Dr. Sharp: [00:00:00] Hey everyone. Welcome back to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of neuropsychological and psychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.
Today’s guest is a special one for me. Dr. Katie Scott is a former practicum student of mine. She was one of my very first graduate student psychometrists in my private practice probably 10 years ago. She has circled back and is now a neuropsychologist. She is here to talk with all about concussions and TBI.
We get into many dimensions of this area. It’s a very nuanced area and we really just do a nice overview of what I would think are the essentials of TBI. So we define some terms. [00:01:00] We talk about assessment of head injuries: when it’s necessary, when it’s not, what can we gain from it. And then we spend most of the second half of the interview talking about managing post-concussion symptoms or lack thereof and supporting folks as they return to school or whatever the “real world” might look like.
So it’s a great episode with lots of fantastic information, some great show notes, and resources that Katie provided. I think you’ll take a lot away from this one.
Before we jump to the conversation, let me tell you a little bit more about Katie, which I am very happy to do. It’s great to see where she has ended up and the career that she is building for herself.
Dr. Katie Scott is a licensed psychologist and clinical neuropsychologist at the University of Michigan’s Mary A. Rackham Institute. She is also a clinical partner with the University of Michigan’s Concussion Center, a multidisciplinary center with research, clinical, and outreach cores that are committed to concussion prevention, identification, management, and outcomes.
Katie earned her doctorate in Counseling Psychology at Colorado State University. She completed her internship at the Denver VA, and that led to her post-doctoral fellowship in clinical neuropsychology at Mary Free Bed Rehabilitation Hospital where she worked with a well-known podcast guest, Jacobus Donders. Many of you have read his book on report writing. So, Katie had the good fortune to train with him for a number of years.
She has experience in a variety of settings, including inpatient acute rehab, outpatient interdisciplinary clinics, and outpatient neuropsychological assessment. She has also served in educational and supervisory roles within an APPCN-affiliated fellowship program.
Let’s see. What else? Specific to concussion, she’s worked in a variety of settings including sideline assessment of acute concussion in sports, assessment and intervention within both sport-related and non-sport-related concussion clinics, and evaluation of individuals experiencing prolonged recovery of symptoms after a concussion. She has worked with athletes across varying levels of competition including youth sports programs, high school and collegiate athletics, and professional teams. Her current research interests include return-to-learn and psychological intervention following concussion.
As you can see, Katie’s been doing this work for quite some time and is well involved in this concussion world.[00:04:00] She has a lot of knowledge to share with us, and I will not keep that from you any longer. So here you have my conversation with Dr. Katie Scott.
Hey everyone. Welcome back to another episode of The Testing Psychologist podcast. Glad to be with you. Also glad to have my guests here today. Dr. Katie Scott is going to be talking with us all about concussion, TBI, assessment, treatment, management, all of those kinds of things. I’m really excited to have Katie here.
Katie, welcome to the podcast.
Dr. Scott: Thanks for having me. It’s good to be here.
Dr. Sharp: A lot of people know I don’t record the introductions until after the interview. So I don’t know what I’m going to say in the [00:05:00] introduction as far as our relationship, but it’s been cool to touch base with you. The last time I saw you was 10 years ago when you were a practicum student in my practice doing psychometrist work. And now here we are like, you’re a podcast interviewee, which is awesome.
Dr. Scott: Yeah. It’s crazy to think about the last 10 years, and where that’s brought us in training and experiences and all of that.
Dr. Sharp: Yeah. Well, I’m really glad that we’re able to connect. I’m excited to talk with you. This is a topic that it’s hard to believe that I have not really tackled concussion/TBI on the podcast before. But here we are. And I’m ready to dive in. So, thanks for being here.
As usual, I’d love to hear, especially, having a prior relationship, why this is important to you and your journey to get here as a specialty.[00:06:00] Dr. Scott: Thinking back on my experience with concussion brain injury, I had some exposure, I would say, like in graduate school and in that practicum training and things like that. And then really on internship when I was at the VA in Denver, just a lot of exposure to patients who had a history of brain injury. We saw or had psychoeducational groups around concussions, things like that.
And I think that’s really where my first step into how important education around concussion can be, obviously for providers and clinicians who work within the population, but also for patients as well. I think talking about concussions with other clinicians and practitioners who maybe don’t find that to [00:07:00] be their specialty or an area that they practice in a lot, but who do on occasion will see patients who have that history, I think it’s really important to have a good primer education about what brain injury is, what recovery looks like because especially with a concussion, we know that that education piece is so important to a patient’s recovery trajectory.
If we look back on the work from Dr. Grant Iverso back in the 90s looking at the provision of education to patients early on in their concussion recovery really did seem to have a positive impact on prognosis and recovery timelines. And we still see that today obviously. And so, I think it’s important to really equip clinicians with good information to be able to provide that to their patients.
I also find concussion work just to be really great. It sits at a [00:08:00] great intersection for psychologists and neuropsychologists in particular because it really leans on our background in psychotherapeutic work and being able to be an empathic presence for patients and have that counseling or clinical psychology background. But then also, obviously it’s important to have an understanding of the neurologic basis of concussion, how to appropriately assess and understand cognitive functioning within the context of income concussion is important. So it really draws on and challenges those pillars of who we are as neuropsychologists and psychologists
Dr. Sharp: I like the way that you phrased that. And it will become evident very quickly, I’m not an expert on concussions, but from what I know, the whole process, [00:09:00] I guess counseling and management piece is huge. It’s huge maybe as important or more important than the actual assessment, right? Being able to balance those is crucial.
Dr. Scott: Yeah. I think in the work that I’ve done, I’ve done concussion work I think in almost all settings. I’ve been present on the sidelines for NCAA DII Football games, soccer games,acute concussion clinics, all the way to seeing patients who’ve had a history of a concussion from decades ago. And I think all of those time points for patients, it’s really being able to recognize symptoms, but also all of the factors that can be driving those symptoms as well. Those are really important [00:10:00] to understand that symptoms present themselves for a variety of reasons. And so, being able to recognize that is a really important piece of assessment within the context of concussion.
Dr. Sharp: Absolutely. I’m so excited to get into this. I already have a ton of questions.
Dr. Scott: I’m excited too. Being able to talk about concussions is… When you’re passionate about something, it’s exciting to be able to talk about it.
Dr. Sharp: Absolutely. Let’s lay some groundwork just right off the bat. So talk me through the terms, concussion versus TBI versus brain injury, and any other terms that feel important to really nail down for our discussion.
Dr. Scott: TBI or traumatic brain injury is the umbrella under which [00:11:00] we see different categories of severity of the injury. Starting on the mild, so a mild TBI is really synonymous with what we call a concussion. If it’s helpful, I can get into the injury parameters around how we category is that is.
Dr. Sharp: Yeah, I think that would be helpful if you could lay that out.
Dr. Scott: When we talk about a mild TBI or concussion, we’re talking about an injury that results from a force to the head where we don’t see any kind of abnormalities or changes on neuroimaging like CT or MRI. Typically, we see a brief loss of consciousness if any. And when I say brief, I mean most commonly we hear people say maybe they went black or were unconscious for two seconds anywhere up to about [00:12:00] 30 minutes.
And then post-traumatic amnesia is another one of those injury parameters that we consider. So that means a loss of memory for events that occurred after the injury. We measure that by asking patients what’s the first thing they remember after the injury. And then we also look at retrograde amnesia. So the loss of memory for things that happen before the injury.
Typically, when we’re talking about categorizing TBI, specifically that mild categorization, we’re talking about a PTA or loss of memory after the injury for less than a day or less than 24 hours. I would say from clinical experience and what we know from the research when we see concussion patients, it’s usually, if [00:13:00] they talk about PTA, it’s a duration of a few minutes to maybe a few hours, much more rare to see a PTA that extends to upwards of that 24 hours period of time.
And then when we’re categorizing TBI, the lapse injury parameter we consider is GCS- the Glasgow Coma Scale, which is a scale that looks at essentially a patient’s functioning directly after that injury. So taking into consideration things like eye movement response, verbal responses. So is the patient-oriented motor response. Are they able to follow simple commands. And for a mild TBI, that’s typically a GCS of 13 to 15.
Dr. Sharp: Do you find that a lot of folks [00:14:00] have that number available? I’m thinking outpatient private practice or a school setting, like any non-hospital setting, parents usually have no idea what I’m talking about when I ask about that.
Dr. Scott: That’s a great question because that’s the number that we see if somebody is evaluated in the emergency room typically and what we recommend right now is that acutely that typically the emergency room is not necessary for a concussion. And in some ways, going to the emergency room following the concussion might contribute to some prolonging of symptoms, just because of so much activity in the ER when really a patient is needing rest primarily again, in that acute phase after an injury.
To [00:15:00] give a simple answer to your question, I think most patients who are presenting with a concussion history probably do not have that specific GCS number. And they may have vague responses to questions about, what’s the last thing you remember? What’s the first thing you remembered after the injury, given that there’s a lot going on if maybe the injury happened and there aren’t good markers during the day of something that might’ve been occurring. And the work I’ve done in sports concussion, and sometimes the sporting event itself is helpful to anchor those events, but not all of these injuries are occurring in contexts like that too.
Dr. Sharp: Sure. So I noticed that you didn’t mention nausea. There was one other that I commonly hear about being associated with concussion. So I just wanted to ask about that if that’s if that is truly a [00:16:00] factor we need to be concerned about when we’re…?
Dr. Scott: Nausea is certainly one of the common symptoms that we hear about following a concussion. I would say it’s pretty common acutely to hear people say that they felt nauseous, less common to hear people that they actually had an episode of MS or were throwing up. I will say, I think it’s important to note that repeated vomiting after hits of the head is an instance where we certainly recommend a visit to the emergency room.
Dr. Sharp: So, we were talking about the mild categorization, what would need to be happening to jump up to moderate and then a severe concussion.
Dr. Scott: For both moderate and severe TBI, that’s when we typically will see findings on CT or MRI, so bleeding [00:17:00] edema or swelling, things like that on neuroimaging study. We typically then see longer periods of time of loss of consciousness. So in the moderate range, we’ll see periods of loss of consciousness of 30 minutes up to one day. For severe categorization, it’s loss of consciousness beyond that 24-hour mark. And then with regard to PTA, it will be loss of memory following the injury for one day to one week in that moderate category. And then beyond a week for patients who fall in the severe category.
We know though that patients don’t always fit into neat categories. I’ve seen lots of patients in acute settings or acute inpatient rehab settings where what we end up categorizing their injuries moderate to severe based on variability. So maybe [00:18:00] they had positive neuroimaging and a PTA of a day, but a loss of … Well, that wouldn’t quite make sense. I was about to say a loss of consciousness is longer, but so maybe flip those. So, they had a period of time that falls in one or both categories that doesn’t neatly really fit under the label that we’re providing.
I think what’s important to keep in mind is that those moderate and severe injuries do come with evidence on neuroimaging. So CT or MRI, which we do not see when we’re talking about concussion.
Dr. Sharp: Sure. I appreciate you making that distinction. It seems rare at least again, an outpatient private practice where we actually see moderate to severe concussions, at least in my experience. I get a lot of parents reporting [00:19:00] a skull fracture. So I’m just curious, that’s an offhand question, but how that fits in? I assume it’s possible to fracture your skull but not necessarily generate anything that’s going to show up on the imaging of soft tissue.
Dr. Scott: Yeah. It’s certainly possible. There are a lot of people out there trying to look into what force is needed to sustain the severity of these injuries. And so, certainly, I would say as possible that you could sustain a force that would result in fracture, but not necessarily bleeding of the brain or other kinds of intracranial injuries.
I think this is maybe a moment to say what really can be helpful in assessment where we’re looking at concussion and brain injury [00:20:00] is a really good review of medical records, which I know is in a very ideal situation available, and in less ideal situations, not always available. For instance, you’ll see patients who will report things like, well, I had bruising and it’s helpful to be able to look into the medical record to see if that’s extracranial bruising or was that really an intracranial injury, if that makes sense?
Dr. Sharp: It certainly does. And I think you’re right. That’s probably a nice segue just to talk about the assessment component. Starting at the beginning, what should we even be asking about? What are those questions that we need to ask? I’m just going with pediatrics here because I feel like that’s a more limited area to tackle. It limits our scope. I [00:21:00] don’t know that it’s more limited than adults, but it limits our scope.
Dr. Scott: For sure. You bring up a good point and we could talk about concussions for hours on end. If we’re talking about assessment in the less acute phase, so just a hypothetical situation, you have a patient who presents for assessment and they report a history of concussion 6 to 9 months ago.
I think again, really just important to gather as much information as possible about what that injury looked like. So information like, do they remember if they had any loss of consciousness? Do they feel like their memory around that injury was fuzzy at all or does it all seem pretty clear? And then what their symptoms looked like immediately after the injury [00:22:00] is really helpful.
There is evidence to suggest that the severity of those acute and subacute symptoms on a concussion are strongly related to prognosis following concussion. So, it’s just helpful to understand what their symptom history looked like after the injury. And then I think trying to gather, are there other available data points? Is it possible to get medical records if they did happen to present to the emergency room can be really helpful as well?
Dr. Sharp: Right. So just to lay it out and be super concrete when we’re, again, I’ll just think about parents in the office. So we’re asking about symptoms within that first. 24 hours, a week, what’s the guideline in terms of what we ask them?
Dr. Scott: I think it’s really important in that first [00:23:00] 24 to 48 hours to understand what symptoms looked like and how those were managed. So for instance, I hear a lot of parents who will tell me, well, I woke them up every 2 to 3 hours because that’s what you’re supposed to do, right? And actually, we know that that’s not what we’re supposed to do anymore. That’s an artifact of times past, but it’s helpful to know. For a child, if their sleep was pretty heavily disrupted like that most first 24 to 48 hours, it might make sense that they have a little bit or they’re experiencing prolonged symptoms.
And then, really understanding or getting a good picture of what the symptom resolution is, if we’re talking about symptoms that have resolved by the point that you’re seeing them, what that looked like, and if those symptoms haven’t resolved, what that trajectory has looked like.
We know of concussion [00:24:00] that symptoms should be worst first. There really isn’t a good reason to expect that after that acute phase, those first 24 to 48 hours that symptoms are going to evolve to be worse. And so, if you have somebody in front of you, a pediatric patient or an adult who is reporting that those symptoms worsened after that acute period, that’s a really good important data point to keep in mind because it’s not consistent with what we know about the neurologic trajectory of this type of injury.
Dr. Sharp: That’s such a good point. I think a lot of us have had that experience where… I mean, you’re describing that, of all the people who report a concussion, this is probably 90% of those cases, where it was like 6 to 12 months ago, maybe two years and they’re wondering if the memory problems [00:25:00] and the attention issues and whatever are attributable to the concussion. Parents swear that things got worse in the months following the concussion, they started tanking at school.
So not to say those things didn’t happen, but it seems safe to say that the research would suggest that it’s not due to the concussion directly or the injury that may have happened.
Dr. Scott: Yeah. I think this is a point where it’s really helpful to bring out those skills around empathy because just as I think you just said, it’s not that those things didn’t happen or aren’t occurring, but that they’re very, very unlikely to be related to any true neurologic change in the brain after a concussion, but there are lots of things that can happen after a concussion that certainly are influential to thinking abilities.
And so, I think in a good assessment, it’s [00:26:00] then gathering the data that helps us to understand what else might be happening that’s causing any difficulties or reported subjective concerns with an individual’s thinking.
Dr. Sharp: Yeah. Before we move to, I would say, beyond that initial assessment phase, are there other things that we should be asking about or tracking with parents just in terms of that acute injury period and then what happened afterward?
Dr. Scott: Yeah. I always want to know who they saw. Oftentimes, they may not have gone to the emergency department, but maybe they went to see their pediatrician or they had some established relationship with a chiropractor or physical therapist or whatever the case may be. It’s really helpful to understand.[00:27:00]
I think another really important data point is what other education they’ve received around concussion particularly from other providers, but also, have they been doing a lot of Googling and trying to figure out in that way what’s going on with their kiddo or for themselves? Again, not to sound like a broken record, but it is very important, I think to know what kind of education they’ve had just because we know how important that education is to prognosis and recovery trajectories.
And then I want to know what they’ve been doing. So how have they been managing symptoms if they are still reporting symptoms? I would say with a fair degree of frequency, we see [00:28:00] children that 9 months to 1 year mark, who did miss a significant amount of school and that may have been recommended to them by their pediatrician or another provider. And so, understanding, were their attempts to go back to school, what did those look like? And then what other activities they’ve been involved in. Were they taken out of sports? Were they taken out of other kinds of choir, do they play instruments, things like that too, just other hobbies. What they’ve been doing or haven’t been doing is really, really important to understand too.
Dr. Sharp: Yeah. Can you speak to how much that limiting of activity is necessary because I know people are asking are thinking like, should kids be out of school? Sports feels a little different because of the risk of re-injury, but [00:29:00] I’m curious about these different activities and whether we should be limiting and in mild cases.
Dr. Scott: We’re talking about concussion. So that mild TBI. We used to tell people to go sit in a dark room and sleep for a month and let us know how they feel. And when I say we used to, I mean years ago. We’ve known for a while that that’s not useful.
But there’s a lot of really interesting research coming out about graded return to activity pretty soon after a concussion. For instance, John Leddy’s group out in Buffalo has been doing a lot of research around graded return to physical exercise and how that does seem to be useful and beneficial to prognosis and timeline soloing recovery. The research on…[00:30:00] Dr. Sharp: And when you say, pretty soon.
Dr. Scott: Yeah, thank you for it. Yeah. So what does pretty soon mean? So we know that probably for the first 48 to 72 hours, a lot of really good rest. So that’s why we don’t recommend any longer waking up kids. If they’ve had a hit to their head every few hours, they really should get some good sleep. And again, for those first 2 to 3days, a lot of limiting of physical activity, mental activity. But after that time point, it does seem like, again, graded return to some activity is beneficial.
The research and empirical evidence on cognitive activity is, and that’s a really newer area of research. It’s a little bit easier to get people on a treadmill and say like, okay, how does this affect your symptoms? It’s a little bit harder to figure out how do we grade cognitive [00:31:00] activity? And so, I think similar though to physical activity, really the kind of current recommendations that we’re seeing reflect the similar time period that maybe 2 to 3 days of time away from school can be beneficial, but beyond that point, it’s really just time to start getting back to some graded activity.
And so, in acute concussion clinic where I will see patients who have had a concussion within the last week, we’ll talk about, let’s try to get back to school for a half-day on your first day and see how that goes, see how long you can tolerate that. And then if you have an increase in symptoms, we want to know when that happens, what activities you’ve been doing in school that seemed to [00:32:00] reflect or cause that increase in symptoms. But we want you to keep going back to school. So Again, grading that return to activity.
There does not seem to be any evidence to support removing kids from school for longer again, than a few days to potentially a week depending on the severity of those acute symptoms, but really beyond that point. So sometimes I’ll see kids who’ve been out of school for 1 to 2 months. And at that point, how do you get kids back to school?
Dr. Sharp: Great question. I’ve had those cases for sure. Also, I want to table that just for a second because I think that totally plays into that education piece and expectation management and our role in that. I do want to ask though, [00:33:00] and this is maybe going back to maybe a more, I don’t know, during the more acute period following the injury, but when is testing actually warranted in the case of a concussion? Let’s just say that’s the only “concern.” When should we actually be testing a kid?
Dr. Scott: That’s a great question. I don’t think that a standard comprehensive cognitive battery is necessary even most of the time. I would say that’s a more rare occurrence where that eventually will be needed in those acute phases. So when I see the kids in an acute concussion clinic and they’ve recently had an injury, we’re really not typically doing a whole lot of cognitive assessment.[00:34:00] I have in the past used IMPACT because it is the piece of the overall puzzle of understanding the recovery trajectory, but I would not say that it is something that is always necessary to have. Sometimes, I’ll see questions from people who will say, well, they’ve had a concussion, so I have to do IMPACT, right? I would not say that that’s a necessity, but it is one tool that we have in a really large toolbag to understand or toolkit, I should say, to understand when people are fully recovered. But I would not say that routinely, again, a long battery of cognitive assessment is this something that is needed.
Dr. Sharp: Yeah. So then the follow-up question to that I suppose, is, in these cases that I tend to see a lot [00:35:00] nonsphere, what we would call mild cases where kids are presenting several months down the road, and parents. It may not be the main referral question, but it’s a subtext, like, oh, and we want to know if that head injury maybe has anything to do with what we’re seeing right now. A question I guess right off the bat is, can our assessment even answer that question?
Dr. Scott: I think an assessment can. I think that’s a case where a case can be made to do a good, comprehensive cognitive assessment where you are looking at different cognitive domains. And I think really making sure to emphasize and include areas of thinking that have been shown in the empirical research to have some sensitivity to brain injury. So [00:36:00] things like processing speed, basic attention, and then including executive functioning measures and some verbal memory measures as well.
But again, that’s in the context of a really good comprehensive evaluation that also looks at mood and takes into consideration things like sleep. Are there other symptoms? I’m thinking of things like headaches or other kinds of physical symptoms that can contribute to overall cognitive efficiency. And I think with a good assessment like that and using those good tools or data points, you can get to see the whole picture and put together that puzzle of everything that is contributing to a kid’s presentation [00:37:00] when they’re in front of you. Does that make sense?
Dr. Sharp: It does. Yeah, certainly. I think it just speaks to how, I don’t know how much longer we can delay this, but I really like that whole post-injury scenario: what they were told, how they were treated and how providers interacted with them in school and so forth, all those things. And I hope… Go ahead.
Dr. Scott: I’m sorry to interrupt. The one, I think additional piece that as you were talking that I did not mention was, this is a case where I think having performance validity testing included in your battery is really important. And that is not because I’m here to suggest that if you have something in front of you suggesting that their concussion is still impacting them a year later, that that’s all in their head or anything like that, [00:38:00] or that every patient who presents in that way is going to display poor effort. I certainly don’t think that that’s the case, but I think that those measures, so having some performance validity tests that are embedded, but also standalone can be helpful to understand if there are any non-neurologic factors present in their presentation.
Dr. Sharp: Sure. Let me ask you just briefly about your preferred measures. Maybe we could work backward and go performance validity testing, verbal memory, executive functioning, processing speed.
Dr. Scott: Particularly in the case of concussion, I will use TOMM and, or one of Green’s measures- MSVT or a Word Memory Test [00:39:00] more frequently MSVT but Word Memory Test as well can be useful. I think you just mentioned executive functioning and we’re in verbal memory. So trail making whether the standard Trail Making A&B, or if you have access to D-KEFS Trail Making could be helpful too.
With verbal memory, I use the CVLT probably 90% of the time when I’m wanting to look at verbal memory. The other thing that CVLT gives you is that embedded measure of effort and performance validity, which I think is again, trying to gather as many points of data related to that can be really useful.
I think it’s important to again, provide that empathy and understand what the patient is [00:40:00] presenting with and what that’s in the context of. For instance, I’ll see plenty of patients who are still reporting concussion symptoms a year later. And in that year, they really have not had good sleep. And so, you can make the argument, certainly, their sleep got disturbed after they have the concussion and they’ve gone now a year without a good quality of sleep. And so, let’s figure out how we’re going to get you sleeping well again. And that will likely translate into some good resolution of other symptoms.
I think one thing that we have not really touched on yet is how premorbid and comorbid mood symptoms really play a role in presentations following concussion. We’ve known for a long time that the history of depression, anxiety whether that was significant at the time of the [00:41:00] concussion or if there’s really just a history thereof mood symptoms that, that certainly plays a role in prognosis and recovery trajectory after a concussion.
I think one of the things I talk most frequently with patients about is the overlap of symptoms between, let’s say depression and concussion, how strongly that overlap is. If you had a Venn diagram there are almost pretty much two circles on top of each other in a lot of ways. I will say I have had the experience quite often of sitting with a patient and explaining the overlap of those symptoms and you see a little bit of relief kind of like a weight off of their shoulders when they begin to understand [00:42:00] just how closely those symptoms overlap.
Dr. Sharp: Yeah. I could see that. Well, I’ve seen it go both ways, honestly. There are some folks who really seem to cling to the concussion as a driver, and then there are some folks who seem very relieved. It’s not a permanent change that they had previously thought it was.
What you’re saying though really speaks to, I think that maybe the clinical interview and trying to gather that pre and post data that if someone is reporting a concussion and symptoms that have continued after whatever context, that’s a trigger to immediately go into asking about what was this like beforehand, how much did things really change or is this familiar from earlier in life, those sorts of questions [00:43:00] especially around like ADHD comes to mind immediately, and like you said, depression, anxiety sort of thing.
Dr. Scott: I think in all of the conference talks that I’ve seen over the years related to concussion, the one clinical Pearl that has always stuck out the most to me was I think actually from Micky Collins at UPMC. He said something like, talking about all the factors related to concussion recovery and the quote that always sticks in my mind is “concussion plays dirty.”
And so, if you have a history of symptoms or difficulties with things that also look like concussion symptoms, those are often things that can get exacerbated or sometimes present as more [00:44:00] problematic after you’ve had a concussion. You brought up ADHD. That’s certainly something that we can see some exacerbation of as well as just some prolonging of symptoms as well. And it’s likely related to, again, there’s just such a strong overlap there with what we know of concussion symptoms.
Dr. Sharp: Right. Could I back way up? You mentioned the term post-concussion syndrome. Can you just define that real quick- what that even means, and what we were looking for over there?
Dr. Scott: Yeah. Post-concussion syndrome is really a label that we use when individuals are experiencing concussion symptoms one month after their injury or longer. There’s a lot of discussions around whether that label is useful. It’s again, a syndrome [00:45:00] by definition. And I think there’s a good argument to be made that the focus being more so on symptoms and how can we treat each symptom appropriately, I think can be more useful for patients.
But I think we probably all have had the experience of seeing a person who was seen acutely in the ER and they’re diagnosed immediately with post-concussion syndrome. And so, I think just being aware of the flimsy accuracy of that diagnosis sometimes if you see it in medical records or things like that.
Dr. Sharp: I see. It seems like wrapped up even in that definition, I guess. So symptoms more than one month after an injury is the idea that those symptoms theoretically shouldn’t be there. Is that [00:46:00] a fair characterization? I mean, if we’re saying that symptoms typically resolve from a mild concussion pretty quickly after the injury?
Dr. Scott: Yeah. That’s a good question point. I think where it is useful for consideration is that patients who are presenting with symptoms beyond that one month/several weeks point, there’s probably something that’s driving the experience of symptoms that deserves to be addressed, if that makes sense.
There’s a wide variety of possibilities of what that could be. And again, that’s why I think a good assessment, particularly with somebody who specializes in concussion at that point can [00:47:00] be really useful. It could be something as simple as, yeah, you had a concussion, but you also had an injury to the musculature in your neck and we need to get you to see a PT who’s going to help you resolve those headaches.
It might be something more complex like, for the last month, you’ve had some worsening of your mood symptoms and we’ve taken you out of a lot of activity and we need to help work through the process of getting you back to regular activity and also addressing those mood concerns. I think there’s obviously a wide spectrum of what that could look like.
Dr. Sharp: Certainly, there’s a continuum and cases are all different, right? So when you run into folks maybe in that period, a few months after they’re still struggling, and [00:48:00] we’ll take kids again, what are some of those things or ways that you might approach them to start to introduce the idea that they could possibly return to activity or to school or more of a normal life again?
Dr. Scott: I think it’s having a really good conversation again, around what concussion is, what we know of typical recovery, and then what we know those factors are that can influence recovery. And then, I think it’s moving into making some really concrete goals about a return to activity and what that again, concretely looks like. It’s easy to say, yes, we’re going to get you back to school, but [00:49:00] what does that actually mean, and how are we going to take those steps to get back there?
And really making sure that we’re putting in the effort to set kids up for success with that return to school as well? If I see a kid who’s been out of school for a month, I don’t want to just plop them right back into 110% activity like a lot of kids are functioning at a baseline. And so, talking through what they’ve been missing, maybe where we can prioritize things.
And then, are there structures that we can lean on within their school system to really help to support that return? Obviously, there can be some variability in how schools respond to that, but I think it’s important to try to work as closely with the school as [00:50:00] possible particularly if the kid’s been out of school for a while.
And then setting goals that seem a little bit, I mean, lots of kids find school fun, but some kids don’t. So are there other things that we can get them to really engage with? Maybe they are a kid who played soccer six nights a week and they haven’t been able to do that. So, how are we going to set goals to get them to get back to that level of activity?
And then also making sure that where the restrictions or limitations that maybe are in place, are they sound? I think for lots of good reasons, what parents want to do immediately is take away any kind of screen time or cell phones, limit those kinds of things. I don’t think we [00:51:00] always need to take screen time away 100% in the presence of concussion symptoms. And so, how do we set good boundaries around that but still allow kids to have what their social outlook is and connection in that way?
Dr. Sharp: That’s important. I hear that a lot. After a concussion, parents were told, no screen time for a month, go into the brain rest, and don’t access your cell.
Dr. Scott: The reality is that screen time is how a lot of kids interact socially. It is for better or for worse really built into the social structure currently. And so, you can certainly see how if you take a kid away from sports since school and being able to talk with their friends through whatever means they have on their cell phone or [00:52:00] things like that, that can lead to some real complications related to mood and then how that drives concussion symptoms as well.
So not to suggest there shouldn’t be any restriction around that, but being mindful of, is this something that’s actually causing any kind of worsening of symptoms, or is it manageable to allow them maybe 10 minutes of screen time or 20 minutes of watching television, things like that and see how that impacts symptoms.
Dr. Sharp: Right. What else feels important at least in that post-concussion treatment, education realm for us to cover before we wrap up?
Dr. Scott: I think we’ve touched on sleep a bit, but supporting, I think kids [00:53:00] getting good quality sleep across the board is important, but particularly in the context of concussion, making sure they’re still getting adequate nutrition and hydration are really important.
And those may seem like really common sense things, but sometimes, and the chaos that can ensue after concussion and whatever else has come from that, those things can get lost sometimes. So making sure to understand how kids are functioning I think in those realms too.
And then, are they getting any kind of physical activity? We know that that’s important to support mood functioning, cognitive functioning, just in general. But I think the research is really telling us that that graded return to some level of physical activity fairly early on is really important to helping people to [00:54:00] recover.
Dr. Sharp: Sure. Yeah, just more evidence that seems like exercise is the closest we get to a cure for anything.
Dr. Scott: Exercise is medicine, right?
Dr. Sharp: Exercise is great. Yes. Now, are there any… oh, go ahead.
Dr. Scott: I’m just going to bring up return to learn as an area that I think we’re only really beginning to understand if there should be specific protocol around that. Obviously, there’s been a lot of talk and activity around return to play. I think we’ve been touching on there. I’ve said several times in different ways that I think getting kids back to school is really important. And I think for kids in structured school environment that re return to learn process can look[00:55:00] varied just because we don’t necessarily have a strict protocol around that at this point.
Dr. Sharp: And is that just because the research hasn’t really caught up yet to define a protocol or are there a bunch of different protocols or where are we at with that?
Dr. Scott: I would say, and this is I think based more so on experience in high school and college settings, but I think there’s a variety of protocols that all look fairly similar. I think the research is a little bit behind where we are with again, return to play and return to sport. But it is in some ways a more difficult phenomenon to measure. I think any one kid’s school day looks very different from any other kid’s school day. So how do we [00:56:00] measure that appropriately?
Dr. Sharp: So, it sounds like we feel like a graded return is probably helpful and relatively quickly after the injury, but the actual schedule and the nuances of it are what we’re still figuring that out.
Dr. Scott: Yeah. And we’re hoping to. I think that’s one of the things our group here at Michigan would really like to explore further. We’re hoping to do some of that work with our school partners here in the area which I think will be of good benefit to our kids.
Dr. Sharp: Yeah. It certainly seems like it. Oh my gosh. So I’m going to ask a question or close with a question maybe that I should’ve asked in the very beginning. Are there any myths around concussions or concussion treatment that we haven’t addressed yet that you want to put [00:57:00] out there for us as clinicians?
Dr. Scott: Lots of them. I think we’ve touched on a lot of them. I’m trying to think through where our conversation has gone. I think the biggest one that really has the most impact on recovery is just, we don’t need you to sleep in a dark room for a month after injury. And that’s probably actually going to hurt you in some ways.
And then getting back to normal activities should be a very realistic goal that I think is emphasized with patients that these are injuries that people recover from. I know there’s a lot in the media around the long-term effect of concussions, and I think it’s [00:58:00] important to note that what we’re talking about here really your uncomplicated concussion outside of the context of multiple concussion history, things like that.
And I think in those cases, it’s certainly really important to have people evaluated by concussion specialists who really understand what the research tells us about that. But I think in almost every especially concussion clinic visit that I have, the thing that I say is, this is an injury you’re going to get better from. And it might take a little bit longer than we’d like, but we’re going to get you back to where you were functioning before this happened.
Dr. Sharp: I like that. Okay. I’m going to throw another question in there since you reminded me. We didn’t touch at all on multiple [00:59:00] concussions. And the last time I dove into the research just briefly, it seemed like we don’t know a lot about what happens with multiple mild concussions in kids. Has that changed at all? Where are we at?
Dr. Scott: I would say that’s a really good summary I think of where we are still. What we know with some good degree of certainty is that when we talk about kids and adults who have sustained concussions, some more than three concussions, we see that 4, 5, 6, what we know is that the duration of symptoms seems to last a bit longer with subsequent injuries. I would not say in every single case that that’s what we see, but I think that the [01:00:00] research supports that.
I think it’s just important to know that the research, I think is still evolving in that area and to be transparent with kids and their parents about that, that this is what we know. And there’s still an area that we’re trying to get a better understanding of. And I think parents can appreciate and kids can appreciate that we may not have all of the answers, but that we’re well versed on where the research is currently.
Dr. Sharp: That makes sense. Great. Are there, just to close, any resources that you might point us toward as clinicians that can help understand this whole realm [01:01:00] research or books, or really anything that can help in
Dr. Scott: There are lots of good websites out there. Some of the institutions where a lot of this good research is happening like the University of Pittsburgh, which is where Micky Collins and his group are at. The Medical College of Wisconsin, which is where Michael McCray and his group are. They do a lot of great research specifically related to some of what we’ve been talking about related to return to activity. I think both groups have put out some really good available resources on their websites and things like that.
Dr. McCray, certainly, I believe is that the AACN [01:02:00] library of books, he has great really digestible primer on mild TBI and recovery that I think if this is something that you do see with some frequency in your practice, it can be really helpful to get a good grip on the state of the research as well.
Dr. Sharp: Great. I’ll list all of those in the show notes. If you happen to think of others, send them my direction.
Dr. Scott: I can do that for sure.
Dr. Sharp: Well, Katie, I will say thank you again for all your time and expertise to talk through admittedly very nuanced and complicated topics. To address all of these pieces in an hour is tough, but I think this is a great overview and people will take [01:03:00] a lot away from it. So thank you so much for being here.
Dr. Scott: Thank you.
Dr. Sharp: Okay. Thanks a lot for listening to this conversation with Dr. Katie Scott as we navigated through a multi-layered complex realm of neuropsychology. There’s a lot more to be said about this, obviously, but this is a topic that has not come up on the podcast before somehow. So I wanted to do a nice introduction and overview. The hope is that we’ll dive more into specific areas related to concussion and TBI as time goes on.
Thanks as always for listening. I have not rated the podcast, I’d love it if you just did me a huge favor and jumped into iTunes or wherever you might listen and take a quick second to rate the podcast. That helps spread the word about the podcast and give it a little more [01:04:00] exposure so that more people can find it, which is a good thing. And if you have any temptation to rate it less than five stars, please reach out to me directly. I would love to hear suggestions for improvement, different ideas. The idea is that it’s helpful and if it is not helpful for you, then please let me know firstname.lastname@example.org.
All right y’all, I hope that your summers are going well. And if nothing else, you’re getting a little bit of a reprieve from some of the demands of day-to-day life. At least for me, the summer tends to be a little more relaxing just inherently. And there’s that leftover from going to school for so long. Getting a break in the summer, even if I’m working just as hard, it feels a little bit like a break. Even though we have a crazy situation here in our country as the virus [01:05:00] continues to ramp up in some areas, I hope you’re at least getting a little bit of relaxation and able to step away from the daily grind.
Okay, y’all. I’ll be back with you on Thursday with another business episode coincidentally about stepping away from the daily grind and designing a think week for yourself to reflect and plan for your business.
All right. I hope to catch you next time. Take care in the meantime.