(upbeat music) - Welcome to "At Issue."

I'm H Wayne Wilson.

Thank you so much for joining us as we talk about something that is going to be hard to understand because we don't really understand concussions.

They come in all sorts of forms, they can happen in just about any scenario that you can imagine.

We have four guests, all of whom have had concussions, but they are experts.

And let me first introduce to you, Don Samford.

Don has suffered five concussions in your lifetime.

- Correct.

- We'll talk a little bit about that.

Thank you for being with us.

Also with us is Dr. Nikki Hoffman.

Dr. Hoffman has suffered 10 concussions.

- Unfortunately (laughs).

- But more importantly, Dr. Hoffman is the Assistant Professor at the ISU School of Kinesiology and Recreation.

Thank you for being with us.

- Thank you.

- And the other doctor who's here is Dr. Deepak Nair.

Dr. Nair is with the OSF Illinois Neurological Institute.

Thank you for being with us.

- Thank you.

- And with us also is Jessica Barrack.

She is an athlete trainer for Carle Sports Medicine, and has two roles.

You work at Carle Sports Medicine, but help at Champaign Centennial High School as well.

And so, as I alluded to in the introduction, it's something hard to define.

So doctor I'll put you on the spot.

(ladies laughing) What is a concussion?

- So this will be the most complicated thing we discuss today.

Simply put, a concussion is defined as anything that results in transient brain dysfunction, often related to some sort of traumatic injury.

We were talking earlier and I pointed out that what I often tell my patients is that the other way to think about this is that it is a mild form of traumatic brain injury.

- So you said transient, that means it doesn't last very long.

- Yeah, and it's probably a horrible misnomer because for all of us who've experienced concussion, even a short while can feel like an eternity, but by definition, a concussion means that the immediate symptoms after the injury last less than a week or two.

- Then let me turn to Don Sanford because Don is currently suffering from a concussion.

Could you describe what occurred and what the symptoms have been and how long it's been?

- Okay, well, this is all gonna be from my wife's recollection, 'cause I have no memory of it.

So that's one of the conditions, but I apparently slipped on ice coming back from Eureka High School where I volunteer for truck.

And she said, I drove the truck to the garage, shut the door, came in, told her that I'm in my house.

I think I'm in my house, I'm not sure.

I don't remember any of this taking place.

She said, I passed out.

My next memory is getting to normal as they're taking me out of the ambulance.

And it took quite a while for my memory to come back but it's headaches, fatigue.

- And this happened in January?

- This was the last week of January.

And I'm still having issues with headaches and fatigue.

- And you have good days and bad days.

- Yes, yes.

- Today is a good day.

- It is and I was having more good days and bad, but now I've kind of slid back.

And that's why I didn't know until I got this morning.

So I'd be here.

- Doctor, is that typical for those that have...

There's various levels of concussion I assume.

- Certainly.

- Is that typical though that you could have three good days and say, "Hey, I'm better, I'm getting there" and then relapse so to speak.

- Absolutely, so the more specific term that we might use for Don's situation is that he has also a post-concussive syndrome, And these are patients who, after their concussion, after a period of three or four weeks, that they have either re-emerging problems or persistent problems.

And that's a situation that can last a variable amount of time.

Every person's a little bit different.

And so there the severity of symptoms will fluctuate.

And even in our daily experience, without a concussion, you'll have good days and bad days.

So all of that is just gonna be much more heightened for someone like Don.

- Nikki, you operate a clinic at Illinois State University.

Can you explain what kind of, and I assume these are students that are coming to you.

When does a student come to the clinic and what's the protocol for identifying a concussion?

- Sure, so I just started up this clinic at ISU.

COVID kind of shut down the initial stages of it, but now I finally get to see patients face to face and how this works is that students on campus, if they sustain a concussion, then what they do is they go to the student health services, see a healthcare provider, get that diagnosis with a concussion or at least a suspected concussion.

If they want more information on what's going on with the symptoms and other cognitive function or dysfunction rather, what they do is they send them to me and then what I'm able to do is sit with this patient for an hour to an hour and a half where usually healthcare providers aren't able to dedicate that much time to just one patient.

So during this time I'll take them through what we consider is best practice as athletic trainers, taking them through a balance assessment and I'll take them through a computerized neurocognitive test, which is basically a computer test that will have them test their memory, their reaction time, and then also go over what their symptoms are at that moment.

- So do you have the ability to say this student cannot participate in a particular athletic venture?

- Since I am a certified athletic trainer, I do have the background in diagnosing concussions.

So I don't override what a physician would say, but based on the information that I gather, I'll provide a report that says, these are my thoughts.

And then I'll collaborate with the healthcare providers to let them know what I found.

- Jessica Barrack works as we mentioned at Centennial High School in Champaign.

And you also have the say so over whether a student goes back into a game.

- Yes.

- How difficult is that sometimes because is I know that grandchildren know that that they say, "No, I'm good, I'm going back in."

- Well, when kids are coming off concussed, like I said before, when talking to you earlier that they can be irritable, they can be angry.

So they will argue with me sometimes.

But since I work with minors, I'm talking to the coach, I tell them they cannot go back in 'cause they have concussion.

I have to call their parents so they cannot go back in 'cause they have concussion.

But then at the same time, I will give them, telling them how serious it would be if they did go out there with a concussion and was concussed again, 'cause I do want to educate the kids, I don't wanna just go over their heads and talk to like the coach and parents as well but I'll tell them, if you go back out there with a concussion and you become concussed again, it can be very detrimental.

- Let's turn back to Deepak because I wanna have a conversation about people who have concussions.

I mean, could the event occur and then you not have the effects until later?

- Yes, absolutely.

So as we were chatting before, one of the things that people get hung up on is the severity of the mechanism of injury, right?

So car accidents, falls, violence assaults, that kind of thing are very common, but we know from our experience taking care of battlefield soldiers, that there doesn't even have to be a direct like traumatic injury to the head for a concussion to occur.

And there we see this with explosive and blast injuries where you may be far away from where the explosion was, but the energy wave that transmits through you can cause concussion injury.

And sometimes you won't know right away.

So even after direct trauma, so a blow to the head, you may feel fine for a transit period of time.

And then it may be hours, rarely days later where the symptoms really emerge.

In neurosciences, there's a term we use for that as the lucid interval.

And that's often related to severe traumatic injuries where there may be active bleeding or other changes happening inside the brain or the skull.

And unless we go do some specific testing, we were not going to know that until a patient has a sudden decline in their performance.

And so we are very mindful of this and irrespective of the severity of the type of injury, we wanna pay very close to the patients, especially if symptoms occur early, but we don't want to ignore people who are "normal" after the insult.

- And we wanna make it clear that the earlier the diagnosis, the more quickly the recovery.

- That's absolutely true.

- I wanna turn to Nikki, Deepak mentioned something very important.

Athletic trainer, athletic trainer, coach.

It's not just as athletics.

- Correct.

- He mentioned war zones, but it could be anything.

- My latest concussion was actually as the result of throwing a stick to a dog and it got caught in my, yes, everyone can make fun of me, it's totally fine.

It got caught in my sleeve and I was trying to throw it with such force and it got caught.

And then I ended up ricocheting against my head and I was like, "You've gotta be kidding me."

And just because I've had so many, just to speak what's been mentioned before, my symptoms don't typically show up right away.

But just because I know the amount of force that it took, it wasn't really that much, but it was enough where I'm like, "I'm probably in trouble," not meaning that you need to be hyper aware of it, but it's enough for it's like all right, I'm gonna have to start paying attention.

Am I starting to feel more fatigued than usual?

Am I starting to feel disoriented?

I mean, there's at least like 22 symptoms that a patient could potentially experience.

So yeah, once you get at least one to two concussions, that takes less force usually to cause the other ones.

- Deepak, we've seen improvements in football helmets, and by the way, for the audience's benefit, the number one source on a per athlete basis in athletics, rugby is number one for men, soccer for women, but helmets?

Have helmets, I mean, they've improved, but helmet, does that protect against the concussion?

- Not necessarily because without getting too technical here, the mechanisms that cause brain dysfunction are not necessarily related to the severity of the impact to the skull.

It's really about the movement of brain inside the skull.

So our brains are sitting in a sort of a fluid bath, that we refer to as the cerebro spinal fluid.

And so our brain is floating.

And if there's a sudden movement of the head, the brain gets jostled around inside the skull.

And there's lots of things that are happening even at a chemical level now.

And that's what's really causing the secondary brain dysfunction.

So the better our helmets get the better they protect against things like skull fracture, direct traumatic injury.

But that doesn't change how the brain is moving around inside the skull.

And so we sometimes get into a false sense of security about, "Oh, I'm wearing all this protective gear."

But we still have to be very mindful and take a preventative mindset.

- Jessica, he mentioned that we have to be mindful and you have to tell athletes, it's not necessarily, the brain is suspended.

- That is for sure.

- How do athletes respond when you're telling them that this is how it works?

- Mostly just stared faces at me if I say something like that.

(all laughing) Especially if they're concussed.

(group chattering) But I will try to preach on how and important it is for proper safety, but also like proper positioning, especially like football players, like you don't see it as much nowadays, but you don't spear tackling, yes, that causes like neck fractures, but that can also cause concussions as well.

- So do you talk to coaches about this in advance that let's make sure that part of the training is no spear tackling and what?

- Oh, yeah, every year I go through emergency care with my coaches and we will talk about like safety with concussions and proper tackling positions.

And also I make sure my coaches are well prepared for like C-spine as well.

And that's just when we like have to actually see spine in athlete where they could have a concussion and a neck fracture.

- Don you were a tracking field coach.

- Yes.

- And you saw concussions as a coach.

- Yeah, I also was an assistant football coach and a basketball coach too.

So I've seen them all across and you're exactly right.

Track and field, the danger was primarily more in pole vault.

And as we discussed earlier, they tried forcing the kids, shouldn't say forced, making kids wear helmets, which they didn't like, but that didn't stop the concussion.

So now they make the pads way bigger.

So for small schools like ours, Eureka, it is a financial burden, and some schools don't have pole vault because of that.

But that's has been the best to protect this just larger high jump and pole vault mats.

But you could get them the hurdles falling (mumbles).

- Well or throwing a stick?

I'm sorry.

(group chattering) - Or shot in discus if they don't keep it in.

(all laughing) - Deepak, let's talk about recovery.

- Oh, boy.

(women laughing) - Well, and we need to understand that the topic of concussion is not an exact science at this point, but recovery for most people is going to be in the two week range.

- Yes, if things are managed appropriately and I'll bandwagon onto what Jessica said earlier.

Part of that early recognition and management is about immediate prevention of the second insult.

And so we wanna make sure that once we've recognized concussions we prevent another immediate injury because then this can compound and there can be an exponential effect on how severe the brain injury is.

And then things become much more dangerous for that patient.

So that's where things start.

The moment you recognize is now getting them on the road to recovery.

Most people who recognize concussion early, and we take the appropriate steps to minimize their immediate risk and we manage them appropriately, they'll see great recovery within a week or two.

But being mindful and paying attention to these patients also helps us then recognize those patients who will have lingering symptoms or reemerging symptoms.

So it's kind of an all hands on deck approach to managing these people.

Recovery, it's hard for us to predict early on, who will recover early versus who will have lingering symptoms or reemerging symptoms down the road, that just requires attention.

So for the most part, and I don't wanna be scaring people unnecessarily, most people, the vast majority of people will recover spontaneously within the first week or two.

- The old way of treating a concussion was, we've identified you have a concussion, you're going to be in bed or sitting still for an extended period of time.

We've changed that approach.

- Yes.

- What do we do now?

- And you're absolutely right.

Several decades ago, the attitude towards any sort of brain injury was don't move and stay bed bound for any number of days to weeks.

What we've actually discovered through clinical trials and following patients overtime is that prolonging the rest period actually may worsen outcomes.

So we want to really focus on rest and avoidance of activity within the first 24 to 48 hours.

Beyond that we wanna start to reintroduce activity in a gradual sort of paced sort of way.

And a lot of when we allow athletes or other patients to advance their activity is really based on then what's triggering symptoms.

And so I think several of us mentioned that before, this requires a lot of close attention to how are you feeling.

And for most concussion patients, there is no specific scientific or medical test that will tell me how you're doing, I have to listen to you.

And so based on how patients are experiencing their symptoms throughout the day, then we'll know where can we start to advance our activity.

- You are in agreement, Nikki?

- Absolutely, like this is kind of my bread and butter.

So my research focuses on sleep and concussion recovery.

So just hearing about the initial 24 to 48 hours of rest is still critical.

But after that, we don't want them to have that cocoon therapy mindset.

I've had people, I mean, there's amazing how many people still have that old mindset.

I need to be in a dark room.

I need to be sleeping the whole time.

Well, not necessarily, but there's a happy medium.

So the sleep aspect that I'm looking at is maybe if we encourage individuals to do like focus on sleeping at night, maybe during the day doing a little bit of activity, whether the literature calls it sub-symptom threshold.

So you're trying to stay underneath that line, where that would trigger your symptoms.

Like anything that would cause a headache.

Well, that's too much activity, let's back you off a little bit.

So that's just one example.

So I'm trying to see, can we do things to help make them feel better while they're recovering?

So there's a lot of research coming out on that like when is the optimal timing to start doing physical activity?

When is the optimal timing to not focus on sleep as much anymore.

- Well, let me turn to Jessica because there's going to be coach that's gonna come up to you and say, "When can my store and my star split in, get into the game again."

- And truly it does depend.

Every brain is different literally.

And it's for one person, it could be a week.

Another person, it could be three weeks.

It really just depends.

- And the coach sits there and says, "Come on."

(women laughs) Seriously, they want their star in there because it means points on the scoreboard.

- That is true and there is a protocol set where, what I use at my school is when they're 24 hours symptom free, then they start day one of a five step protocol.

And that first step is they have to pass like a cognitive test one's that Nikki uses probably in her clinic where it's like impact test, that's cognitive tests, as well as symptoms test too.

And after that, they have to wait another 24 hours to start the next one, where we do light physical activity.

And then the one after that is a little bit more intense and steps go more intense as you go, but if there are any point they have symptoms with those they have to start over.

- Don, you just took the IHSA test.

And what does that entail?

- It has the return to play and return to learn protocols.

So there's a team of certified people as well as my coaches or administrators, the school has to have a plan.

And then that team has to, okay, make sure you followed all the procedures before the athlete can go back to the sport or in the classroom as well.

- Deepak, why did it take so long for us to take concussions?

(Deepak laughs) I know there's not a clean cut answer, but for instance.

- Sure.

- The NFL, I mean, they knew about concussions, but they didn't really take it seriously until they developed a protocol in 2013.

Why so long to get serious about this particular issue?

- There's probably multiple reasons, even in clinical medicine has taken us some time to recognize how the potential for serious long term problems for our patient who suffer concussion.

I mentioned earlier on that I use the term mild traumatic brain injury to refer to these patients.

The misnomer here is that it's mild, right?

These are potentially disabling periods of time for patients.

And that tells us something about how the brain's performing, if you're not able to get back into your normal routine of activities, there is something seriously wrong with your brain function and recovery is imminently possible, but that requires some careful management.

And so it's taken us a long time to recognize that even clinically and scientifically, and then you add in multitude of public pressure, right?

So you're talking about the NFL, which is a multi-billion dollar industry.

There's a lot of incentives at play here.

I will give kudos to the NFL Players Union for drawing a lot of attention to the potential impacts of concussion and other traumatic injuries among their athletes.

And I think that wide open public discussion and discourse about this has drawn a lot of attention to this.

And that's ultimately why now we pay attention to this.

Previously, these were things that if you looked at an NFL player, these are elite athletes, simply looking and talking to them, you wouldn't necessarily tell that there was anything wrong.

And so without a focused approach to that, looking at that, you would never know./ - Which I would add lawsuits into that.

You had players and families of players who passed away who were starting to file lawsuits also.

And that seemed to be when the NFL made its biggest move.

- Money, money.

- Yeah.

- Nikki, the Centers for Disease Control and Prevention estimate that approximately 3.8 million concussions occur every year.

- Correct.

- Are we seeing an increase in the number of concussions and why might that be or are we just pay more attention?

- I don't necessarily think that it has anything to do with whether more concussions are occurring.

It's more or less like people are able to recognize them a lot more.

I don't have specific numbers to back that up, but I know that there's a lot of protocols, especially at the high school and college level where we have our athletes sign an agreement saying we've received concussion education, and we've been educated on this information.

So a lot more people are ready to come forward with it.

And I think we're just learning more about it.

Just, yeah, that's kind of what's going on, I think.

- Your practice is not just with concussions?

- Correct.

- But are you seeing more attention to it?

And I ask this question, not necessarily from the number of people who are coming in, but is medicine paying more attention to this?

- Absolutely, this has become a much larger area of education, research and patient management.

And that 3.8 million number is mostly focused on athletic related injuries, right?

And I think the most recent literature suggests that may maybe only half of those injuries are being recognized in a timely fashion.

So the number could be much, much higher.

And certainly that doesn't account for just day to day life that can cause concussions, their own sticks.

(group chattering) Exactly, and so I think that as we pay more attention to this, we see these numbers grow that should not necessarily be cause for alarm.

If anything, I take some solace in the fact that we're finally paying attention to something that we should have been making attention to for a long time.

- Final thought from Jessica.

And athletes at the high school level, are they taking this more seriously?

And let me add, because it wasn't too long ago that we didn't have athletic trainers in high school sports.

- That is true.

And I do definitely think that us having athletic trainers is helping educate both the coaches and the athletes.

And I do think that my team is taking it seriously, like yes, every now and then an athlete will argue with me when I'm telling them they have a concussion, but they do take it more seriously because of the education.

And that's what's really important that we're educating everybody on this.

- [Wayne] And you're finding that the coaches back you up when you tell an athlete, I'm sorry, cognitively speaking, you can't go back in that game, the coach backs you up.

- The coach does back me up.

I can't say that for everybody, but for mine, they definitely do back me up.

- Okay, and with that, we have run out of time.

We hope you continue the conversation in your home.

We'll probably continue here, but let me say thank you first to Jessica Barrack, who's the athletic trainer for Carle Sports Medicine and to Dr. Nikki Hoffman, who's Assistant Professor at the ISU School of Kinesiology and Recreation.

Also, thank you to Deepak Nair, who is with the OSF, Illinois Neurological Institute, and to Don Sanford, may you recover quickly.

- Thank you.

(group laughs) - And with that, we thank you for joining us on "At Issue."

We're going to stay on the subject of medicine next time, because we're going to be talking about the shortage of nurses and what impact that has on our medical centers.

Please join us for that conversation on the next "At Issue."

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