Concussions

Episode 17 - Concussions

Dr. Savino Episode

[00:00:00] Eric Chehab, MD: Welcome to IBJI OrthoInform, where we talk all things Ortho to help you move better, live better. I’m your host, Dr. Eric Chehab with OrthoInform. Our goal is to provide you with an in-depth resource about common orthopedic conditions that we evaluate every day today. It’s my pleasure to welcome Dr. Anthony Savino, who will be speaking about concussions. Dr. Savino is a board certified neurologist with fellowship training in sports neurology. He received his BA in psychology at the University of Colorado in Boulder. In 2004. He then received his medical degree from Rush Medical College here in Chicago in 2012 and then did his residency in neurology at Boston University medical center in Boston, Massachusetts. After completing his residency at Boston University, he went on to fellowship training in sports neurology at the sports neurology clinic in Brighton. He then joined IBJI in 2017 and has since treated thousands of local athletes with sports related concussion injuries.

Dr. Savino serves on multiple local high school concussion oversight committees is the team neurologist for Lake Forest College and works with the Chicago Wolves and Chicago Red Stars. Dr. Savino’s areas of interest include the management of acute concussions, autonomic dysfunction in concussion, the treatment of post concussion headaches and the treatment of post concussion syndrome.

During his fellowship, Dr. Savino collaborated on long-term research projects that evaluated the repercussions of repetitive head trauma over time in youth and high school, college football players. Dr. Savino specializes in the treatment of concussion, neurologic disorders and athletes, and the maintenance of long-term brain health.

Dr. Savino’s expertise is more timely than ever as many young athletes return to full-time sports after what has been a turbulent high school athletic schedule over the past two years. So Anthony, welcome to OrthoInform and thanks for being here today. 

[00:01:48] Anthony Savino, MD: Thank you very much. Good morning, Eric. 

[00:01:50] Eric Chehab, MD: So, let’s get right to it.

How would you define a concussion? 

[00:01:55] Anthony Savino, MD: Concussion is a form of a brain injury and, taking a step back. We categorize brain injuries in a couple different ways. First is the severity and in a general sense, we divide it into mild, moderate, and severe, and concussion would fall into the mild category.

And we can also, divide brain injuries into functional injuries and structural injuries, meaning, functional injuries are injuries that you don’t see with conventional imaging, but change the way that the brain normally operates. And then there are structural injuries, which you would see on a scan such as a cat scan or an MRI, which would include things like, bleeding inside the brain, and, brain bruising.

[00:02:33] Eric Chehab, MD: So concussions on the mild end of the spectrum and then moderate, severe brain injuries. What would those be classified as? 

[00:02:40] Anthony Savino, MD: So those would, be more severe in terms of their presentation, the disruption in the normal operation of the brain. And those would typically include structural findings, as I mentioned, including bleeding or bruising on the brain.

[00:02:51] Eric Chehab, MD: Okay. And so a concussion is a. Functional brain injury in general, 

[00:02:57] Anthony Savino, MD: Correct. 

[00:02:57] Eric Chehab, MD: Okay. And what brought it to the forefront? Not too long ago, we weren’t really talking about concussions. And over the last 15 years, it’s really risen into prominence and most athletes and parents’ minds. So what brought concussions to the forefront?

[00:03:11] Anthony Savino, MD: So that was really a lot to do with the NFL, and the concerns among, football players and their families at that time. It really put a focus onto these injuries in addition to long term brain health and contact sport athletes. For sure. Today is the safest point in time in terms of recognizing head injuries, concussions, and optimization of long-term brain health and athletes, due to the awareness brought on by the NFL, about 15 years ago or so, we’ve changed a lot of the rules, primarily in relation to football, but that’s, expanded to other sports in terms of.

Level of impact that these, youth and collegiate and professional athletes are sustaining on a daily basis and practice change to rules. And most importantly, a lot of recognition of this injury, and appropriate management. 

[00:03:56] Eric Chehab, MD: Besides football, what are some of the other sports that carry a relatively high concussion risk?

[00:04:02] Anthony Savino, MD: It would depend on what study you look at, but in general, in, in the male category, it would involve sports such as hockey, wrestling, and, lacrosse, rugby as well. For female athletes, soccer is typically the highest rated, but other sports or activities are less well recognized, including those, like gymnastics and cheerleading.

[00:04:23] Eric Chehab, MD: As an athlete, how do you know you have a concussion? 

[00:04:28] Anthony Savino, MD: It’s a great question because, can the brain recognize when it’s injured? so oftentimes it’s recognized by people around, which would include, fellow teammates, coaches, athletic trainers, referees, and when assessing a concussion, you can look at both.

Signs and symptoms of concussion. So, symptoms are things that people around the athlete would notice. So things like loss of consciousness, where they’re knocked out, amnesia, where they don’t remember what happened maybe before or after the injury, or just appearing very confused and dazed. Whereas signs are things that the athlete themselves would notice.

Those would include physical signs, like head pain, lighter noise, sensitivity, nausea, vomiting, change in vision, confusion, loss of awareness, not, again, understanding what’s going on in the game. So both of those can be used to assess head injuries and make a diagnosis of concussion.

[00:05:17] Eric Chehab, MD: Yeah. It’s funny when you say, how does the injured brain know that it’s injured? That’s a really good insight with when an athlete does present with a concussion, are there ways to assess the severity at that time. What’s the initial evaluation of an athlete who’s presenting with a concussion?

Or a suspected concussion. I’m sorry. 

[00:05:37] Anthony Savino, MD: So good. I like that you use that term. So we evaluate head injuries and try to decide if there’s a concussion or a brain injury. As I mentioned, there’s some objective signs that make the assessment pretty clear and the diagnosis pretty clear.

Any head injury followed by loss of consciousness, amnesia again, loss of memory or just a very confused athlete is by definition, a clear concussion. No question there. And again, those objective signs are things that people around the athlete can notice. Pretty evident.

Typically, 10% or less of the serious head injuries or head injuries that are ultimately diagnosed as concussion most of the concussions, again, around 90% involve just those symptoms that the athlete will notice. So again, whether that’s physical symptoms, cognitive symptoms, sleep or mood changes more specifically to your point in the assessment of the athlete that.

Does not have the objective signs. So the assessment is typically done by an athletic trainer. If that’s available otherwise coaches, parents or physicians or whoever’s around and it will involve, first speaking and observing the athlete to again, observe for anything that seems out of the ordinary with that athlete.

And then. Basically asking them about any symptoms that they’re experiencing. And then depending on the setting, whether it’s, again, youth high school collegiate there could be a more formal evaluation. The most typically used is called a scat evaluation sideline concussion assessment tool.

And that in addition to the symptom evaluation will include a physical examination looking at multiple different neurological aspects. 

[00:07:06] Eric Chehab, MD: Okay. That athlete who’s on the sideline, who has some of these objective signs and symptoms of a concussion, who has the luxury of having a trainer also evaluate with the sideline concussion assessment tool, the scat tool. That athlete would likely be withdrawn from play at that time or what’s the immediate treatment for that athlete?

[00:07:28] Anthony Savino, MD: Correct. With any concern for concussion or again, head injury filed by neurological symptoms. Athletes at this point are immediately removed. They will never return to play. Day at the very least . And then they will be followed again, whether they have the resources of an athletic trainer to follow them up the following day or go to their local physician or concussion expert for evaluation.

No athlete will return unless they, until they’re assessed have a proper diagnosis and a return to play plan. 

[00:07:56] Eric Chehab, MD: Okay. And so how does the typical patient present. To you. If you’re not on the sideline, which you are frequently with many of the teams that you cover, but if you’re not on the sideline, what’s the typical present for a patient for you. 

[00:08:09] Anthony Savino, MD: I see patients in the office and ideally they’ll come to me, quickly after their injury, but that doesn’t always happen. And I will get patients or athletes sent to me from local athletic trainers, pediatricians or orthopedic physicians, if there’s a concurrent orthopedic injury emergency room and.

It will be a typical office visit. So again, we’ll review the injury itself. Parents are, I deal with a lot of youth athletes, often parents are there and they can provide integral collateral information regarding the injury. Again, if there were any of those objective signs, which make the diagnosis more clear and any ancillary information as to how the athlete was doing surrounding the time of the injury, which could be helpful for the diagnosis, because again the majority of the athletes.

Have those objective signs, loss of consciousness or amnesia. So it’s evaluating symptoms. So parent’s input or collateral information can be crucial. Then we’ll review what types of symptoms they’re having. Again, physical cognitive sleeper mood are the typical symptoms. I will do a neurological physical evaluation.

Oftentimes that’s normal because again, it’s a functional injury and it doesn’t involve focal neurological deficits or abnormalities. But sometimes you can pick up things and the common. Physical exam findings are things like abnormal eye movements, symptoms with eye movements, trouble with balance.

I will also evaluate for any concurrent injuries, oftentimes there’s involvement of the neck soft tissue strain, muscular strain, but as you can imagine, with any significant impacts to the head, that’s often contributing as well. And then I will make my assessment. And another point about concussions is it is a clinical diagnosis and I’m sure, you have a question regarding that, but basically taking all the information together and making the best assessment management plan and and plan to get back to school oftentimes in the, during the school year and the sport as safely and timely as possible.

[00:10:01] Eric Chehab, MD: And so are there any laboratory tests that can help you diagnose a concussion? 

[00:10:05] Anthony Savino, MD: No, there’s not. And in a greater sense that’s a great question because there’s no objective data really at all, to help us with concussion. More specifically there’s no one test, so it’s different than a lot of these injuries.

I’m sure you’ve talked about before on this podcast, in terms of orthopedics, where you might have an x-ray or cat scan or an MRI to make a definitive diagnosis. So again, in the absence of those clear objective signs, loss of consciousness, amnesia, or confusion, which represents, 10% or less of the athletes that present to me concussions are clinical diagnoses.

So it’s always a gray area. Certainly there’s cases that are more clear than others. When they present with a myriad of symptoms, it’s oftentimes more clear, an athlete presenting with. A headache after, for example, taking a header in soccer, that’s a less clear diagnosis. There are objective measures in research for sure that we’re looking at and hopefully within the next five to 10 years, that will help us with the diagnosis.

And then those do include things like laboratory markers. Whether in the blood or the cerebral spinal fluid or imaging techniques such as functional MRIs. But again, those are very much in research at this point. 

[00:11:12] Eric Chehab, MD: Got it. And if you have a patient with a concussion, since it’s a clinical diagnosis, how do you grade the severity of the concussion?

[00:11:21] Anthony Savino, MD: So we’ve stepped back from grading severity of concussion. And again, that’s because we don’t have a marker of the actual injury, so we’re really evaluating the symptomatology and certainly you can assign a level of. Severity to the symptomatology, but how that directly correlates to the actual functional injury.

We, we don’t know. So at this point, we’re, we’ve really moved to yes, we do think this is a concussion or no, we don’t. And even in that regard, again, dealing with a clinical diagnosis, you can never be a hundred percent sure. One way or the other, especially with ruling it out. So often, most of the time, unless it’s absolutely clear that we’re not dealing with a brain injury, we do tend.

To manage these injuries. Similarly, in that we never return an athlete back to contact sports or a situation where they can take another significant impact to the head, if they’re still displaying neurological symptoms, following a head injury. 

[00:12:14] Eric Chehab, MD: Okay. So once we’ve established as best we can, the diagnosis of a concussion, what’s the protocol for treatment and return to play.

[00:12:24] Anthony Savino, MD: Similarly to lack of objective test or one objective test or objective testing in concussion. There’s also no one treatment for the actual pathophysiological injury of concussion. So we also end up treating the symptoms that the patient presents with. Again, Those can be divided into physical symptoms.

Most commonly a headache. Second com most common is dizziness, but also could include, changes in vision, nausea, vomiting, lighter, noise, sensitivity. Some athletes may experience a change in mood. Feeling down, feeling anxious, feeling irritable changes in sleep. And that’s either sleeping more than normal or changes their sleep schedule.

Or having difficulty with sleeping and then cognitive symptoms, again, difficulty processing difficulty at school. So every athlete is individual and certainly every brain is individual. So we look at the symptoms that they’re having in their presentation, and we come up with a comprehensive plan to manage those symptoms.

And that’s in concert with time. So the brain also heals itself over time. Young. Tend to heal a little bit faster than older people just says with any other injury. As again, I’m sure you’ve discussed with your other people on the podcast. And and most importantly, we prevent that athlete from sustaining another significant head impact while they’re recovering.

And that’s because that’s the only thing that we think we can really do. Worsen the physical injury of concussion. We certainly understand that other situations can worsen the symptoms that a patient is experiencing. And that’s actually not uncommon and not expected. Especially as we’re getting back to activities like School and day to day life.

But again, of most importance is never returning an athlete with a possible concussion to full sport participation till they’re fully clinically recovered. 

[00:14:04] Eric Chehab, MD: Okay. So an athlete who is going through this process of time and symptoms, is there a goal to gradually challenge them to provoke symptoms and see how they do?

[00:14:19] Anthony Savino, MD: Yes. So you’re talking about the return to play process. That’s a process of graded steps that do challenge them from a physical standpoint to, as you said, see if any of their concussion or head injury symptoms return, and also to assess their performance. And the reason we do that is again, because we don’t have that objective marker.

At the end also to make sure that injury is recovered. We’re following this, based on symptoms and from a clinical standpoint we wanna put that athlete through as much as we can from a safe perspective, both cognitively again, most commonly school and physically with the return to play in the non-contact and safe cardiovascular space to see if any of those symptoms return.

And that may indicate to us that in. Even though they’re tolerating day to day life, their injury is not recovered. And again, we want as much information as we can that they’re recovered before we put them back to full play 

[00:15:10] Eric Chehab, MD: And on the academic side, because obviously these athletes, most of ’em are student athletes that or many of ’em are student athletes that see how you do a graduated return academics. And what’s the advice in general that you give on that front? 

[00:15:23] Anthony Savino, MD: That’s important and that’s really changed. Within the past two to three years or so in that and concussion management in general, I should say that we’ve moved away from the complete rest approach or Conco cocoon therapy.

Which essentially was removing these student athletes from their normal lives and secluding them in a dark room for days and weeks at a time. Because we found that actually that can have negative, detrimental. By itself irrespective of the injury, we were seeing athletes have prolonged recoveries because we were actually significantly changing their day to day routines.

So now with the understanding, again, that the most important thing is prevention of further head impact. While they’re recovering, we really are proponents of getting these student athletes back to some semblance of their normal life, which would include school as soon as they can tolerate it. While providing them symptomatic management and accommodations to help them be successful. Concussion is often called the silent injury because you don’t see it. You don’t have a cast that you go to school with. You don’t have crutches that you’re using. So when they return to school, it’s not necessarily evident that they’re injured.

So it’s very important that they have accommodations that they can use to help them successfully reintegrate to school and be successful while they’re recovering. Because we also see that extended time removal from school is also detrimental. 

[00:16:45] Eric Chehab, MD: So we’ve come a long way from waving two fingers. And how many fingers do I have and going back in the game, and then the pendulum swung way in the other direction, where we were cocooning athletes who were injured and now we seem to be taking a more middle road approach to the treatment of concussions.

For the injured athlete. What were some of the effects of cocooning? Were kids getting depressed? Were they having more stress from being removed from their normal environment? 

[00:17:14] Anthony Savino, MD: Yeah, so both of those things. So again that’s a great point. And not to anybody’s fault, but again, with the awareness that came about, 15 or so years ago with the NFL players and with the increased awareness surrounding these injuries, we really wanted to protect the athletes.

The natural response was to essentially remove them and avoid symptoms and make sure that they’ve recovered. But again Unfortunately, what it seemed to have done was have a negative effect. And those would include things, as you mentioned, like changes in mood, these student athletes were feeling down because they weren’t around their friends.

They were missing school, they were outta school, isolated and active. They were anxious because they were missing school. And as we know now, more than ever, there’s very high demands on these students, especially in high school. So missing one day is you. Six to eight hours of homework.

You compound those times, weeks and suddenly they’re significantly behind. It would also lead to physical symptoms. Again, part of the therapy was sitting in the dark. So they’d come out of the room, they’d have sensitivity to light. Sure. They’d develop headaches. Their diets would be off and a very important aspect was sleep.

Without light and dark and without normal activity or sleep schedule can become out of whack very quickly. We know that sleep is very important, obviously for recovery of the brain. And we found that not unsurprisingly, right? This treatment was actually contributing or prolonging the recovery of these athletes.

So again, we’ve shifted towards the middle road. Again, with a focus on prevention of further head trauma, but really getting them back to normal as they tolerate. 

[00:18:40] Eric Chehab, MD: And I think your point is well taken that you made earlier that patients may have their symptoms exacerbated by stimulus, but they’re not injuring their brain further by that stimulus.

Correct. It’s really the second impact at another brain injury that occurs externally, that you’re really trying to prevent. And the symptoms that may be provoked is really just a matter of how long you’re gonna be dealing with it. Not so much how injured the brain is. 

[00:19:09] Anthony Savino, MD: Correct. So good points. So again, we don’t know how the symptoms directly correlate with injury, but certainly we could think that more severe symptoms may correlate with more severe injury.

But to your point, I meet with student athletes and their families. Having symptoms and even increase in symptoms does not correlate with worsening of your injury. And in fact, that’s something that’s actually expected during the recovery. And as you get back to your normal life and that we think that’s in a general sense, your brain is recovering and just getting used to those activities again.

Outside of taking another significant impact on the head, or as you mentioned another possible injury to the brain we really promote getting them back to normal life as soon as possible. 

[00:19:49] Eric Chehab, MD: Okay. So that’s like a critical part of this is reintegrating the students back in their normal life, as soon as reasonably possible without provoking symptoms or with minor provocation of symptoms. Look, we all have days where we have a little bit of a headache. We, we feel a little bit outta sorts. But the treatment that was initially done of basically ignoring it or the treatment of cocooning is just, those are two extremes that we no longer want to be approaching. We’re more in the middle at this point. 

[00:20:15] Anthony Savino, MD: Yes. Said. 

[00:20:16] Eric Chehab, MD: Okay. What about the parent who has a concussed athlete that occurred that day is at home. What are some of the things that they should be looking for? Where, Hey, this may not be a mild brain injury. This may be more moderate or severe brain injury.

What are some of the things they should be able to look out for? 

[00:20:34] Anthony Savino, MD: Yeah. So I, in a general sense, I always say if something makes you uneasy as a parent, then that’s a good indicator, your child the best. And if something isn’t sitting right then, having an emergent evaluation is never gonna be harmful.

But more specifically, things that may be indicative of a more significant injury. Would include things like prolonged loss of consciousness. So usually, for more than a couple minutes we’d be concerned about a decreasing level of awareness or consciousness. If your child is becoming less, arousable more sleepy, they’re sleeping, you can’t wake them up, obviously that would be concerning.

Any, what we would call focal neurological deficits or abnormalities. So weakness, numbness, tingling on one side of the body changes in speech. Any seizure activity. Shaking or convulsing any significant worsening of headache that may or may not be associated with nausea or vomiting, so repetitive vomiting, what may be concerning.

Not unusual for someone to feel nauseous and possibly vomit, once after an injury, but 2, 3, 4 times that would be concerning. So those would be the main things that we would look at.

[00:21:35] Eric Chehab, MD: Those are signs of a less functional injury, more of a concerning for a structural injury, 

[00:21:40] Anthony Savino, MD: correct.

[00:21:41] Eric Chehab, MD: And in the emergency room, what do they do? And again, we don’t have that test for a concussion. So they’re clearly not looking for that. They’re looking more for the structural injuries, correct? 

[00:21:49] Anthony Savino, MD: Yeah. They can assess for possibly both, but yes, in an emergent situation, they would be essentially ruling out a worse injury, which would include a structural injury possible, bleeding inside the brain.

Okay. 

So we’ve walked through what a concussion is. What are some of the signs and symptoms of it and what is a typical treatment strategy for a graduated return to play and with gradual. Challenges to the athlete and on the academic side, trying to return as quickly as possible with minimal provocation of symptoms on the horizon.

What are some of the treatments that you would like to see be more mainstream for the management of concussions? If we are out there, do you see anything that’s promising? 

I think first of all, as we just spoke about, we’ve really swung to a more, middle of the road approach to concussions.

And unfortunately the both actually of previous management styles are still out there, but more so the super conservative route. So it’s not uncommon that I’ll see athletes. 2, 3, 4 weeks or maybe even 2, 3, 4 months out from their injury. And they’ve really been managed ultra conservatively with the cocoon approach or that in a general sense.

And I see those negative effects from that. Again, no fault from any provider. And this is an area of medicine that’s always changing, so we’re learning a lot. But that would be number one in that we are appropriately managing them. Allowing them to return to some semblance of normal, certainly things.

Hanging out with their family, hanging out with their friends, going to school again, we’re never putting an athlete at risk by returning them back to sport too soon, but we can certainly get them back to some semblance of normal. The second would be taking that a little bit further.

The early return to cardiovascular activity. Even more recently we’ve found that in addition to getting back to normal life, including daily activities in school, we have found that early return to tolerated symptom tolerated cardiovascular activity tends to lead to a better outcome and a faster recovery, especially in athletes than no activity alone.

And we don’t know exactly physiologically why that is. One could presume that it’s due to blood flow to the brain endorphin release that we get a benefit from. Just from a psychological perspective. Again, athletes are very, tend to be very invested in their sport and their athletics.

So just getting them back to some, something that feels normal tends to have a positive benefit. To that point with our athletes, we get them back to a cardiovascular program as soon as we think it’s appropriate. And that again, could be two to three days out from their injury.

And that could be either under the guidance of someone like an athletic trainer, if they do have that resource or, with a structured plan either at home or with someone like a physical therapist that’s versed in concussion. To further that a little bit physical therapy can be helpful at times with concussions or head injuries.

And those tend to be in two main categories. What we’d call vestibular ocular therapy. And again those are for those athletes that have symptoms such as visual symptoms, trouble with eye movements, trouble with motion or dizziness. And then again, because neck injuries tend to be fairly common with concussions or head injuries.

We will often send athletes to cervical physical therapy. And then even beyond that, on the horizon with hopefully more indicative and objective markers of concussion, we’ll have more therapeutics that we can offer, whether those are medicines, more focused therapies and those types of techniques.

But again this area of medicine is something that’s evolving very quickly and hopefully we can get more treatments for these athletes. 

[00:25:14] Eric Chehab, MD: What are some of the pearls? What are what’s, what wisdom can you impart for the family that has an athlete with a concussion or, a non-athlete with a concussion for that matter?

What are some of the things that would really be helpful for us to know as we navigate these somewhat choppy waters with concussion manage. 

[00:25:34] Anthony Savino, MD: Oh, great question, Eric. And you really open the door for me there but the first thing I would say, and again, taking a step back is concussions are important, certainly.

But they’re manageable for, we do believe concussions to be a temporary injury and in the right hands with appropriate timely assessment and management. We can get student athletes back to their daily lives and their sports in a timely and safe fashion. I will also say that proper assessment of head injuries is important because not all head injuries, even head injuries, followed by symptomatology, represent brain injuries.

And again, Speaking to our point about how we manage these athletes, including, super conservative management or more middle of the road. It’s also not uncommon that I see patients in my office that I don’t believe necessarily sustained a brain injury. But they’ve been managed ultra conservatively or removed from those activities.

And again, develop symptomatology that confounds the diagnosis. Sure. And makes it difficult for them to get back. So that’s why, in my opinion, it’s really important for these athletes, following head injuries or possible concussions to be evaluated by someone who understands the brain.

Can evaluate a possible brain injury as soon as possible to come up with a possible diagnosis or the best diagnosis that we can again in the clinical realm and a proper management plan in a timely fashion. And we’ve seen that if that happens, we can get, again, these student athletes back to their normal lives as soon as possible.

[00:26:57] Eric Chehab, MD: So, today my guess is Dr. Anthony Savino talking about concussions, Anthony. Thanks for being here. 

Thank you very much, Eric.