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[00:00:00] Dr. Sharp: Hello everyone. Welcome to The Testing Psychologist podcast. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

Many of y’all know that I have been using TherapyNotes as our practice EHR for over 10 years now. I’ve looked at others and I keep coming back to TherapyNotes because they do it all. If you’re interested in an EHR for your practice, you can get two free months of TherapyNotes by going to thetestingpsychologist.com/therapynotes and enter the code “testing”.

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The Neuropsychological Assessment Battery offers the combined strengths of a flexible and fixed neuropsychological battery. Now you can score any of the NAB’s six modules on PARiConnect, PAR’s online assessment platform. Visit parinc.com\nab.

Hey, y’all. Welcome back to [00:01:00] The Testing Psychologist podcast. I’m here today with my guest, Dr. Josefine Combs. She’s a licensed clinical neuropsychologist that specializes in the assessment, management, and treatment of concussions in people of all ages. She has extensive experience in the evaluation and management of concussions for athletes at any level of sports participation. Her patients include professional, collegiate, high school, and youth athletes. Dr. Combs also treats non-athletes who suffered a head injury from work, home, or motor vehicle accidents.

Our episode today is fascinating. We haven’t talked about concussion a lot on the podcast and I’m honored to have Josefine here to dig into some of the nuances. I have two kids who play competitive sports so this topic is both personally and professionally relevant for me.

We talked through a lot of aspects of concussion and we approach it through the lens that Josefine was trained in and [00:02:00] mentored in at the University of Pittsburgh Medical Center. It’s a profile model of concussion symptoms and trajectory of recovery that was new to me, at least. So I had a lot of questions about this.

We cover things like the basics and definitions of concussion, TBI, brain injury, severity, and so forth. We do talk through the profile model that I alluded to a minute ago and how that is a different conceptualization than you may be used to. We talk about what recovery from mild TBI should look like. We touch on treatment approaches for each of the concussion symptom profiles within the model and we have a bonus question at the end that is personally relevant to me, which is whether kids should play tackle football, and if so, what age is appropriate?

So we cover lots of material and as you’ll hear us say in the episode, there is plenty more that we could cover but I think this is a great medium dive, I would say, into concussion [00:03:00] and particularly looking through a sports lens.

If you are a practice owner and you would like some support in business development and either growing, scaling, or even starting a private practice with testing as a focus, I would love to help you out. I have two spots; this is probably going to be toward the end of April, I may have a spot or two open for individual consulting. We can work one-on-one and dig in and help you set goals and achieve those goals for your practice. If that sounds interesting, you can go to thetestingpsychologist.com/consulting and schedule a pre-consulting call to chat with me first.

All right, let’s jump to my interview with Dr. Josefine Combs on concussion.

[00:04:00] Josefine, welcome to the podcast.

Dr. Josefine: Thanks for having me.

Dr. Sharp: I’m glad to have you. It’s been a long time since we’ve talked about concussions. We only did the one episode on concussion a few years ago, so I’m excited to chat with you and dive deeper into a pretty hot topic. So welcome. I’m very grateful for you to be here.

Dr. Josefine: Yeah, I’m excited to share the knowledge and spread the word.

Dr. Sharp: Sure. Well, I’m sure we’ll get into this but I have more and more of a personal interest in this stuff because both of my kids are relatively competitive. They’re different sports and there’s a risk of concussion every weekend, essentially and it’s gotten more important personally and professionally, of course, but we’ll dive into all that.

Dr. Josefine: For Sure.

Dr. Sharp: I’ll start the way I always start, which is, of all the [00:05:00] things you could do with your life and your degree, why this?

Dr. Josefine: That’s a great question. I can’t claim that my path has always been super-defined. Some of the things that I’ve gotten the opportunities to do, I’ve found through luck, I’ve found through connections. So I definitely cannot say that, ever since I was a little girl, I dreamed of doing this, but I am very thankful for the opportunities that I’ve found and the people I’ve met along the way.

I’ve been an athlete myself. I started playing volleyball when I was 11. Played ever since high school, college, and some in moral stuff during graduate school because schedules were not super compatible. Graduate school is very competitive.

Through graduate school, I was exposed to sports [00:06:00] psychology, which I also do, and the personal experience as an athlete, the care you receive as an athlete, and found that concussion is a topic that affects people that deserves respect. It’s an injury that we’re still learning about but I’m happy to be part of that and be able to help advance the field and provide athletes with even better care.

And so through being an athlete and then being very interested in testing as a neuropsychologist, that was a very nice way for me to marry two of my passions and be able to dive deeper into that.

Dr. Sharp: Well, I love it when those two things intersect; personal and professional. I think that’s what drives a lot of us. Can I ask [00:07:00] a personal question whether you ever sustained a concussion while you were playing any of your sports?

Dr. Josefine: Yeah. Funny enough, I did not sustain a concussion until I was already in the concussion field. I was already working as a concussion care provider if you will. It was very textbook and it was very funny to be like, yes, there’s that. Being able to run through the checklist by myself and having all the resources definitely helped.

I was very fortunate that during my middle school, high school, and college career, I was relatively uninjured. The injuries I sustained did not pertain to my brain. So that came later when I already had a lot of knowledge and a lot of resources. I was very fortunate in that regard, but it was an interesting [00:08:00] experience to be on the other side of things and live the side that you normally only care for and give advice to.

Dr. Sharp: Yeah, of course. I suppose that’s a blessing in disguise if you were in the place where you had a lot of knowledge about it and presumably folks around who could help you out and are very knowledgeable as well.

Dr. Josefine: Yeah.

Dr. Sharp: I was also very lucky. I played sports growing up too and was super fortunate that I never sustained a concussion, at least that I know of. My brother maybe gave one another concussions like wrestling around the house but nothing that I’m aware of.

Dr. Josefine: That’s not uncommon, especially during our intake when I ask, have you ever sustained a concussion? A lot of people are not quite sure. They will tell you things like, oh yeah, I hit my head and I had a headache for two days but it wasn’t formally diagnosed or things like that. There’s a lot of [00:09:00] undiagnosed concussions around, for sure.

The good news is it is getting better. People are more aware and therefore more likely to report. The other good thing is that about 80% of concussions resolve on their own. The majority of them doesn’t need a whole lot to get better and that’s also reassuring. So even if you did get one or give your brother one, there’s very good odds that neither of you needed anything to get back to normal, to get better. So that’s the good news.

Dr. Sharp: Good to hear. We’re going to dig into all the times when we might want to be concerned or when things don’t resolve but before we do that, let’s lay a little bit of groundwork and do a refresher or maybe provide some new information for some listeners. I would love to do some definitions. We’re using the term concussion, let’s contrast that with brain injury versus TBI. All these [00:10:00] terms get thrown around. So what exactly are we talking about here?

Dr. Josefine: Yeah, that’s great. Essentially, concussions are classified as mild traumatic brain injuries. That further falls under the umbrella of acquired brain injury, so something has to happen to get the concussion. Essentially, the word concussion comes from Latin and it translates to shake violently. That’s how it got its name because that’s exactly what happens.

If we think of the anatomy of our brain, our brain essentially sits inside our skull and there’s fluid around it, which is a good thing. We all want that. We need that. But there’s no hold or things to keep it in place. The only contact is the brainstem that then goes into the spine and down our neck. So there’s nothing that the brain can grab onto.

Dr. Sharp: There’s no seat belt, right?

Dr. Josefine: Yes, exactly. And so it [00:11:00] essentially floats for a lack of better term. There’s not a ton of space but that fluid cushions it, and keeps it in place on a day-to-day basis. It is a pretty good design and our skull is pretty thick and protective. So the makeup is pretty good.

But if we sustain a significant force of blow, and this might be where the new part information comes in, it does not have to be a direct blow to the head. Anywhere to the body can do the trick if the force is big enough. So we do need a significant amount of force, not just a little bump, or then we couldn’t play any kind of contact sports. It has to be a significant blow but it does not have to be directly to the head, anywhere to the body can do the trick.

And if that threshold is crossed, if the energy, if the g-force is big enough, the brain essentially gets shaken. When the brain gets shaken, what happens is there’s those [00:12:00] tiny cells inside the brain called neurons, which we all are very familiar with. The neurons essentially get shaken too and that process stretches the cell walls a little bit. That can then trigger a metabolic cascade where essentially the inside of the cell can get out, the outside can get in and we have things in places where they don’t belong, where they shouldn’t be, which then triggers those typical concussion symptoms, most commonly headache but it’s not a requirement.

The other thing that’s good to know is that those cells don’t rip. They’re just temporarily out of shape. They do get back together. So the neurons are very driven to reset to get back to normal. If they do rip apart, we’re moving into the realm of moderate to severe traumatic brain injuries. That’s a different category with the concussion itself, which is very much that mild traumatic range. We do expect a full [00:13:00] recovery. We do expect people to get back to their normal.

The other thing that’s helpful to know is that the process that I just described with those cells stretching is not a floodgate. It’s more of a trickle mechanism because when I say fluid, our brain is not liquid. It’s more like a jello-ish consistency. So that movement can certainly take a little time.

24 to 48 hours is typically a good time frame to be on the lookout for concussion symptoms because they don’t have to be there right away, especially in a sports setting when adrenaline is going and people are revved up and want to finish the game, want to finish the set, whatever. You might not feel the symptoms right away, so that’s why we always teach our athletes, when in doubt, get out. It was a big hit. It doesn’t feel good anyway, wait it out, take a break. It’s better to miss the last five minutes of the game than to push through and potentially risk a much longer recovery.

[00:14:00] Dr. Sharp: Yeah. I’m glad you brought up the sports setting. I know that’s a passion of yours. That immediately makes me think, well, what do we do? And then with the concussion tests on the sidelines, how accurate can those be? Are there any symptoms that might show up right away that could be triggers to pull someone out or is it typically 24 to 48 hours?

Dr. Josefine: A lot of concussions tend to have some signs pretty quickly. It is relatively rare that someone is not fine and does not get identified. We’ve gotten a lot better about providing care and identifying concussions more early on. That being said, if a trained healthcare professional’s around, whether that’s an athletic trainer, a [00:15:00] team physician, a lot of coaches are much more invested in receiving training and psychoeducation now, which is a very positive trend. That’s something that we’ve noticed a lot more. Honestly, like I said, when in doubt, get out. It’s always better to hold an athlete out and make sure they’re okay.

In terms of sideline evaluation, one of the biggest go-to’s for that is what we call the VOMS, which is the vestibular ocular motion screen, where we get the cranial nerve check. A lot of times eyes and balance are very quickly affected and then also a symptom checklist. We always want to see if they have any kind of balance problems getting off the field, getting off the ice, getting off the court. Do they have any kind of headache? A lot of people will talk about light [00:16:00] sensitivity, feeling like they’re in a fog, feeling very fatigued all of a sudden way more proportionate to the exertion that they have done already.

And then evaluation-wise, typically, besides balance and ocular stuff, we check immediate memory. Do you know who you’re playing? What’s the score? Where are we at? Is it a home game? Is it an away game? What is their concentration like on the side? Can they do delayed recall, the words I just told you, are they still there minutes later?

And then obviously, we always want to look out for any kind of red flag signs. If an athlete suffers loss of consciousness, we always want to remove them immediately, which the good news is that a loss of consciousness does not necessarily mean that they’re going to have a protracted recovery but it’s something we want to act on immediately. If they have other red flags like slurred speech, they cannot recognize people that [00:17:00] they know really well. If they suffered a seizure post-impact, if they start to …

Dr. Sharp: Where does vomiting fit in?

Dr. Josefine: Vomiting can be a symptom but it’s not a requirement, which is also the other thing. None of these things have to happen. They’re just things we want to be on the lookout for. I sometimes have people that get told that, oh, I didn’t have significant headaches so I was told it’s not a concussion. All of these symptoms are possible. None of them are a true requirement. So it’s not like only if your headaches can you have a concussion. It’s rarer because headache is one of the most common symptoms but I do, every now and then, have people that are like, oh, I’m only dizzy or something like that.

Vomiting can certainly happen on the sideline and there are two things; if someone gets elbowed in [00:18:00] the stomach and then falls to the ground and hits the head, which one is due to versus individuals that have vestibular deficiency from the concussion certainly can vomit. If I’m dizzy. and if I already have, for example, a pre-existing risk factor such as motion sensitivity, I’m probably much more likely to do that than somebody that doesn’t have. So if somebody does throw up, that’s a sign that we want to hold them out and do another check-up and re-evaluate. So yeah, that can definitely be a sign too.

Dr. Sharp: Got you. Okay. Just to back up a little bit and make sure that I’m clear on the labels and descriptors; there’s the big top-level umbrella of acquired brain injury and then underneath that we have mild, moderate, and severe TBI’s, and a concussion is a mild TBI. Is that right?

[00:19:00] Dr. Josefine: Yes, that’s correct.

Dr. Sharp: Okay, great. I always like it, vocabulary is important.

Dr. Josefine: Yeah. And often too, MTBI or mild traumatic brain injury and concussion, the terms get used interchangeably.

Dr. Sharp: Sure. Okay. That sounds good. I love it. These terms get thrown around a lot and want to make sure that we’re all on the same page as we go forward.

So tell me, the discussion we were having a minute ago, are there any pathognomonic features of any of these levels, mild, moderate or severe; defining features where we say, yes, this means this person has a moderate TBI or a severe TBI, or is it a spectrum continuum mix? How do we gauge severity?

Dr. Josefine: That’s a great question. [00:20:00] The medical community, unfortunately, has some trouble agreeing on a universal writing system. So there’s two ways that you could go about it. Typically, we classify concussions by mild, moderate, or severe. There is a grading system where sometimes you will hear people talk about, oh, I had a Grade 2 concussion or oh man, it was a Grade 3 or whatever.

There are criteria for those different grades if you will, and they have to do with the severity of symptoms. For example, when people go to the emergency room, there’s often an assessment used called the Glasgow Coma Scale and that will [00:21:00] render a score. For example, if your score is anywhere from 13 to 15, then you definitely are classified as mild traumatic versus 9 to 12 would move into the moderate TBI realm versus 3 to 8 would be classified as a severe TBI. So the grade varies.

And then even within the MTBI range, there’s still differentiations where you can say, Grade 1 means post-traumatic amnesia of less than 30 minutes versus a Grade 2, you have to have amnesia lasting anywhere from 30+ minutes to 24 hours. Loss of consciousness; 5 minutes or less versus then Grade 3, a severe concussion, we would talk about loss of consciousness [00:22:00] greater than five minutes, amnesia greater than 24 hours, those kinds of things.

So there are some cutoffs but honestly, I and a lot of people in the field classify concussions more as profiles rather than just severity of mild, moderate, severe. There are these five concussion profiles, if you will. And that stems from the way the symptoms can cluster in patterns if you will.

There’s a total of about 22 or so concussion symptoms that can occur, that doesn’t mean they all have to be there, but through research heavily spearheaded by the group in Pittsburgh UPMC, there’s been essentially these clusters that have crystallized and they’re now referred as concussion profiles or concussion trajectories, [00:23:00] and that’s how these typical symptoms cluster together. For example, we talked about vomiting. We talked about dizziness. So that is very common for what’s called the vestibular profile.

For the vestibular profile, the part of your brain, the vestibular system, gets affected through that neuronal stretching through that metabolic cascade, which then leads to very common symptoms. The hallmark sign is dizziness. There are two others.

There’s also the ocular motor profile where our eyes are affected and that does not come from the eyeball itself; that comes from that brain interaction, the brain not being able to use those neuronal pathways accurately, which often leads to people having, for example, convergence problems or tracking gaze stabilization problems, those kind of things.

There’s also the cognitive and fatigue profile where people that fall into that profile have a lot of difficulty with concentration, [00:24:00] memory, integrating ideas. Typically, people with a concussion feel very tired, even with doing less because we can think of the concussion as an energy crisis, if we will, and that leads to that deficit.

And then there’s also the post-traumatic migraine profile, migraine medically here just means really bad headaches. So typical headache presentation. Migraine is a risk factor pre-injury.

And then the fifth profile is the anxiety, mood profile because emotions happen in the brain and a lot of people actually are not aware that that can be very affected after an injury. I often have athletes as well as non-athletes that are like, I feel like crying and I don’t know why, or I feel much more emotional than I normally would be, or for some reason, I’m very irritable. Especially in teenagers, anxiety [00:25:00] often comes out through irritability and that is absolutely a symptom of the injury and not just a personal flaw or a personality trait.

We do expect it to return to pre-injury levels after the injury heals but by being able to identify those clinical profiles and which one the person falls into, allows us then thereby to cater and tailor their treatment approach much more efficiently and thereby being able to speed up recovery. That’s where the beauty of neuropsychological testing comes in, it can help us identify people and help them get the care they need to get out of the concussion more quickly.

Profile-wise, you can have one profile, you can have all of them, so they’re not mutually exclusive. [00:26:00] Obviously, the more profiles you fall into, the more we can brace ourselves for a little bit of a projected recovery but it’s a very helpful conceptualization. And in terms of new information, I think it also helps to know that not every concussion is the same and that there’s a very individual aspect to it.

Concussion itself is a heterogeneous injury and keeping that in mind, especially when you like talked about your children playing sports, like when other people come and want to give advice and want to be helpful, that’s very well intentioned and appreciated but knowing that there’s different types out there helps also like, yeah, that might not be accurate for my case or for my child’s injury because they might have a very different profile than the other person.

So being able to provide a tailored treatment approach can be [00:27:00] very beneficial, not just in speeding up the recovery, but also providing the athlete and the non-athlete too, with feedback and support, like what you’re experiencing is normal. This actually happens a lot with concussions.

Dr. Sharp: Right. I want to definitely spend some time on the treatment and how we talk with folks about concussion and post-concussion recovery and so forth but I will say, and I’m not an expert in this area. I don’t specialize in concussion by any means. So these may be naive questions, but this profile model is new for me. I haven’t heard that conceptualization before.

You answered one question, which is, are they mutually exclusive? It sounds like that’s not true, folks can fall into multiple profiles. And so I guess my spin-off question from that is, if folks can have multiple profiles, [00:28:00] what was the utility of creating profiles in the first place? I assume somehow it was born out in the research that we could distinguish these different profiles, but then I’m trying to reconcile that with, okay, folks can have multiple profiles. So what’s the value in separating them in the first place?

Dr. Josefine: I don’t know that separating, like I said, it’s not like if you have one, you can’t have the other. The clinical profile approach, the trajectories are simply a good way of being able to match treatment and recovery to the athletes need, because if it was a one fits all, like a cookie cutter situation, a lot of athletes would have to spend their time doing recovery tasks that aren’t necessarily needed for them to get back to normal. And [00:29:00] vice versa, too; if you have multiple profiles present, you’re not going to be able to do as much as quickly as someone that only has “one”.

So it’s not so much to distinguish or cut and dried put people in certain boxes, it’s more for the clinician to be able to understand the patient’s need and being able to accurately tailor to that because especially concussion-wise, there are overlap symptom wise. Some of the symptoms were like, oh, I’m feeling drowsy, having trouble concentrating, having a headache. Well, that can also be sleep deprivation. That can be caffeine overuse. That can be anxiety. That can be a lot of things. So being able to parse that out a little bit more and know where it’s coming from will allow the clinician to provide tailored [00:30:00] treatment much easier.

For example, if I have an athlete that is also a student, which most of them are, and they’re complaining about brain fog and difficulty concentrating, knowing if that comes from the cognitive fatigue profile or if that is a side effect from the vestibular dysfunction is going to be helpful for me because if I don’t know about the vestibular dysfunction and just try to give them more cognitive rest, more academic accommodations if we don’t help the vestibular system to reset, the cognitive fog is not likely to resolve.

And so by identifying and knowing what we fall under and what the athlete needs, because each profile then has its own targeted tailored treatment approach, we can assure that they’re not only getting back to normal faster but also that can act as a preventative measure to avoid increasing the risk [00:31:00] of getting further concussions.

Dr. Sharp: That makes a lot of sense to me. Do you know, as in the development of this profile and trajectory model, if the profiles were identified and then that each profile drives treatment, or was it almost reverse engineered, where we know there are these different treatments and then we retrofitted profiles to match the different types of treatment that might be needed. Does that question make sense?

Dr. Josefine: Yeah, I feel like I have to go back to my mentors.

Dr. Sharp: I am sorry. I don’t want to put you on the spot. These are detailed questions that may or may not be important.

Dr. Josefine: My understanding is that, like I said, UPMC has been a driving force [00:32:00] in that research front, especially Dr. Kontos and Dr. Collins have been doing a lot on that front. And from my understanding is that, like I said, there’s a total of 22-ish symptoms. They’ve just done a lot of research and found that these symptoms tend to cluster in groups. So people tend to have certain, if I give all the concussion people a checkbox of like, do you have this or that, there tend to be certain groups that come together. And so into looking what those clusters are, they have then developed these profiles from that.

It is ongoing thing whereby no means done, for example, when I did my training years back, we still had cervical, also the neck as its own profile, which has been then “demoted” to a [00:33:00] modifier because the neck simply isn’t part of the brain and it is however, attached. If you have someone that struggles with whiplash or neck injury, or even just muscle tightness, soreness that can radiate up, it can mess with headaches, it can impact the concussion recovery. So it’s now considered a modifier instead of its own profile.

So it is an ongoing thing. It is research. We still have to learn a lot about this injury. There certainly have been made a lot of advances, especially in the last 10 to 15 years or so but we’re by no means done and we still have to learn more. This has just been the most recent way to conceptualize is that allows us to make sure that we can not only find timely but also effectively targeted treatments for the individuals.

[00:34:00] Dr. Sharp: Yeah. That lands with me. I apologize for all the nuanced questions. I’m just really interested in this.

Dr. Josefine: No, that’s a good thing.

Dr. Sharp: Yeah, that’s a new construct for me. And so one last question, then I do want to move to the way that we might approach treatment for each of these profiles. The question then is just to clarify, are we also within these profiles grading severity to some degree or is it assumed that these are all within the mild MTBI concussion realm?

Dr. Josefine: Yeah, all of these profiles still fall under the so-called mild traumatic brain injuries of concussion realm but you can certainly have a more severe concussion. Typically, you can certainly think of it as a compounding thing. If you have one profile, that’s one thing that needs fixing. The more profiles you have, the more work we have to do, which doesn’t mean it can’t be done [00:35:00] but it certainly, if you and I have to do a three-legged race and my foot hurts a little bit, you can help me out but if your foot hurts too, we both have to struggle together to still get to the finish line kind of thing.

A body, at the end of the day, is a system. Everything has to work together. Anybody that’s ever been part of a group project, if somebody doesn’t do their work or doesn’t do it well, there comes a point where it affects the group and even now, everybody else in the group is trying very hard to make up for that and offset that, if it continues, it will create problems for other group members.

In terms of severity, there’s certainly levels but I’m not aware of any significant grading systems. We think of it as more like a symptom severity. If someone has a vestibular problem where it’s only higher level, where [00:36:00] they do extremely taxing stuff, like a high-level performing athlete that gets some dizziness with heavy rotations and a lot of back and forth, let’s say a hockey player on the ice quicked directional changes, very high-speed object to track, those kinds of things versus somebody that already gets dizzy by simply turning their head left and right.

Those are very different, they still both fall into vestibular problem realm, but one is much more severe than the other one. We absolutely can think of it as a severe, moderate or mild kind of situation, but I conceptualize it more under the individual’s symptom burden and impairment; what can, what can’t they do? what needs fixing. The more things that need fixing, the more we can safely assume it’s not just a mild, it’s more of like a moderate or severe concussion, but [00:37:00] like I said, the good news is that, from a concussion standpoint, we do anticipate full symptom resolution. We do expect people to get back to their normal. In my experience, if that doesn’t happen, it’s because one of those profiles didn’t get what it needed to fully rehab.

Dr. Sharp: I hear you. I wonder if we could pivot to maybe the intermediate step between the event and the treatment, which is our assessment a lot of the time. Although there’s some questions there, and maybe you can speak to this, of whether sending someone for a neuropsychological assessment after a concussion is going to exacerbate their identification with the injury and add some emotional component, like, oh, this must be severe if I have to go get this assessment. I don’t know. I’m just guessing.

Let’s talk about the testing part. What does [00:38:00] testing look like for someone who’s referred for a mild TBI or concussion? Where do you even start?

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Let’s get back to the podcast.

Dr. Josefine: That’s a great question. I’m going to [00:40:00] touch a little bit of a timeline to that to give people a better idea of the steps in the “assessment”. We already talked a little bit about the sideline assessment. So a lot of times, especially with organized sports, there is a trained healthcare provider covering those sports, athletic trainers, and sometimes team physicians and they will do a sideline evaluation. If anybody gets identified as being suspect, even just suspected of a concussion, they are to be removed from any contact activity for 24 hours, especially because we talked about that delay in symptoms. So that is a very normal procedure.

People have become much more accepting of this. Back in the days, we did coaches and parents that were very angry with this but we have long since learned that it is in the best interest of the athlete. There’s been research that has suggested that people that get removed immediately [00:41:00] tend to turn around much faster and have a recovery of 14 to 21 days versus people that play 5 to 10 more minutes, tag on several weeks to their recovery. And then some that played 10 to 15 minutes more can often end up with months and months of recovery.

We worsen our odds if we push on. And that’s very important information, especially for our athletes, if I don’t feel so good but I could make it to the end of the game, okay, is finishing this game worth risking potentially the rest of my season versus, okay, I’d rather come out right now, miss one or two games, but then I’m back strong and as good as new.

Information is power and it’s really helpful. I do focus a lot of efforts on outreach and psychoeducation because the better people understand this injury, the better they can make informed decisions. So we have the sideline evaluation, [00:42:00] hopefully by a trained professional. If symptoms don’t subside, a lot of people will go through their primary care or their pediatrician, which they often do an in-office evaluation, which typically contains of a cranial nerve shark, hopefully, the VOMS, and then some general questions, sometimes balance assessment.

And then a lot of times, they provide some academic accommodations. Like I said, about 80% of concussions do take care of themselves and resolve in around a 21-day span. If there are no improvements made by around two weeks, then we want to consider some more advanced, some more specialty care.

Concussion is an interesting injury because, for a really long time, it was an unclaimed domain. People couldn’t agree on who should treat it; neurology, [00:43:00] sports medicine, neuropsychology, pain management, and rehabilitation. Depending on the location, it varies in terms of setup and availability, but the trend definitely, the neuropsychology taking over as the point guard, if you will, and helping and coordinating care and that seems to work really well.

So if they do get referred to specialty care, for example, in my case, I run the concussion clinic for my location, and for that, they will then engage in neuropsychological testing but it differs a little bit from a traditional battery. Technology has made a lot of advances and allowed us to provide a much shorter battery that checks all the important domains in the much more time-efficient way.

There is a lot of, especially in the past, there was a lot of back and [00:44:00] forth paper and pencil testing, traditional testing versus computerized but as always, technology does not go away. The number one tool that is pretty dominant on the market is what’s called the ImPACT test. It’s computerized concussion assessment. There are other options out there, C3 Logix Tests developed one way, which originally started out as a simple balance assessment, has expanded and created a cognitive assessment tool that scans those and those main domains as well.

So there’s definitely changes and competition is not a bad thing. It can drive quality. It can promote change. With that, concussion specialty cares have very much moved to those type of assessments. So when somebody now goes to a concussion clinic, [00:45:00] yes, they are completing neuropsychological testing but it’s not a 4 to 6 hour battery. It’s very much tailored to the injury and to choose that particular problem.

And then subsequently the report is also not 10 pages long versus if you have individuals that fall more into the moderate to severe TBI, if they go and do neuropsychological testing, 90% of the time, that’s more the traditional, the long battery, the much more traditional tests. But for time, efficiency, and monetary purposes too, especially from a concussion assessment, now it’s much more a streamlined and targeted assessment approach.

Dr. Sharp: Yeah. I’ve certainly seen the tests that you mentioned, the ImPACT in particular, what they use at our local sports medicine facility.

Dr. Josefine: Yes.

Dr. Sharp: And so [00:46:00] even in, yes, go ahead.

Dr. Josefine: I was just going to elaborate on that. When they go to a concussion clinic, obviously speaking from mostly mine, how I set it up and from what I’ve seen that’s fairly similar for specialty clinics, doesn’t mean there aren’t people that do it a little bit differently but generally, there should be some type of vestibular, ocular assessment, what does their balance look like? There are different ways to assess that. Like I said, Sway has provided a method.

There’s different balance board that are out there that will provide ways of assessment. There’s also tools like the SCAT that don’t require technology that can be administered in the office, that don’t require any additional tools.

On top of the vestibular and ocular screen, we want to assess neurocognitive functioning is [00:47:00] where ImPACT or C3 logix or now Sway typically comes in. So a lot of times you want to, those tests look for reaction time, visual motor tracking, memory; immediate and delay, processing speed, all those kind of factors. And then those results together inform, paired with obviously symptom checklist typically the PCSS. There’s multiple ones, personal preference. And then all those data points combined help me come up with a care plan for the individual and help determine whether they need formal therapies for those profiles that we talked about.

Dr. Sharp: I see. Another detailed question. In the process of these assessments, is it the neuropsychologist who’s administering the vestibular and [00:48:00] ocular assessment or is that another kind of medical professional or is it automated through the testing platform so much that psychologists can do it? The way you describe, it sounds like it might fall outside of our purview but I could be wrong about that. I just wanted to clarify.

Dr. Josefine: No, that’s a great question. I, as the licensed clinical neuropsychologist, I’m administering the vestibular and ocular screening. So the VOMS is a screening tool. Basically, it’s helpful to identify, do they need formal treatment? Are there deficiencies or is that within normal limits and does not need further attention?

I am completing that. I did receive training for that because my fellowship was in concussion care. So my two-year postdoc was at a concussion clinic because I knew this is what [00:49:00] I wanted to do. I do have the training. There are trainings out there, so if someone is interested in that, you can certainly obtain the necessary training to do that as the neuropsychologist. UPMC hosts CME opportunities and there’s lots of them.

And then if, let’s say my evaluation identifies that there’s need, then they would be referred to more specialized. So for example, I work in my clinic, I have a vestibular physical therapist and I also have a vision therapist that then address those deficiencies and obviously, do a much more in-depth evaluation of that and then tailor the treatment to those needs, depending on what deficiencies they evidence. So both ways, if that makes sense.

Dr. Sharp: It does. I appreciate your diplomacy here and reading between the lines and very clearly. Folks, don’t just [00:50:00] jump into doing the screening, there is training involved and you should know what you’re doing before you try to do that. So I appreciate you clarifying in a very good way.

Dr. Josefine: I recommend it.

Dr. Sharp: Right. That sounds great. Also another question with the battery, we’ve alluded to this idea, and we’ve certainly seen this in our practice, with our neuropsychologist that the emotional component can be really influential for a lot of these mild TBI cases. So are you also including any kind of personality or emotional assessment in this process?

Dr. Josefine: Yes, as a specialty clinic, I basically assess for each profile that a patient could potentially fall into. I do assess for emotional [00:51:00] distress as well as pre-existing mental health concerns because we know a nice little, I used the catchphrase earlier, when in doubt, get out, lots of those.

Another one that I always like to use is, concussions don’t create, they exacerbate. So if somebody has anxiety prior to the injury, they’re very likely to feel that more to heighten someone turned up the volume while they’re recovering, because if we remember, concussions are essentially an energy crisis. And if my brain doesn’t have the resources to keep my anxiety and check the way it normally does, I don’t have access to my normal go-to coping strategies, I’m probably going to feel that a lot more going through my recovery phase, just like any other pre-existing concerns, for example, depression or I’ve also had individuals with, for example, tic disorder that had just a higher frequency of that while they were recovering, those kind of things [00:52:00] very much expected, which is also why we always assess for not only, in general, the medical history, but also what we consider “risk factors” for concussions like that can make for a protracted recovery.

I want to mention that just because if you do have a so-called risk factor, that does not mean that your recovery is bound to take longer, but obviously, the more risk factors accumulate, the more likely we are to need a little bit more time. For example, individuals with pre-existing headaches or migraines almost always are more headachey than their baseline while recovering. People that normally get migraines with a certain frequency can definitely experience an increase during the time they recover.

If somebody has pre-existing [00:53:00] learning disabilities, like if focusing and executive functioning is already a challenge for my ADHDers or something like that, we know that during the recovery time, that might be extra challenging. So just having as much as information possible about those factors that can influence and potentially protract a recovery can be helpful, not only in setting realistic expectations for the patient and the parent, but also being able to be proactive if needed.

Dr. Sharp: Right. I like that phrase; concussions don’t create, they exacerbate. My understanding, feel free to correct us if needed but my informal understanding over the years is that, if someone has a true [00:54:00] drastic change in personality or mood or something like that following a concussion, then it’s way more severe than we would then, it’s not just mild. It has to be pretty significant. I don’t know if that’s true or not. I wanted to check that out while we’re on this topic.

Dr. Josefine: No, I think that’s a fair statement. The problem is that especially the anxiety and mood problem/profile is often very nuanced. Just because I have a lot of patients that tend to then after the injury, put all their problems in what we call the concussion basket, anything that goes wrong must be my concussion. That’s certainly not unique to this injury.

We see that with other illnesses or other injuries as well, but it is very tempting especially because a concussion is such a unique injury because there’s no visual feedback. If I ever break [00:55:00] my leg, there’s going to be likely a cast or at least a brace, crutches, those kinds of things versus concussions, you don’t even get a bandage on your forehead. A lot of people struggle with that. They look fine but they don’t feel fine.

Especially when it can seep into so many aspects of our life, it can certainly be very invasive and very devastating in ways. Especially from an emotional standpoint, we know that the mood and anxiety profile tends to reattack later on. There’s a little bit of a delay for a lot of people.

There’s multiple factors into that because if I have a headache 24/7 and I don’t normally have them, that’s going to impact my mood. If I just had to forfeit the championship game because I got hurt and I can’t help my team, that’s going to affect my mood. If I get pulled from school and I can’t see my friends, that’s going to affect my mood.

So there’s a [00:56:00] lot of factors that can, on top of the injury already, your brain not having the resources to emotionally regulate the way it normally would, that can then compound that and make it even worse. That’s, for example, especially for my student-athletes, one of the biggest reasons why I hardly ever pull someone from school. I will give very heavy-handed academic accommodations, especially in the acute phases of the injury, but I almost never will pull them because that’s their social environment. That’s where they see their friends. That’s where they have normalcy and distraction. The more normal we can have them do, even if it is with modifications, the better they will fare from an emotional standpoint as well.

That’s what I mean with exacerbate instead of creation because we shouldn’t see a dramatic change, if anything, it would be [00:57:00] heightened features. So like my introverted people might be a little bit more quiet or want to even engage less because they simply don’t have the energy to muster and deal with all the extroverted loud people or someone that’s always been sensation-seeking or more outgoing might be a little bit more down or similar.

That’s the other thing, as much as a lot of people can feel whatever they had pre-existing more loudly, sometimes it also swings the other way where the brain just hits the mute button on all emotions and we just are more flat because we don’t even have the energy to go through that. So it varies and it certainly doesn’t have to be the same every day, either, which is another layer of why people struggle with concussions, because not every day feels the same.

And there’s a lot of [00:58:00] well, I could do this yesterday, why can’t I do it to get it today? Well, because it’s a resource problem, and if we’ve already taxed this area today, this is going to be a lot harder than it was yesterday; what we didn’t tax that. Again, we should not see any dramatic changes but it certainly can height things.

And then I think the other thing where people sometimes get misled is if you have someone that is already hanging on by a thread and just pushing to the max constantly and then the injury, especially because it’s so invasive in multiple areas in their life, unravels a lot of things that were already wobbly but now the injury has depleted those resources, those coping mechanisms, it can certainly feel a lot worse and create this almost avalanche that for better or for worse has been waiting to happen, and then [00:59:00] the concussion almost acts as a catalyst for that.

So if you have someone where there’s dramatic changes, and we’re talking about a true concussion and we have ruled out moderate to severe through imaging and the like, then it’s much more likely that if we dig a little deeper, and for example, the clinical interview, that there’s things that already were struggle some before.

I’ll give you examples from clinic; I also see non-sports concussions. My clinic covers almost the lifespan, not quite. I don’t like to go much beyond five just because assessments get very tricky. I think my oldest patient was 95, so I’ve not made the 100 quite yet, but I see everything in clinic, non-athletes or also NARPs, how we lovingly refer to them, non-athletic regular people.

Dr. Sharp: I like that.

Dr. Josefine: We​ talked about the [01:00:00] anatomy issue at the beginning; they can happen anywhere. They get associated with sports because she’s heavily associated with sports, contact sports in particular, because that’s where they happen a lot. Like if I run on really high speed, I’m much more likely to get hurt than if I just walk around.

I will say, I see a lot less golfers than I see football players but it happens. Any sport, any situation, any work, I see a lot of work accidents, car accidents, slip and falls, DIY gone wrong, you name it. It can happen anywhere to anybody. Especially adults that are already high functioning or are the sole organizer of a family and then all of a sudden they can’t fulfill that role, that adds a lot of pressure, and that also can sometimes disrupt the pre-existing system that then has external pressures because all of a sudden mom can’t do everybody’s [01:01:00] schedule anymore. She needs a break or dad is too dizzy to make a docket practice or whatever.

So, I think, especially for working people, having a place where they can get not only catered care, but also have a return to work plan that accommodates and accounts for those kinds of things is incredibly helpful in getting people back to their normal more quickly.

Dr. Sharp: That makes sense. Yes. Oh, and I think we’re segwaying into treatment here, which I like. I did want to ask, you said something in our pre-podcast chat about men and boys typically struggling more with the emotional aspect of concussions. I’m curious about that. I wanted to follow up on that and get detail there.

Dr. Josefine: Research suggests [01:02:00] that women and girls are much better about reporting the concussion and also estimated to report higher symptom scores. It’s theorized that that’s because women are socialized to just be more comfortable talking about emotions, talking about things that don’t feel right versus a lot of males receive the tough it up, walk it off, rub some dirt on it, kind of messaging, which it definitely has gotten a lot better, but it is still very much a trend that when you ask boys how they’re feeling, how they’re doing, there’s a lot of, I’m fine, good. And then dig deeper and they’re like, oh yeah, well, I get cheeky and I feel sweaty when that happens. I’m like, okay, so are you nervous? Well, a little. Okay, that’s anxiety.

[01:03:00] I do think it’s getting better, but it is definitely socially, culturally, also dependent but women tend to be socialized to be more open, to be more identifying too. That being the norm, we talk about how we feel versus it’s like, ah, you’re fine. Walk it off. Like, you’re good. You’re good.

Dr. Sharp: Yeah, that makes sense to me. Okay. So treatment-wise, I feel like we’ve been teasing the treatment this whole episode. So treatment-wise, I’m going to start with the emotional side of things because that, at least in our experience, that’s the trickiest one. When we find ourselves in a situation where the individual “should be recovered” from a [01:04:00] physical or medical standpoint, and there continue to be, I’m saying the emotional component, those are the folks where I’m thinking they are continuing to put everything in the concussion basket. They’re having a really hard time moving on, even though, by all indications, they should be recovered.

I’m curious how you maybe tackle that conversation with folks to say, okay, from a medical standpoint, you should be okay, and here’s why we still see these symptoms persisting. This is a messy question but I think you know what I’m getting at, how do we approach those folks?

Dr. Josefine: Yeah, lots of thoughts. Let me see that I can take you on the trip with me and hopefully get back where we need to be. I want to start by talking about what the clearance criteria are, what we’re even looking [01:05:00] for to know when somebody is good to go when somebody is “healed” and then I’ll use that to dive more into the emotional treatment part of it, and then we can certainly talk about the other ones as well.

Essentially, what we’re looking for to be sure that someone is fully recovered, that someone is safe to return to contact or their physical labor job or whatever it is:

1. They need to be asymptomatic at rest. I always joke with kids like, you need to be able to be a couch potato and feel good, like lounging around, watching TV, doing your normal stuff and feeling okay doing it, feeling your normal self.

When I ask people if they’re back at their 100%, that doesn’t mean everything is perfect. It just means we are at baseline. We are where we were before this happened. Everybody brings different things to the table. Everybody has strengths and weaknesses. So that’s where we want to be back at.

2. We want to be [01:06:00] asymptomatic with academics or for adults, work. Can you get through your normal school or work day and feel like your normal self? Are you doing all your assignments, homework? Are you doing all the responsibilities at your job that you normally have and can you get through them okay?

3. Asymptomatic with exertion. Can you work out? Can you do your normal physical activity for the people that don’t have organized sports and feel okay doing so? Meaning, for example, for adults, can you put the laundry away without tipping over by picking up the laundry basket, without getting dizzy? Can you reach the upper cabinet by emptying the dishwasher without feeling off balance, without feeling woozy, without having a headache doing it?

With athletes, that tends to be a little bit easier because there’s other things that we can measure. I can make you run the sprints. I can make you do squats. I can make you do a lot of [01:07:00] rotational movements that then let us assess more easily if they’re good to go.

There’s also research and a push for what’s called Exertion Therapy. There’s also an EXiT test. Not all the places have that available, but there is a physical test people can take to see if they’re at pre-existing baseline, to see, as an athlete, you should be able to do X, Y, Z without problems. That’s in the process of getting standardized and my favorite part is then now working on adding sports-specific components because I have very different expectations for a figure skater that I would for a linebacker.

That’s definitely an interesting an exciting area the field is heading and working on. From a day to day perspective, can the athlete do their normal non-contact activity because no contact until the form is [01:08:00] cleared.

And then last but not least, do you have good numbers on all of the assessments? Are those numbers lining up, what I would expect from a healthy individual of that person’s age, gender and background? Once we have all of those things combined, we can be very certain we can feel safe to return them to “risk activity, contact activity”.

From an emotional standpoint, it depends on severity because like we talked about, it’s not unusual to experience heightened emotions or be a little bit more irritable, but I always want to know about that if we are back at baseline because anxiety can be a risk factor for future injury. If I have an athlete that is super nervous about taking another hit, they’re not going out there with the same confidence and they could be distracted, which can post them at risk of reinjury, not just from a [01:09:00] concussion standpoint, but also orthopedic, ligaments, joints, muscles, you name it. That’s definitely something we assess and always look for; do they feel ready to go back? Are they excited to go back? Those are good indicators.

And then for the people where they have a significant mood or anxiety profile during their recovery; one, research has shown there’s a little bit of a delayed onset. People tend to get really frustrated with this injury if it’s not over in two weeks. Side note, anywhere from two weeks to six months is considered “normal”. Some textbooks will tell you up to two years. Like I said, the more profiles, the longer it takes. And that kind of aspect is very frustrating for people because there’s no visual feedback. You don’t feel right but you look good. A lot of people in your environment don’t understand it.

In my [01:10:00] experience, it’s often the people that have anxiety, depression, or pre-existing that has never needed treatment, where they don’t have experience with formal treatment, that they feel floored or out of the depths of; what never was bad, why is it now? What’s wrong with me that I feel this way? Versus my anxious people, almost vets like, I know this, this goes up and down. They tend to be a little less taken by surprise. They also often can fall back on previous coping that is very effective.

So one of the biggest changes that has paid off tremendously in my own clinic is I was very fortunate to add an IHT, integrated health therapist, that can actually work with those folks that I identify during [01:11:00] testing as at risk or is not coping very well. Typically, she works with them, typically, like 5ish sessions. If they need more, then they get connected with a more long-term solution.

Some people have loved it so much, they wanted to continue and found a counselor in a more traditional sense but we have lots of people that find this type of treatment very helpful and very beneficial. I will say it differs from traditional psychotherapy. We don’t talk about childhood. We don’t talk about your parents. It is very much injury focused. It has a lot of CBT modality, and then also a lot of mindfulness components to help with that frustration tolerance, to help through symptom burden and those kinds of things. We’ve had a lot of really good success with it.

Research-wise, [01:12:00] there are some studies and articles that look at CBT models for post-concussion treatment, but unfortunately, there’s not one established modality. Hopefully, we’ll get there like how CBT has been adjusted for sleep problems or how, for example, EMDR protocols have exceeded just trauma work and now can be utilized for migraines and multiple applications. I’m hoping and I think that’s where the future is headed.

From an emotional standpoint, there’s no one type fits all. And then also what does the individual need? For example, we talked about school and practice being the social environment for the kids a lot of times so I often will allow my athletes [01:13:00] to watch practice if it’s not safe for them to start with the exertion part or have a modified activity or practice plan. So they can at least see their friends. They can be there. They feel like they’re still in touch with their sport. They’re not out of the loop.

And depending on what the sport is, like cheer, dance, those kinds of things where we’ll start with walkthroughs, so you can learn the steps, you just can’t execute them, but at least you know what’s happening at practice. You don’t feel left out. You don’t miss out on the inside jokes or the funny thing that happened or whatever. So just trying, like I said, creating as much normalcy as possible.

And then also for especially folks that don’t have any experience with counseling or any kind of mental health treatment, for lack of a better term, selling it, as a part of like this is just concussion care. We do that for everybody, helps a lot. Like I said, we’ve had people that loved it and then actually end up doing it for [01:14:00] themselves long after and unrelated to the concussion simply because they had such a good experience of taking that time and having someone that’s there for them one on one and nonjudgmental and taking that deeper dive but because of the limited number of sessions, we are very injury focused; which a lot of people seem to like.

Dr. Sharp: Sure. I like the thing that you said about selling counseling as a part of the concussion treatment. This is just what we do. It normalizes it, yes.

Dr. Josefine: That tends to go very well, especially for my, for lack of better terms, manly men’s pull yourself up by the bootstrap kind of thing. They tend to respond to that very well, so it’s working.

Dr. Sharp: Yeah. As far as the other profiles, we’ve talked about the emotional side of things or the emotional profile, which [01:15:00] is super important and interesting as a psychologist but from the other side, the other four profiles, can we touch on appropriate treatment for each of those before we wrap up?

Dr. Josefine: Absolutely. From a profile standpoint, the profiles are often shown as these circles. So I have a visual representation of that when I give feedback and talk about testing results so I can explain it to people on how they interact and also how they can pull on each other.

For example, people that have a vestibular profile tend to often have some increase in anxiety, they might not always have the full-blown profile but they have a slight elevation, and feel a little bit more irritable. And so talking about that in that mind-body connection up, they both rely on the [01:16:00] autonomic nervous system. So yeah, you’re going to feel it. If one’s affected they can talk on the other and vice versa. Same with dizziness and the vestibular, anybody that has significant anxiety, there’s many people that have also experienced dizziness with that so vice versa. They have to work together because their body, at the end of the day, is a system.

Treatment-wise, there’s a formal therapy for each profile if needed. We talked about if symptoms don’t self-correct or at least improve by the two-week mark, we want to pull in some more formal treatment to make sure that it gets back to normal. The good news is that there’s no statute of limitation or anything. I have a lot of people, even two years out from injury are like, ah, man, am I in trouble now? Am I doomed? Is this even going to work? Absolutely, it is.

The good news is it’s not like, oh, it’s been X amount of days, weeks, or months, I can’t do anything about it. No, [01:17:00] we can absolutely do things even with the delay. I do like to catch people at that two-week-ish mark. We’ll see them at any point, but just so that things don’t get worse or they don’t start significantly altering their life because something is not being addressed or I have lots of, we talked about employee, people have lots of people that quit their job because they don’t feel like they can do it anymore. Some people have to feel like they have to retire from the sport because something was unaddressed or just didn’t get better. And so we want to ideally, prevent that from happening.

And then in terms of formal treatment, I always describe it to people as like, we’re going to do some physical therapy for your brain. We’re going to train your brain back to normal. We want to recalibrate those systems that got out of whack or off track by that shaking that we talked about. This will depend a [01:18:00] little bit on location as well because different states have different legislations and different accreditations; what type of provider can do what?

For example, the vestibular treatment part usually falls under physical therapy. So I have a physical therapist that is specifically trained in vestibular physical therapy and will help recalibrate, reset that system. And then depending on location, the ocular treatment sometimes falls on the physical therapy. Where I’m currently located, it’s actually under occupational therapy, so it depends a little bit on state legislation and on resources to find what does the health care system have? What does the provider, the practice, depending on where you go, can provide, what do they have? Whether it’s physical or occupational therapy, the idea is [01:19:00] through specific to targeted movement and intervention to rehabilitate the system back to normal.

For post-traumatic migraines, 90% of the time, we expect that to resolve through the vestibular system and the ocular system resetting. If it doesn’t, typically supplements are a good idea to boost that; whether it’s CoQ10 or riboflavin. If that doesn’t cut it, then I would either consult with the PCP or work with neurology for better medication management because over-the-counter medications like Tylenol, and ibuprofen are not designed for long-term use and we don’t want to wreck the stomach or risk rebound headaches, which is also a thing if you take too much of the ibuprofen or Tylenol, it can give you more headaches, which is not helpful either.

So it is very much a [01:20:00] multidisciplinary approach to treatment. Especially too, for my people that already have pre-existing headaches or migraines, we want to make sure they don’t have to suffer and be miserable, so we might consider a medication route similar for the cervical modifier.

If there is a neck injury, we want to make sure that the orthopedic or pain management rehabilitation, if they need some physical therapy specifically for the neck, there’s treatment for that. And then we already talked about the anxiety, and mood piece through potential CBT or in my case, the IHT in a clinic.

And then for the cognitive fatigue profile, a lot of times that will get better through the other ones. If it doesn’t, speech therapy, even though it’s a little bit of a misnomer, can do a lot of cognitive rehabilitation and help with that. And then also depending on location, my [01:21:00] ocular therapist will do a lot of cognitive loading and dual tasking while we having and helping with that as well. So it depends a little bit on the setting, but those are the treatment options that are available and that are the gold standard.

Dr. Sharp: That’s fabulous. I know that we’re flying through those and we could spend probably an entire episode on each of those profiles and treatment options. I appreciate you being able to quickly and concisely summarize each of those. It’s truly fascinating. I love the approach that y’all are taking in this integrated model. This profile model sounds really useful and I like it. I’m going to dive into it a little bit more.

Dr. Josefine: The multidisciplinary treatment approach has [01:22:00] been extremely beneficial and rewarding because there’s such a nuanced injury. That’s why the profiles are so helpful and not a one fits all because not everybody is going to need neurology but the ones that do, we want to make sure that we don’t wait months and months to help them facilitate that because nobody wants to have headaches and be miserable that long.

We will catchphrase, it takes a village. I’m very fortunate to have a team that can help me achieve that and help tailor the treatment to our patients specifically.

Dr. Sharp: I’ll close with a personal question that will hopefully benefit some folks in the audience as well. I mentioned at the beginning of the episode that both of my kids are pretty athletic and play their respective sports. [01:23:00] However, we have been locked in a debate, I suppose, with my 12-year-old son about playing tackle football. I’m curious what you know, from the research or experience, about kids playing tackle football. Should they do it? If so, when is okay to start, and anything else you might want to share with that?

Dr. Josefine: Sure. That’s a great question. Yes, there is definitely a research and it is a very hot topic with a lot of debate. I can tell you that from a research perspective, the general recommendation is that waiting is not a bad thing. People tend to benefit from not starting too young, which 12 being the what seems acceptable starting age. And then obviously personal preference also plays a role widely [01:24:00] because you guys need to be comfortable with that decision. Just because a research article says, yes, 12 is good to go if that doesn’t work for your family, then that’s not the cutoff you should go by.

The developing brain definitely benefits of delay, like starting at eight versus starting at 10 versus starting at 12; there’s huge developmental differences. That being said, the good news is too that concussion awareness have become much better. We’ve seen a lot of rule changes, especially in football. We’ve seen a lot of changes in practice; how many hitting practices are actually permitted versus every practice and those kinds of things.

So there’ve been a lot of changes made that make it safer to do so. That being said, obviously, the risk is never zero. There’s [01:25:00] always an assumed risk, especially with contact sports. And then it becomes a personal choice, like how comfortable are we with that? How much does my kid love the sport? How much do I love the sport and want my kids to play it? What do they want to explore? Are there different options?

And then proper gear. I always teach that to my athletes too, if your helmet is off, don’t be horsing around. And even if you do have a helmet, don’t just run into each other headfirst because you think it’s funny, because you think you can. And if I joke about it, it’s happened.

Dr. Sharp: Oh, yeah. I believe you.

Dr. Josefine: Good awareness, good education but research-wise, 12 and up. There’s still lots and lots of stuff to learn. There’s often very scary things that make the media, that means fear sells. Typically, it’s [01:26:00] only the best stuff gets a lot of attention. That being said, we still have a lot to learn, and we still are doing a lot of research and just pushing for more information to learn more about it, the initial findings, especially about those guys that played football in the 80’s, that’s not the same game that it is today.

So even though it’s done a lot with the awareness, and it’s done a lot for our general understanding, those results aren’t as generalizable as a lot of people think. And so we need to continue to learn more and we need to continue, obviously, to investigate because the safety of our athletes always comes first but there’s also a huge argument for youth sports, not just developmentally but also the social aspects and the things they learn and having something that you can be good at outside of academics and all [01:27:00] those kinds of things. So it’s a balancing act.

At the end of the day, when I get asked that question, I always provide the research background but at the end of the day, the decision is with the family because you’re the guys that have to do it so you need to be comfortable with that.

Dr. Sharp: That’s fair. Again, another graceful response to a hard question. It’s just my job to figure out how to bend your response to fit my side of the argument so I will work on that. I appreciate you diving into that and everything today. I think this is helpful for me and just having a little bit of a newer conceptualization of concussion will give folks a lot to learn about and practice. So thanks for being here. It was great.

Dr. Josefine: Thanks for having me.

Dr. Sharp: All right, y’all. Thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can [01:28:00] implement in your practice and in your life. Any resources that we mentioned during the episode will be listed in the show notes so make sure to check those out.

If you like what you hear on the podcast, I would be so grateful if you left a review on iTunes or Spotify or wherever you listen to your podcasts.

And if you’re a practice owner or aspiring practice owner, I’d invite you to check out The Testing Psychologist mastermind groups. I have mastermind groups at every stage of practice development; beginner, intermediate, and advanced. We have homework, we have accountability, we have support, we have resources. These groups are amazing. We do a lot of work and a lot of connecting. If that sounds interesting to you, you can check out the details at thetestingpsychologist.com/consulting. You can sign up for a pre-group phone call and we will chat and figure out if a group could be a good fit for you. Thanks so much.

[01:29:00] The information contained in this podcast and on The Testing Psychologist website are intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment.

Please note that no doctor-patient relationship is formed here and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, [01:30:00] please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

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