Hi, guys. Welcome to another episode of the Factor podcast. I'm your host, Jessica Riddle. Today, we wrap up the second part of our series on concussion and return to play with doctor Michael Olson. In our last episode, we were introduced to the concept of crafting individualized concussion management plans and discuss the importance of ensuring every member of the health care team is in agreement on the best path forward for optimal patient recovery. In today's episode, we will be discussing the finer details of RTP or return to play protocols and how to manage the delicate balance between healing and returning to daily activities. Doctor Olson highlights the differences in special considerations in working with elite level athletes versus recreational or youth athletes, and he will also discuss the important role that hormones and blood pressure can have in recovery from a TBI. Finally, he will guide us through the RTP formula.

His structured approach for getting athletes back in the game safely, focusing on gradual increases in activity and constant monitoring. So grab something to take notes with and be sure to hit the save button. This is one you'll definitely wanna listen to more than once. Let's dive in.

Now we're going to get into, all real quick here. This is my this is what I give to the athletes here. Again, my form's slightly outdated and that technically now this this complete rest is 24 to 48 hours. This is considered step 1. So that's why let me see. Step 5 is return to play, whereas now they list this as step 6. But same thing, it just outlines it. And anytime an athlete of mine has to see the concussion, I give them this form, and we just walk through it with them.

And their coach is gonna get 1, mom, dad's gonna get 1, and the school administration is gonna get this form so that they we're all on the same page and following the same plan. Some barriers to recovery. Okay. Could there be genetic barriers, age differences? Really, what we're seeing is couple barriers are neurodevelopmental FAKTR. Such as, like, ADHD, family history of migraines, or other mental health problems as these can be substantially altered or changed. But our biggest barrier is having or the biggest risk FAKTR if we've had a previous concussion or or a brain injury. A lot of times, we're gonna see those individuals have a little bit harder time progressing through and and returning to their normal state. Severeity of a person's initial symptoms in the 1st day after injury is the strongest predictor.

So what that means is if you diagnose someone with concussion, but their symptoms are on the fence, like, you know, I don't know if it is. This is if it is, it's very mild. You maybe have a 2 out of 10 headache, and he also don't know. Is that just from, like, your your skull hurts from the hip type of thing? You know, or or again, they they have all the signs and symptoms above concussion. That's gonna tell us a lot, how fast you're gonna recover. So you can you can use those as pretty good predictive indicators as you're as you start to manage this. And factors eating recovery is there's more and more literature out cardiovascular exercise, which is why after that 24 to 48 hours, we wanna start getting them up and getting them moving a little bit, get that metabolic rate increased. And I'm also seeing more more and more literature on b 12, and specifically, a lot lot of times I'm seeing more providers just give them the whole b complex to aid in their recovery, but there is indication that b 12 is gonna help improve our nerve neuronal repair and and restore our nerve function.

But, again, rest primary treatment in that 24 to 48 hours, and then move into rehabilitation specific to this function. That's gonna be completely different. I I'll be talking about concussion management at the upcoming TCC convention. We're gonna gear a little bit more into some of that rehabilitation standpoint. So if you're interested in tuning to that, that's gonna be good. But there's there's 3 types of post concussion, and that's cervicogenic, physiologic, and vestibular ocular. So from a cervicogenic standpoint, chiropractors, is if they're looking at into, like, rehabbing it fit in well there. If they're following the fist to be ocular, they may need to see rehab specialist.

They may need to work with, like, a behavioral optometrist and and do more things along those lines. But all of those things help aid in recovery and and depending on what type of of care that athlete's getting from a rehab standpoint is going to definitely help improve their recovery. Elite versus non elite athletes, guys. Concussion doesn't shouldn't matter if you're 12 and on the sandlot team or if you're Tom Brady. They they concussions need to manage be managed the same. The only spot where they differ is depending on how fast or slow an athlete is recovering. But there's not a different set of rules for an elite person or non elite athlete. And there is there's a few different guidelines depending on if you're a child or adolescent or or an adult.

And and something that you as you read through the contested statements, you you can look at and see. Let's move into this return to school here quickly. And the return to school guidelines and what you can also modify to return to work are new with just the the recent consensus in sport update that 5th edition. Never really used to have these guidelines out there, and there's not a step by step progression with these like there is with sport again. But the more you manage concussions, the easier this is gonna get. And so, typically, I I manage our football team the most. Typically, concussion during the game, Friday night game. I have them rest Saturday, Sunday.

Typically, what they'll do with me for me then is then I'll send them to a half day on school on Monday and then follow-up with me right after that half day, and we see where they're at. If they if they had a struggle with that half day of school, I'll hold back farther, maybe give them a couple more days of rest from school, but it's kind of the same thing. You wanna gradually reintroduce things. And this this chart does a good job of stage 1 as we're looking at do some things at home, okay, that are gonna be similar to what they're doing at school. Maybe that's just trying to, like, read or or text some friends or do a couple math problems and see. And if if if that goes fine, then, yeah, let's get them back to school. Things that you're gonna have to limit initially is the amount of homework they're doing, the amount of reading, the difficulty of cognitive levels, and, again, returning them to school part time first prior to returning them to full time activity or full time school. So it is also important with schools is that if you're gonna start managing the concussions and your school doesn't have a program that won't be established, okay, schools should have a a return to school policy, or you should help them create one.

So if you're sending Johnny back to school, you're informing the teacher, hey. He needs to be doing this. He might need to be allowed to wear sunglasses at school. He might need to be allowed to sit in front of the the classroom so he doesn't have to straighten his eyes. She might need to take more breaks or be allowed to be dismissed to her next class a little bit sooner so she can avoid noisy halls. They you might need to set up an excused absence policy. So all of these things are things that schools need to consider when they're working with athletes and and groups that are trying to manage these concussions. Obviously, I think all of our teachers need to be familiar, like, some things that we're looking for for a concussion.

The athlete, the parent, the school nurse, the principal, the teachers need to that and especially those that really know that child, are they having difficulty difficulty paying attention? Are they having problems remembering things? Are they needing more time than usual? Are are their grades dropping a little bit? Do they not seem like they're they're normal soft? Are they irritable, emotional? They falling asleep in class? So these are all things that we need to educate our schools on and teachers on and and making sure that they're paying attention to so that they they can report back to the physician who might be managing this individual as well. Obviously, as you as you're probably aware, concussions can affect our athletes' ability to learn, And thus thus adhering to a well thought out plan of the return to school is going to be important, but it's also going to be unique to each student. Twyla might be able to go back on that Monday and do just fine for a half day where John said, hey. A half day is still too much. In most cases, concussion bumps significantly limit, but, again, there's always these cases where that concussion is severe and at will. So, again, read it's just important to to read through those contestants' statements and and get a a general understanding of how these return to school guidelines. And, again, you might have to alter it to return to work guidelines, how how they work, and things that we need to be cognizant of and and pay attention to. When are they ready to to return to school? Well, that's gonna be your call, essentially.

That's end. And that's their ability to problem solve, to think, to stay awake, to sleep. Again, go after that that line graph I drew away. It just it's it doesn't just pertain to physical things. It's a physical cognitive checklist. As the days progress outward, they should be able to cognitively start to do more and more as well. A lot of times with my cognitive rehabilitation, I'm printing out 3rd grade multiplication tables or math charts and having them do some of those at during the day. If if they're pretty symptom free, I'll have them fly through the through a couple sheets in my office to say, hey.

How did you how did you do what pillows? Did that give you a headache? Did that strain your eyes at all? Paying attention to that. And, also, if you're using any type of neurocognitive test, that's gonna tell you a lot. I have a baseline for all of my athletes before the start of every season. And so I will put them through post injury test when they start to be pretty asymptomatic, and and I can see where they line up from a standpoint of post injury compared to their baseline. And I I wanna get them back to baseline before, obviously, they're in return to play physically and before I remove all limitations from school. Can understanding concussion symptoms help identify with a specific student's individual needs? Absolutely. If you're dealing with a an individual who has cervicogenic post concussion syndrome, the way you're treating and managing them from a rehabilitative standpoint and a cognitive standpoint is completely different than if you're dealing with someone with vestibular ocular. Okay? A cervicogenic patient might not have any problems seeing the chalkboard.

They might not have any any problems with, like, their balance, things like that. And so they I I might allow them, hey. You can sleep you can sit in the back of the room. I'm not worried about eye strain with you. Whereas that vestibular ocular, they're sensitive to bright lights. And, again, I might need to wear glasses or they might need to sit closer. Or if they have a computer class, I I might say you're only in class for 20 minutes with with the computer because I I wanna avoid that strain. So understanding what areas of the brain are affected with concussion is gonna vastly help you continue to manage this these individual symptoms.

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Essentially, this is a breakdown of of the limitations that I give my my kids when they go back to school. And you also gotta be cognizant as if they're not an athlete, but they have gym class. In gym, they gotta follow those same return to return to play and essentially return to gym guidelines. But I have a form that I I developed that is a checklist essentially of how these kids go back to school. No. So here, this this top example is deals with testing. If if there's some important tests, I might have that conversation with that student. Hey.

I don't mind if John takes a test, but right now, he just needs to open book. Or can he take the test broken down in a couple days? Like, give him the 1st page this day, the 2nd page, the next day, and and so forth. And, again, broken down. Right? Stages, we want this this is this is the first slide here, but we want stage 1, these just daily activities to be done at home. Okay? So that we know if it's gonna be safe to get them back in the school and start with that 5 to 15 increment. 35 to 15 minutes. Stage 2, some easy light school activities. I'll hold a little bit on the homework.

I'll hold a little bit of reading. There are cognitive activities outside of the classroom, but they they still might be at school only part time during this stage. We're just trying to build up that tolerance of cognitive work. Right? We're trying to as days progress out, we're trying to move up along that symptom line. Again, back to school reintroducing more school work and just classroom activity, the noise levels. If they're a band or choir, you might have to hold from that for a a week sometimes depending on the band setup and still building up that tolerance level until we can get them to return to school full time and and back to normal academic activities. And then, ideally, they're we might have to play some catch up. And so is it, you know, safe when and is it safe for them to do their normal stuff and and play catch up? Those are all some things to think about and consider.

Like, again, I'll be at TCC, and then FAKTR through Southeast Sports Education has, I believe, it was an 8 hour module. Just if if you can correct me that I put together that kinda deals with that whole entire bubble on on our on that second side of mine and and explains and goes through the entire concussion management, procedures that I I work with and where individuals can get involved. But I can open up the floor to any questions here now if if anyone has any.

Awesome. Thank you so much, doctor Olsen. And as he mentioned, we do have a full 8 hour online on demand course on our course online learning website. I'll put that in the chat so that you guys a link to that so you can check it out if you're interested in learning more. We'll also follow-up via email to let you guys know a little bit more about that. Again, there's only so much that we can cover in this 1 hour format when it comes to a big topic, such as concussion. And doctor Olson gives some really great in-depth directives on post concussion care, And, of course, helping patients with their recovery from that, from a rehab standpoint in that online course. That being said, we have had a few questions that have come in from our live audience.

Very early on, you were talking a little bit about the fact that there's been this fourfold increase in concussion in recent years, especially with youth athletes. And that as of today, at least, the research hasn't come to a conclusion about why that is or why we've seen that increase in prevalence. But I'm sure as a provider that works with a lot of patients that have concussion, you have ideas or thoughts or maybe correlations that you're seeing. What do you think? And I know, obviously, this is your opinion, not based on research because they haven't come up with a definitive conclusion yet. But why do you think we've seen this increase in concussion in recent years?

Yeah. I think if I'm I'm gonna I'm gonna go if if we're gonna use 4 fold, I'm gonna go give a 3 to 1 ratio. So I talked to a lot of older athletes that may have played sports back in the seventies, the eighties. My dad being one of them, and he he's just like, man, I probably had several concussions going through football, but half the time, you're just told to to get back in there. So that being said, I think we we have so much more knowledge now. Oodles oodles more. And so of that fourfold, I would say at least 3 of it is we are recognizing concussions faster. Okay? So a lot of these concussions back in the seventies, eighties, early nineties, probably going missed, probably not being dealt with at all or even reported as a concussion.

However, that one fold, I I I do think, like, bigger, faster, stronger. Right? Our athletes are getting bigger. They're FAKTR. They're stronger. Collisions are harder and probably substantial substantially more compared to, again, seventies, 80, nineties. But with that being said, our protective equipments get better too. Okay? And and our practices are are better in how we're managing these. So me personally don't don't think it's that drastic change in the sport as much as is our awareness to recognize and manage these.

But I I think there's a little bit of both definitely just heavier on the on the recognition standpoint.

No. I can absolutely see that. And I know even within kind of the general public's knowledge and understanding of concussion, I think parents on the whole are probably way more cognizant of brain health for their kids now since major movies have come out about it, since the NFL has had the major news stories that they've had about CTE and the long term effects of concussions. So I can certainly see how a lot of that factors into public awareness, which, in turn, a lot of times, parents might be the ones kind of looking at that for their kids a little bit more than their young athletes who are just trying to get back in the game. Absolutely. Now kind of going along that same line, you mentioned that a lot of times, you'll have those conversations, especially with parents when you're dealing with an underage athlete, someone that their parents are typically the ones bringing them in. Do you find that most of the time, having those conversations with parents is a really effective way to make sure that their young athlete is recovering on an appropriate timeline. Do you often get a little bit of pushback from the athletes themselves because they want things to hurry up and and get better faster? How do you have those conversations with the athletes so that they understand that this is a process and that recovery takes time?

Absolutely. And I'm very blessed and fortunate to be practicing in such a small rural remote area. So I I believe that aids to to the betterment of the athletes simply because a lot of these athletes, their parents are my friends now. And over the 12 years of doing this, you you start to be recognized as, well, you know, the concussion guru. And so when I first started, yeah, I had a little bit more pushback 12 years ago. Are you sure he's got one? Or, you know what? I and and it also goes to the level of of of our our team used to be better 12 years ago. We're competing for stayed a couple. So you have those athletes that they're not gonna miss a game.

And but I think in, again, in of these past 10 to 12 years, the amount of concussion loss that's come out right now, you're you're almost having athletes more worried from themselves than you were than you than you used to. Like, hey. I I had a little headache or what do you think? Should I go back in? And I think we're finding more and more athletes with concussion, wanting to play an air on the side of caution or air on the safe side. And the more people I can get involved in again, during a football game, if it happens, mom and dad come over, and I sit and I talk with the parent and mom and dad about this, what's going on at the end of the game. If the coaches wasn't able to come over in the game, we discuss it. A lot of the teachers, I have their number and I can send them a message, hey. As far as as far as we got a concussion, here's what we gotta do. What's your what's your weekly schedule look like? How can we get this individual back to school safely? And so the more the more education I mean, the big the biggest part of concussion management is education.

And if you can tell that athlete what to expect, that's gonna come down any nerves or fears. That's that helps. Especially if mom and dad most of them, they're not, you know, on the athlete and and making them more nervous. More people you can get to understand this, the better. And every year I give a concussion management talk to our school at the beginning of the year, and so teachers are on board, the parents are on board, everyone everyone just has a good awareness, and I would say, I don't wanna say we're a role model for for a program, but I I I do think it is it is. And it's taken 12 years, but I think we have a really good, good program here and, and parents fully understand and, and the teachers fully understand how to operate this. It's made it's made my job easier.

No. Absolutely. I can I can see that, and I know that along those same lines, it's really important when you are dealing with an athlete that has coaches involved and athletic trainers involved and maybe their medical doctor involved and other other members of their health care team that you communicate regularly with them about their care? What are some kind of tips or best practices that you utilize in your office to communicate with those other members that are overseeing that young athlete as members of their health care team?

I was I'm trying to think of tips here. If if I I would have to say it was allowing myself to to establish, like, hey. This is, like, man, he's concussion expert, concussion guru, and that didn't happen overnight. That happened with years of practice, years of reading the literature, following the guidelines. The more you know, the easier it is to talk about something, and the smarter you are about that. So if you fully understand all this, sitting through this presentation, you're not gonna be able walk away and say, okay. I can go manage concussion. Like, it's not a 1 hour it's not a 1 hour webinar.

It's it's a lot of research and almost trial and error in in getting those concussion patients. And if your first concussion patient you have, you might not wanna be the the the primary guy that manages that. You might just wanna be a a part of the team. But then after that, if you stick to the internationally accepted guidelines and and essentially, a soda has adopted the national accepted guidelines. So I can go right out of my Minnesota State High School League and and print off this that same stepwise progression and use those forms. And if I'm evaluating this, but that athlete's also they chose to see their medical doctor first, and he wants to do it. Then they come to me for symptom management. I'll I'll I'll write those guidelines out and say, hey.

Here here's what I'm finding. Here's our state guidelines. He should be on step 1 or on step 4. Hey. I see, like, you didn't hold him from school. I think he he's not quite ready for that that, and and I'm the one that administers all the the neurocognitive baseline. So most of the time now, it's like, if there can cost nurses to say, you just gotta you need to go follow-up with doctor Olsen. He's gonna progress you through it.

But it's, I think it's just, it takes time to develop and it's in the biggest, the biggest help is you, if you're gonna manage it, establishing yourself as the expert in it.

No. Absolutely. And I think that's that's key again. Just kind of keeping everyone in the loop, letting them know that what's going on with the athlete and and how they're doing. As you mentioned before, I mean, there's so much coming out still in the research. They're still updating things regularly, which I think it's it's nice that the medical community is now really paying attention to this has this as a high priority, especially when it comes to sports and athletics. And it seems like we're just kinda scratching the surface on our understanding of the brain and long term effects of concussion. So if you could kind of speak a little bit to some of the long term effects of concussion that you've seen with patients.

Obviously, there's the recovery period where we know we're gonna have specific symptoms. But have you had any cases where even years after the fact or after having multiple concussions over time, you're seeing patients that have symptoms that just become chronic throughout the rest of their life? Or what are those things that you're seeing that make you ask that question in that initial exam with a patient? Have you ever had a concussion in the past? Have you had one in recent years or multiples, etcetera?

Okay. Couple answers to this question as well. I've only been in practice again for for 12 years. In my 12 years here, I've had 2 that have had multiple concussions, and, unfortunately, one was multiple concussions within 5 minutes. So he fell into the second impact, and then he essentially was got knocked over in gym class, hit his head. And then as he was walking out of gym class, someone threw a a basketball from one floor to the other, hit him in the head, and then he fell over the ground and his head hitting the ground again. He was top of his class student. He was, I believe, 6th grade at the time and just really took a a turn from the from the for the worst and struggled with school and mother's name and things like that, and his recovery was a long a long time.

He had to get pulled out of school and going to homeschooling, and with all that just came. He he's a different individual, and so I think this individual is learning how to adjust to someone that he wasn't used to being. And with that middle school age friends and bullying and picking on each other, I think, came some social issues. These other two individuals that I spoke about with that previous concussion was the the biggest thing is, like, depression. Right? They they can't provide for their friends and their family or their kids. Like, they were so used to doing such a light switch change. Right? It's like, boom. Here's your injury and all of a sudden you can't do this.

And those are the biggest things that I see with patients that I know very well before they get the concussion. And, again, small town, unfortunately, where a lot of my athletes again, I know these athletes, and so I have an easier time managing concussions because I I know this individual is normal. Whereas, my worst fear is trying to manage their concussion. I have no clue who this individual is. That was the first time I see him as post concussion. I don't know what they look like, how they talk, how they act, and how and what they're normal. So that being said, the concussions I've managed, I'm just getting to the to the point now where it's like some of my early ones would be, yeah, have they fallen into any long term deficits now from a just a regular provider side of things. Like, do I get patients that come in and say, yeah.

I've had multiple concussions when I was a kid, and now I have, like I've after my 3rd concussion, I've had chronic headaches and chronic neck pain. Yeah. I I see that. So a couple of patients I can think of quicker to get angered a little bit more higher anxiety. I never used to be anxious or agitated, and I think I think that agitates I I get irritated more. Both of them will probably say, I don't know if that's related to pain and or just brain dysfunction. But I think those those are kind of the the top things that I can think of that come to mind.

Wonderful. Thank you so much, and thank you so much for this presentation today. Again, thank you so much, doctor Olsen, for tackling this very big topic for us today. You provided a lot of great information that I think our providers will be able to take into practice immediately. Thank you so much, everyone. We're signing off for today. Thank you, doctor Olsen.

Yes. Thank you, guys, for having me.

That's it for today's episode. Be sure to tune in for episode 79 where we kick off our brand new series on harnessing the science of HRV or heart rate variability for enhanced patient care with doctor David Hopper. You won't wanna miss it. Episode 79 drops in 2 weeks. If you're more of a visual learner or wanna see the full presentation slide deck from today's training, be sure to visit the link in our show notes to watch the full recorded replay of this webinar. You can also scroll through our show notes to find a link to our newly launched FAKTR podcast website, factor podcast.com, as well as links to all of the special offers from our sponsors. We'll see you next time. Hey, guys.

If you like what you heard today, I encourage you to visit our website at FAKTR hyphen store dot com. That's spelled faktrhyphenstore.com to find out more information about all that we have to offer. We have a variety of online offerings as well as our hands on FAKTR rehab system course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.