Speaker: Deepak Patel, family doctor and sports medicine/concussion specialist.
Personal anecdote to frame topic: his daughter in fifth grade read a passage about concussions but didn’t read it; she answered questions based on prior knowledge from what he teaches rather than the passage itself.
Use of anecdotes to illustrate increasing concussion awareness among students and coaches.
Comments on district concussion oversight work and classroom implications.
Emphasis: concussions are relevant beyond sports; both athletes and non-athletes are affected.
Activity disclaimer and disclosures: no conflicts of interest.
Objectives
Cover etiology and pathophysiology of concussions.
Identify signs and symptoms (S&S).
Review concussion assessment tools and updates to those tools.
Discuss clearance decisions for school, sports, and work.
Interpret neuropsychological testing and its pros/cons.
Discuss complications, especially second impact syndrome.
Explore prevention, rehab, and practical management strategies.
Signs and Symptoms of Concussion
Amnesia: retrograde or post-traumatic.
Loss of consciousness: not required but can occur.
Speech issues: delayed or incoherent speech; delayed verbal or motor responses.
Confusion and disorientation.
“Zoned out” or “foggy” feeling: helpful cue when talking to teens.
Vacant stare; impaired concentration.
Excessive drowsiness; changes in activity level.
In children/teens: difficulty answering questions about where they are or what they’re doing; struggle with following questions.
In activities of daily living (ADLs): symptoms may present later when cognitively demanding tasks arise.
Baselines: many settings run large group baselines; performance can be affected by the testing environment (classroom, timing, distractions).
Disclaimer: NCTs should not be used as sole determinants for diagnosis or return-to-play; used for supporting decision-making.
Balance testing: Balance Error Scoring System (BESS)
Objective balance assessment; more sensitive with baseline data.
Tests involve three stations: double-leg, single-leg (non-dominant foot), tandem stance; each tested for 20 seconds.
Scoring: count errors (hands off, eyes open, extraneous movement, etc.); maximum 10 errors; if excessive errors, stop and record 10.
Practical notes: baseline testing improves accuracy; equipment-free version (modified BESS) available for sideline use; full BESS uses foam surface for added difficulty.
Vestibulo-ocular motor screening (VOMS):
Assesses oculomotor function and vestibular processing; four phases include smooth pursuit, horizontal/vertical saccades, convergence, and vestibulo-ocular reflex (VOR) tests.
Useful for identifying oculomotor/vestibular contributors to symptoms and guiding rehabilitation.
Oculomotor and other neurological exams:
Additional tests include extra tests like orthostatics (re-controlled autonomic signs) and detailed cranial nerve examination.
Gait testing and tandem gait, plus dual-task gait (e.g., walking while counting backwards) to reveal subtle deficits.
Orthostatics and vitals:
Postural (orthostatic) vitals can help detect autonomic dysfunction that may predict persistent symptoms.
Return-to-Activity Protocols and Return-to-Learn vs Return-to-Sport
Return to Play (RTP) vs Return to Sport (RTS):
SCAT-6 to SCOAT shift emphasizes a staged, individualized plan.
RTS protocol is the terminology used; emphasizes progression based on symptoms and functional tolerance rather than fixed dates.
General progression and timing:
Initial rest: symptoms-guided rest for the first day or two; gradual reintroduction of activity as tolerated.
The SCOAT/SCAT framework uses an algorithm starting with red flags and proceeding to assessments if no red flags are present.
The SCOAT algorithm and red flags include neck pain/tenderness, seizures, double vision, loss of consciousness, deterioration of consciousness, vomiting, severe headache, restlessness/agitation, Glasgow Coma Scale deviations, and obvious deformities.
If red flags are absent, proceed with a stepwise assessment in the clinical context.
Timing and sequencing details:
The new SCOAT-based approach commonly uses a 72-hour post-injury checkpoint; official RTS decisions are often made after this period.
The process is individualized; not a one-size-fits-all timetable.
Return-to-Learn (RTL) and Return-to-Sport (RTS) policies:
RTL: school accommodations and graded cognitive load; avoid exacerbating symptoms with excessive screen time and heavy cognitive demands initially.
RTS: after cognitive and functional recovery at school, progress through stages under supervision (often with an athletic trainer).
Practical considerations for schools and workplaces:
Policies should be individualized rather than cookie-cutter; include accommodations for light/noise sensitivity and screen time.
Ensure clear documentation of restrictions and accommodations for learning and work tasks.
Exertion-based progression and monitored exercise:
Buffalo Concussion T treadmill/bike tests demonstrated that supervised aerobic exercise could speed recovery for those who tolerate it and help identify those at risk for persistent symptoms.
Practical adaptation: using estimated heart rate to guide exercise progression when full supervision isn’t feasible; stop if symptoms worsen by more than ext{ΔS} = 2 points on the symptom scale during exertion.
After initial rest, begin with sub-symptom aerobic activity, then advance gradually to sport-specific activities.
Typical RTP/RTS timeline:
While studies varied, the updated guidelines suggest a practical progression that often takes at least 7 days to complete the core RTS protocol, with activity increments spaced roughly every 24 hours depending on tolerance.
Exercise, Rehabilitation, and Persistent Symptoms
Persistent post-concussion syndrome (PPCS):
Defined as symptoms lasting >4 weeks; affects about 30 ext{%} of affected athletes.
Referrals: neuropsychology, physical therapy, vestibular/oculomotor rehab, vision therapy as needed.
Exercise and rehabilitation evidence:
Structured exercise is generally helpful; therapist-guided multimodal therapy tends to yield better outcomes than isolated interventions.
Some evidence supports cervical, vestibular, and oculomotor rehabilitation as part of a multimodal approach.
Behavioral and sleep management:
Melatonin as a sleep aid: evidence supports 3 mg; 10 mg less clearly beneficial for sleep latency and depressive symptoms; overall cognition/behavioral impact remains unclear.
Other sleep medications (zolpidem, trazodone, nortriptyline) are generally avoided acutely; may be considered as last resort in persistent cases.
Biofeedback and autonomic regulation:
Heart rate variability (HRV) biofeedback and resonance frequency breathing (long-term training, ~20 minutes, 4 days/week) can improve autonomic function and may support cognitive/affective outcomes when combined with exercise.
Pharmacologic and non-pharmacologic rehab:
Systematic reviews show exercise with professional guidance is beneficial; limited evidence for cervical, vestibular, and oculomotor rehabilitation as monotherapy.
Multimodal protocols for persistent symptoms are more effective than single-modality approaches.
Special Complications and Prevention
Second impact syndrome (SIS):
Occurs when a second concussion happens before full recovery from the first.
Can cause rapid brain edema, herniation, and catastrophic outcomes; higher risk in younger children.
Emphasizes the importance of proper evaluation and clearance before resuming activity.
Prevention and public health implications:
Limiting head contact and improving neck strength may reduce injury risk by limiting neck acceleration and brain movement.
Protective strategies and rule changes can reduce incidence in youth sports; education campaigns help coaches, parents, and athletes recognize concussions early.
Practical Insights and Clinical Pearls
Sciencific context and decision-making:
Tests (SCAT/SCOT/SCOAT, KD, NCT) assist but do not replace clinical judgment.
Baseline testing is helpful but not definitive; a test result must be interpreted in the broader clinical context.
A structured algorithm (SCAT-6) can guide red-flag recognition, but a clinician must perform an actual clinical evaluation first.
Communication with patients and families:
Use accessible language (e.g., “foggy,” “headache,” “worse with bright lights”).
Provide clear return-to-activity plans; avoid fear-based messaging but emphasize the seriousness and the risk of recurrence or SIS.
Practical clinic workflow tips:
Do not discharge patients the day of injury; ensure follow-up evaluation within the first few days.
Use objective measures (balance tests, oculomotor tests, tandem gait) alongside symptom reporting for a holistic assessment.
Document individualized RTP/RTL plans with accommodations for school/work.
Everyday advice for patients:
Early cognitive engagement with manageable tasks (e.g., reading a paper rather than full-screen activity) is encouraged.
Light, gradually increasing activity is preferred over prolonged complete rest.
Encourage family and school support; avoid “one-size-fits-all” restrictions.
Everyday Scenarios and Metaphors
Banana analogy for brain injury: green/yellow banana squished today may look a bit dented; after a few days it becomes mushy and brown, similar to how brain tissue may deteriorate before symptoms fully resolve. Helps explain delayed recovery and the need for follow-up.
Questions and Takeaways for Practice
Key takeaways:
Early recognition and reporting are critical; second injuries and SIS are real risks.
Use a combination of S&S, imaging if indicated, and a battery of tests (SCAT-6/SCOAT, BESS, VOMS, KD, NCT) to form a comprehensive view.
RTP/RTL plans must be individualized and supervised (often by athletic trainers) with clear steps and accommodations.
For PPCS, multidisciplinary rehab and timely referrals improve outcomes.
Sleep hygiene and addressing autonomic/psychological symptoms can support recovery.
Situational example used in talks:
A 19-year-old with ongoing sleep complaints two months post-concussion: melatonin 3 mg is favored as a first-line option; avoid habit-forming sleep meds unless necessary.
References and Resources Mentioned (to Seek Further)
SCAT-5/SCAT-6 and SCOAT guidelines and office tools; concussion recognition tool for coaches; child versions of SCAT; vestibulo-oculomotor screening resources.
Buffalo Concussion Treadmill Test and Buffalo Concussion Bike Test (early supervised exercise concepts).
Resonance frequency breathing and HRV biofeedback as adjuncts to rehab.
Multimodal rehabilitation approaches for persistent concussion symptoms.
Practical literature on return-to-learn and return-to-sport protocols and their implementation in schools and clinics.
Closing Thoughts
The speaker emphasizes the need for ongoing updates as guidelines evolve and for consistent, individualized care plans.
The overarching goal is early detection, safe clearance, and efficient, evidence-based rehabilitation to return individuals to full function with minimized risk.