdo
it so that we know if we can
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progress the next day. If I
have a fifteen year old athlete who the
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area of did they sustain a concussion
was great, which you're gonna see at
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some point. Sometimes it's it's hard
to say, ah, yeah, you
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for sure had a concussion, or
maybe maybe it did. We're not really
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sure, but we're gonna follow these
guys lins and we're gonna play it safe.
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Well, they're probably gonna be able
to tail the line here closer at
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twenty minutes. But if I have
fifty year old individual that was horseback riding,
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they're not really an athlete and they
got puffed from the horse and hit
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their head and there's they're still this
miserable. But I got to get them
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out of just this rest stage and
do just a little bit. This duration
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of exercise might be ten minutes.
I think globally we want about thirty to
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forty percent max things othership right here. Step three, we're going to get
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a little bit more support specific so
light sprinting or some jogging, now some
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scrating drills. Remember we're still in
non contact, so no head impath.
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The goal here is to add various
forms of movement, with my progressions being
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somewhere between that one hundred and twenty
one hundred and sixty beats per minute that's
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00:22:38.039 --> 00:22:42.000
again that modern run, skating,
dribbling, to do a little bit of
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00:22:42.079 --> 00:22:48.200
lightweight training, thinking on more repetitions
versus maxing out. I'm progressing that time
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00:22:48.240 --> 00:22:52.160
typically up to the thirty forty minute
range, and my exertion level is going
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00:22:52.240 --> 00:22:57.359
to be around that fifty percent max
exertion rate. We do fine with that
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00:22:57.480 --> 00:23:02.519
for a day, then I want
I get to progress onto the next step.
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00:23:02.759 --> 00:23:06.640
Okay, and again this is still
non contact. We're looking at still
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00:23:06.720 --> 00:23:11.799
sports specific training. Toils are just
getting harder with the goal is to involve
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00:23:11.839 --> 00:23:15.240
a little coordination with us too,
so when we think of percussion, our
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00:23:15.240 --> 00:23:21.200
coordination can get thrown off in reaction
time. So this is looking at increasing
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those a little bit. Our heart
rate. We're starting to get up there,
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00:23:23.279 --> 00:23:26.279
and with some of these individuals around
one hundred eighty pats per minute.
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This is sixty eighty percent of our
exertion levels. Possibly they're working out for
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00:23:32.160 --> 00:23:36.559
an hour here we got full sprinting. If they're doing fine, we can
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00:23:36.599 --> 00:23:41.519
get them back up onto the typical
non weight training again non contact though,
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00:23:41.880 --> 00:23:47.640
okay, and very heavily sports specific. So after that, if they do
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00:23:47.759 --> 00:23:51.920
fine there, that's when I have
them back in my office if we clear
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00:23:52.000 --> 00:23:56.440
them, and now they need to
have a full contact practice before they go
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00:23:56.559 --> 00:24:00.759
back to a game. So if
they've gotten the step before they come back
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00:24:00.799 --> 00:24:03.680
into my office, I go through
my exam. At this point there should
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00:24:03.680 --> 00:24:07.200
be pretty symptom free, so I'm
gonna go through my impact tests or any
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00:24:07.240 --> 00:24:14.359
type of neural cognitive assessment along with
my muscular skull th the neural exam.
305
00:24:14.799 --> 00:24:18.480
And if that all looks good,
okay, and they're progressing through school,
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00:24:18.559 --> 00:24:22.680
fine, then I sign my form
say all right, tomorrow they're you're doing
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00:24:22.000 --> 00:24:27.319
a full contact practice, and now
we're looking at participating at practice at normal
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00:24:27.440 --> 00:24:33.880
levels and looking at just restoring that
cognitive and support related confidence. And then
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00:24:33.920 --> 00:24:37.079
I also want to follow up with
the coaches. Hey, how Joe look
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00:24:37.160 --> 00:24:41.680
at practice today? Okay, so
duration, we're looking at that full practice
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00:24:41.680 --> 00:24:47.200
and I want to see somewhere at
least up to eighty percent. And again
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00:24:47.279 --> 00:24:52.599
we're starting to match off that heart
rate here. And after that you've already
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00:24:52.640 --> 00:24:56.480
medically cleared him. And if I
practice goes fine, great, they're gonna
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00:24:56.480 --> 00:25:00.400
be ready to go for game.
If I clear someone for practice, rule
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00:25:00.519 --> 00:25:03.720
is is I want to talk to
a mom or dad, the athlete and
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00:25:03.000 --> 00:25:07.240
or the coach, and then I
do a second clearance. Say for our
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00:25:07.359 --> 00:25:11.359
program, that's not necessarily how you
have to do it. I'm just working
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00:25:11.400 --> 00:25:15.000
with high school athletes, so I
want to be open and communicated with all
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00:25:15.240 --> 00:25:18.359
all individuals involved. So then they
practice goes fine. Then I said another
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00:25:18.359 --> 00:25:22.000
thing. Hey, they're clear to
go from game time now, and obviously
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00:25:22.039 --> 00:25:27.319
game time we're looking at a complete
and normal return to function and that normal
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00:25:27.480 --> 00:25:33.319
game gameplay. So that's kind of
that step by step plan now if full.
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00:25:34.160 --> 00:25:37.839
It used to be if if you
failed a certain step. So let's
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00:25:37.880 --> 00:25:45.480
say you went through step for non
contact training drills and at the end of
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00:25:45.480 --> 00:25:48.200
the you had symptoms, it used
to be take the day off and then
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00:25:48.519 --> 00:25:52.200
start back at step four. Well, those fifth International Guidelines, and now
327
00:25:52.119 --> 00:25:56.839
I'll say i step four brought on
the symptoms. You should actually jump back
328
00:25:56.880 --> 00:26:00.519
to step three and start from there
again after you take a day off,
329
00:26:00.640 --> 00:26:04.079
So keep that in mind too.
I've brought you through the steps, but
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00:26:04.119 --> 00:26:08.039
if you start to fail any of
these steps, wait twenty four hours and
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00:26:08.119 --> 00:26:14.200
start at one previous. I also
like to look at as I get an
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00:26:14.240 --> 00:26:18.480
athlete onto this program, I asked
them, what's our game time? So
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00:26:18.519 --> 00:26:21.839
I'm going to use an example here. If they get a concussion on a
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Friday night in their next football games
on the following Friday, we basically have
335
00:26:27.079 --> 00:26:30.000
they can't have any stepbacks if they
want to play again in a week.
336
00:26:30.119 --> 00:26:33.359
Right, this is a week long
process. If they have one step back.
337
00:26:34.400 --> 00:26:38.920
Then essentially we have another two weeks
before the game. And so in
338
00:26:38.960 --> 00:26:41.640
that case, if it's longer than
a week, a lot of time time
339
00:26:41.720 --> 00:26:45.880
I tell an athlete, we're going
to do step two for two days,
340
00:26:45.920 --> 00:26:48.200
step three for two days, step
four for two days. So if you
341
00:26:48.240 --> 00:26:53.319
get a good idea of the length
of their games or the duration apart,
342
00:26:53.559 --> 00:26:57.160
we can you can kind of tailor
this plan a little bit too to be
343
00:26:57.279 --> 00:27:03.079
more beneficial to the end athlete as
well. And there's always a we call
344
00:27:03.119 --> 00:27:07.079
our MEBA game in Minnesota wars on
Tuesday or Wednesday night, and then the
345
00:27:07.240 --> 00:27:10.799
following week at talk till Friday.
Not that I ever want a concussion,
346
00:27:10.799 --> 00:27:12.759
but if I'm going to get one, that's a nice time for a kid
347
00:27:12.799 --> 00:27:15.599
to get one, because then they
don't have to rush through the program.
348
00:27:15.839 --> 00:27:19.119
We have a week and a half
for them to progress through it, and
349
00:27:19.160 --> 00:27:22.319
it's in my opinion, it's a
little bit less pressure I'm a kid,
350
00:27:22.400 --> 00:27:26.839
especially if they're that elite athlete and
they don't want to miss a miss a
351
00:27:26.880 --> 00:27:40.480
game. That's it for today's training. Be sure to suite in for Part
352
00:27:40.480 --> 00:27:44.559
two, where we'll talk more about
the differences in working with elite versus recreational
353
00:27:44.599 --> 00:27:48.279
and youth athletes. Doctor Olson will
also elaborate more on the role that hormones
354
00:27:48.319 --> 00:27:53.079
and blood pressure can play in concussion
symptoms and recovery, and he will guide
355
00:27:53.119 --> 00:27:59.279
us through the RTP formula, his
structured approach for getting athletes back in the
356
00:27:59.319 --> 00:28:04.319
game safe, focusing on gradual increases
and activity and constant monitoring. You won't
357
00:28:04.319 --> 00:28:08.519
want to miss it. Episode seventy
eight drops in two weeks. Be sure
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00:28:08.559 --> 00:28:12.000
to check out our show notes for
a link to the brand new Factor podcast
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Hey guys. If you like what
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