So, I think we should go ahead and get started with our lead-off session. I don't think there's a moderator, so I am just going to start. My name is Austin Sumner, and today I'm going to be talking on work related to concussion, and I feel that this is really an emerging epidemic of cognitive disability. So part of the reason I am giving this talk is I do see a fair amount of concussion, and I find them to be very challenging cases clinically to manage. So let's get into it. This is ideally going to be a talk to give you some strategies on really how to manage concussion, particularly acutely. Most of what I do is chronic concussion. These are often people that have been in this system for over a year. But if we do it right up front, then I think the back end can be better as well. But I want to be heard, too. All right. So just a few quick disclosures and disclaimers. I don't have any actual or potential conflict of interest here. I do run a multidisciplinary concussion team and program. Within my program, I do have vestibular PT, I've got neuro OT, I've got speech-language pathology, I have a neuropsychologist on staff. And so I do run a program, but I don't have any conflicts of interest. I would suggest this talk is given as is. There is no formal warranty made. Concussion is a challenging issue, particularly in the work environment. And I do think that work concussion and sports concussions are really very different entities in many respects, even though the mechanism is the same. The outcomes are often quite different, partly because the motivations are different. All right. So today, what I'm really hoping to go through is we're going to talk a little bit about what concussion is. We're going to talk about mechanism of injury. We're going to talk about both acute and chronic symptoms. We're really going to try and make this focused on treatment, because I hear so often, well, there's nothing you can do to treat concussion. So we're going to give people some ideas for treatment. We're going to talk about return to work. And then we're going to talk about important ideas of misattribution, depression, anxiety, role of neuropsychologic testing, and some other aspects of concussion. So here we go. So most straightforward, concussion is a mild traumatic brain injury. This is where there has been less than 30 minutes of loss of consciousness. There is generally memory should, there should be less than 24 hours of memory loss. Your Glasgow Coma Scale should be intact, or 13 to 15, and your neuroimaging is usually normal. And so everything seems normal, but why do these people not always improve? All right. So post-concussion syndrome, now this is not a term that I really like to use that much. It is out there. For me, within workers' comp, once I have a work-compensable concussion, I just continue to call it concussion, all right? However, post-concussion syndrome is the concept of when symptoms really last, they continue to persist. And it's usually greater than three months. Concussive symptoms, in my experience, can really last years. I see people that continue to complain of their post-traumatic headache. Fifteen percent of individuals with one concussion actually can go on to develop chronic symptoms. And so really getting on it early, I think, is very important. Some of the symptoms that really characterize a post-concussive syndrome is really this noise sensitivity. It's this perceived problem with concentration and memory. It's being irritable. It's being depressed. It's having some anxiety. And I would also put in here, headache is very common, as well as some visual changes are very common in these post-concussive individuals. All right. So our Congress did petition CDC to study brain injury. Regrettably, the study ended in 2014 when trying to find updated trend data. It really ends there because it was a time-limited study. But the trend of head injury with hospitalization, as well as ER visit, is increasing. And really, as we see here from the study, the most common cause of head injury is actually a fall. As we know, a slip, trip, and fall is the leading mechanism of injury, both in and outside of the workplace. However, if you look at specialty centers, maybe it's different. At my location, patient-caused injury is more common than falls. But for concussion, falls continues to be the leading cause. Age is a risk factor. Older age is a risk factor for hospitalization. All right. So mechanisms of injury. For broad classifications, there is the direct contact force. There's the acceleration and deacceleration with no actual force being made to the brain except the motion in the head. There's rotational force, such as your combat fighters and what have you. And then for our military folks, we really have to remember blast forces. Artillery can create concussive forces. It can actually result in symptoms of concussion. All right. So the idea, I mean, the next two diagrams talk about acceleration, deacceleration. So this is when someone's head actually is in motion, and then it strikes something, and it stops being in motion. Really what I want people to take away from this is to look at sort of the areas of the brain that tend to be injured in this type of mechanism of injury. And then you have the blow, counter blow, which is actually where the brain actually will hit the back of the skull too. So the reason I bring this up and is relevant is it can actually, the type of concussion can predict the types of symptoms that we will see. Sort of the lower areas, you know, these contribute to our sleep centers. The frontal portions and some of the lower portions can contribute to our mood. The posterior portions certainly can contribute to our ocular centers. And so there are reasons why people present the way they do following their injury. And so it is important to understand actually the mechanism and what was happened to suspect the areas that might have been affected. So I also find that concussion is, it's helpful to break concussion into subtypes or into actual types, because then we can actually strategize our treatment. So I think on a global scale, there are six primary types of concussion, okay? So this is the cognitive fatigue case. This is the person that's tired, that has the brain fog, has difficulty concentrating, is easily distracted, and then has difficulty learning new stuff. Now there is overlap between these types of concussion, particularly vestibular and ocular. But a vestibular concussion is really a concussion that really has significant dizziness. There's coordination issues, particularly with head and eye movement, and there are balance issues. Ocular type are concussions that predominantly have eye symptoms, including a convergence insufficiency, accommodation insufficiency, or just general movement tracking disorders. Then we have the post-traumatic headache concussion. I personally find this to be one of the more difficult groups of concussion to deal with, because the headache can just persist. It's so hard to measure. And they say, oh, it's so bad, I can't do anything. And then, and it's just, it can be very difficult. And so understanding the background of headache, which we'll get into in a minute, can be really, really important as well. Then there's a cervical, which is really where your concussive symptoms come more from the neck. Your headache is coming from your neck. It's radiating to your head, and if you don't actually treat the cervicogenic component, they're going to persist with their headache. And then there's the anxiety mood group. This also tends to be a difficult group to deal with. But by breaking it into these six subcategories, it helps direct which direction you're going to go with treatment, okay? All right, so there are some important things that I want people to collect at the time of injury. If you are the first or second person evaluating this concussion, there are a few things that I really think need to be in there. One of them is memory of the event. If someone remembers the event, it does imply that it's a less serious head injury. If there is greater amnesia for the event, it does correlate with a more serious head injury. And so we also need to tease apart pre-injury amnesia from post-injury amnesia. Is there really just a complete absence of information that they recall from the event? Or do they really recall events very clearly to the event, then they lose them? Or do they lose the event entirely? So this is an important part of your history that when I see them a year out and they tell me, I don't know if it's really right anymore because memories fade and we don't really know acutely. So documenting acutely the memory of the event I think is very important. Documenting at the time of the injury also a pre-existing history of headache or migraine and what the frequency of those conditions were. So if I see someone after their event and a year later and they're telling me they have headache every single day and then they have the most severe headache that's three times a month, what I want to know is not their recollection of what it was, but their immediate post-event recollection of what their headache history was so that we can really determine is this a departure from that baseline? And have they returned to their baseline? And that is what the critical piece is. People always want to be worse. They always want to attribute everything to their concussion. So a very good description of pre-injury history of headache is very important. Understanding their background of anxiety, depression, and PTSD is important too. Although there's not a direct correlation, it is important information to learn. Also previous concussion. Concussions in many respects are multiplicative or at least cumulative, but it does seem that the more concussions that you have, the worse you, the longer your recovery or to return to your baseline is. And then there's also of course this progression into CTE or chronic traumatic encephalopathy, but we're not talking about that here. Yes? I have a question. Where do we download your slides? I don't know. That's a very good... They ask an AECOM person, but they are available to be downloaded and there is a recording. I'm not entirely sure though. Sorry. Is there an AECOM person here that knows the answer to that? But delighted to answer questions. I'm very sorry not to have the answer to that one. All right. So then what we want to do is we really want to document the acute symptoms someone's having. All right? Are they having a headache acutely? Are they reporting dizziness acutely? Are they having trouble thinking and having difficulty with the memory and concentration acutely? Are they having nausea? Really cluing into the visual things I think is very important. People often do extraocular motions, shine a light, but they won't really understand the eye movements. And so looking for eye movements, which we'll get into in just a minute, take your history for sleep disturbance. Sleep is a major issue with concussion and if we let people not sleep well, they will continue to do poorly. Want to assess signs acutely for mood changes and then impaired balance and coordination. All right. So in terms of physical findings that I really want people to be looking for acutely, the first one is convergence insufficiency. All right? So this is a diagram to help you understand convergence insufficiency. Essentially this is normal looking straight ahead at someone. This next thing is when you've actually asked them to, you brought their finger to their face and you're watching their eyes. Their eyes should come in nicely and they should not have any double vision until about three inches from their face. Now a convergence insufficiency though is when you bring your finger in and someone's watching it, what happens is one of their eyes will pop straight ahead and you'll see it and then it'll pop straight ahead and they will no longer converge. As soon as that eye pops out, then they start reporting their double vision. All right. So you really want to watch that on your eye exam. See what's happening with their convergence. You can treat the convergence if you recognize it. If you don't recognize it, you can't treat it. Okay? So it's a major source of ongoing symptoms and we have to identify it early and it really can persist through the course of the condition, but ideally it does resolve and you can monitor its resolution. All right. So the next one then is accommodation insufficiency. So accommodation insufficiency is when folks with head injury cannot focus in front of them. All right? And so something I really want you to do is have somebody read something for you acutely. Are they able to actually read it? It should be standard print. Are they really struggling to focus on it? Are they getting irritated because they can't read it? This is an important sign of accommodation insufficiency. We want to identify it early so, again, it can be addressed. All right. Again, with eye movements, so we've had someone do their convergence now. We've had them read something for us and we want to actually follow their eye movements in both a horizontal and a vertical plane. And we want to make sure those eye movements are nice and smooth as they follow your finger. So a saccade is a non-smooth eye pursuit. Nystagmus is when you actually have a slow phase and a rapid phase. Generally I don't see nystagmus in my concussion pupils, but I do frequently see saccades. I also, you'll see things like they won't track well. So once you've done their movements in both the horizontal and the vertical plane, then you want to actually do some sudden movements and really encourage them to follow your finger. Are their eyes tracking? Are they actually able to effectively track your finger? Do their eyes go past the point? These are things that we want to identify because they really are a good clinical finding of acute concussion. And often there's just an absence because nobody's asking the question. Nobody's really looking acutely. All right. So the next couple of things I like to do that I think everybody should document is first I will watch somebody walk. I personally find walking is the most sensitive clinical test you can do. I get everybody up and walking. Some people think it's funny, but it tells you so much when someone can get up and walk. After I have them walk, I do a heel-to-toe test. So I ask people to actually put their heel-to-toe and walk down a line on my floor. Once they've started to walk, I then do a cognitive challenge. All right. But what you're looking for on that walk is, first of all, can they do it? Are they able to walk heel-to-toe? Or are they off-stepping? Are they having to hold on to the wall? Do they have to put their hand down or the foot down to balance themselves as they're doing it? All right. If they cannot do it, that would be a positive finding. Now, what's critical with concussion is that when someone's focusing on the heel-to-toe walk, they can usually do it. So really what you need to do to elicit the symptoms is you have to administer a cognitive challenge at the time of doing the heel-to-toe walk. What I like to do is I like to ask you to say the months of the year in reverse order. All right. Everybody can do it frontwards. In reverse order, you have to think about it so it distracts you a little bit from your feet so that you elicit the imbalance. You'll all of a sudden notice that this person was walking fine as they're concentrating on the September next. They will then off-step, and you want to monitor that because that will improve over time. But if you don't do it acutely, when I do it later on, I can't tell if there's a deviation or an improvement. The next thing I do is I do a 30-second single-leg footstand. All right. I want to see how long you can stand on that foot. All right. What they will do is they will put the other foot down for balance. They'll touch the wall, and you want to count how many times they're putting their foot down or touching the wall during their 30 seconds. This is something that improves as their concussion resolves, and so you can use it to follow improvement in clinical symptoms, all right? Now, again, to add a cognitive challenge, I've taken a note from my law enforcement colleagues, and I have people, when they're standing on one foot, to monitor the 30 seconds themselves. So I say, monitor how long 30 seconds is and tell me when you're done, so that they're thinking about that while they're trying to maintain their balance. Often, people totally forget to count, and they have vastly inappropriate estimate of how long things are. All right, I do like to do memory and tests, memory and attention tests. Something I certainly do is the three words, can you remember these? I do it early and late. I also like to do saying numbers backwards. I'm sure everyone here is very smart, but when put under pressure, it can sometimes be hard to do four or five words, you're supposed to, or numbers in reverse order. All right, so what I want to do now is really go through some treatment recommendations. So these are things that I think that we need to look for and treat. We need to identify our sleep disturbances. We need to identify our headaches, our nausea, vomiting, our convergence. I'm going to talk a little bit about the role of rehab services. I'm going to talk about the role of exercise in concussion, talk about pituitary dysfunction, a little bit of cognitive behavioral therapy, and then we'll do some return to work. All right, so sleep disturbance can really prolong concussive symptoms. It is really quite common following concussion, and it can really interfere with recovery. Acceleration, deacceleration trauma frequently affects the anterior and the inferior portions of the brain that can actually contribute to sleep initiation, and we can actually see some biochemical changes in the brain that affect melatonin levels, the hypocretin one, dopamine, serotonin. So these things are all involved in sleep modulation, and so the act of concussion itself can affect sleep, and you got to ask about it. 40 to 65% of people with concussion experience some form of insomnia. It's more likely after repeat TBIs. There does not seem to be a relationship of the insomnia with gender, age, and education, but poor sleep does lead to poor outcomes, and so getting on it early and recognizing it, asking about it. Now, often, acutely, people say, well, you need to rest, you need to rest, but sometimes that resting actually really interferes with your sleep patterns even more. So part of what you want to learn about is you want to learn about their sleep quality and quantity. How are they sleeping? How long are they sleeping? Are they able to get off to sleep, or are they waking up from sleep because it will change how we handle it? Are you waking too early? And the really thing is, are you feeling rested? Now, I think it's important, in the presence of sleep disturbance, to also not take off your thinking cap because other conditions can also be present. I find that obstructive sleep apnea is a fairly common in the prolonged head injury people. Nobody ever wants to get a sleep study, but you get the sleep study and you discover they have sleep apnea, and that is actually the reason why they're not sleeping well. So first, what I try to do with my patients that are struggling with sleeping is just good old sleep hygiene. Only go to bed, same time, wake up, same time. Don't do anything else in your bed besides sleep. Avoid naps, but sleep hygiene first. Then I do have a neuropsychologist on my team, as I said, and so I will send people for behavioral therapy for sleep. My first line medication, if I'm gonna use medications, is melatonin. The reason for that is, as you saw, part of the brain that are injured can affect melatonin levels. It doesn't work for everybody. I will also use the Z drugs. Zolpidine is probably the more common one. If they're really having waking and not staying asleep, I consider the dual-acting medicine that can help keep you asleep. But for the most part, I don't use drugs that much. But there's always amitriptyline, particularly if there's a headache component that seems to be prevalent. Trazodone, I don't ever really use benzodiazepines, but they are at least acutely something you could consider. All right, so post-traumatic headache. As I said early on, it is one of the more difficult aspects of managing concussion is the post-traumatic headache. It is present in something like 90% of cases. It usually begins around seven days after the event or seven days of regaining consciousness. What the literature says is it usually resolves in three months. I find that they often persist and can be very, very difficult. So, CT is indicated when you have abnormal neurologic exam, you have worsening headache. Often if they're chronic and I send them to my neurology colleagues, they will get an MRI just as part of their workup. It commonly resembles migraine. Often treatments that was effective before the injury is effective after the injury as well. It is important to identify the blurred vision, the double vision and the accommodation insufficiency and the dizziness, because these things can always perpetuate. So, indications for treatment, when should you treat is when you're really having three to four headaches days a month. I find people are often reporting daily headaches or very, very frequent headaches. Or what they'll tell me is, well, this is just my baseline headache that I always have and then I have this more severe headache at these times. And so it could be really difficult to sort of tease it out and really understanding someone's pre-injury headache history is critical, but the farther you get away from the injury, the harder it is to learn what that pre-injury headache history was. So please get it early if you can. Treatment is largely empiric. So, there are a number of agents that can be used for headache. I do think trying to identify the type of headache is important. I would also encourage people not to forget about occipital neuralgia, particularly when we have cervicogenic headache, partly because occipital neuralgia tends to respond pretty well, gives you a retro-orbital headache with radiating down the side. And it sometimes responds better to treatment. And so keeping that in mind. But for the most part, you start with your NSAIDs, you do have your triptans, your tricyclic antidepressants. Things that I have been finding helpful more recently are the calcitonin gene related peptide monoclonal antibodies or the monthly injections. I find that particularly, because what I'm mainly dealing with is the chronic, at this point, I mean, they've cycled through the amitriptyline in their NSAIDs already and often they'll do well. Another thing I use is a forehead TENS unit, also called a cephaly device. I'm not promoting that product, that brand name, I swear. But what it is, it is an FDA approved transcutaneous electrical stimulation device that you put on your forehead. And it's got both a prevention and a treatment setting for migraine, but because it's non-invasive, often I find my concussion people don't want to take medicines, the cephaly device can be really very helpful. So the nausea and vomiting, recognizing it, this is more of an acute finding as opposed to a chronic finding. But if someone is having a lot of nausea, addressing it, I will give odosterone under the tongue, I will give promethazine. Sometimes this can be a real difficult issue and I will sometimes send them to my vestibular people for help as well. All right, so when you identify the convergence insufficiency, what should you do? What I do is I send someone to my neuro OT. I've got an OT on my team that specializes in neuro OT and she will work through that vestibular ocular reflex. We'll do all sorts of home exercises, teach people how to follow the doorframe, we'll do a string test where you try and line up the beads. So there's a number of different modalities that you can do. With my folks that are not resolving, we do sometimes send them to neuro optometry, mixed results with neuro optometry. Ophthalmology I have found doesn't do anything very much helpful for me. The optometry will often, often my neuro OT wants them to go to optometry and they'll use prism lenses, they'll do additional exercises to help with the convergence and what have you. It can sometimes be frustrating for me because I see sometimes that these neuro optometrists just endlessly want to see somebody and they're not really improving and then they're getting this set of glasses and this tint and that tint. But I do think that there is a role for them and I'm happy to discuss this afterwards, but I do think there is a role in your complicated eye cases for referral to neuro optometry if you have that in your area. All right, so PT, OT and speech language pathology. I use, I have a vestibular PT and an orthopedic PT. So when there's really a strong vestibular portion, they go to my vestibular PT. When there's really a strong cervicogenic, I'll send them to my orthopedic PT. But one thing that I think is very important for PT to do and I'd like to encourage them to do it early is an exercise test, also called a Buffalo stress test. You do follow a similar to a Bruce protocol on a treadmill, you monitor someone's vital signs. Acutely after concussion, a true concussion demonstrates autonomic instability and you can assess that through an exercise stress test. And it is the, it's really the gold standard, I would say, for objective evidence that someone truly has concussion is when you start exercising them, their vital signs go all nuts. And so my, sometimes it's a little hard on the treadmill depending on your setup to monitor their blood pressure and their pulse, but it is, sometimes they'll just use the verbal report of symptoms of, oh, I'm feeling nauseous now, I have to stop. I don't consider that a positive. I really think you've got to see an aberration in your vital signs to really be a positive stress test. All right. And so I use OT for my neuro and my vestibular cases. My neuro and vestibular OT will work together. I use speech, I send people to speech pathology when they really are seeming to have a cognitive or a memory issue and they're just not functioning well. They're not able to do their shopping because they forget stuff. And so my team will help teach them strategies to really cope in their current situation. All right. So moving along here, I want to talk a little bit about pituitary dysfunction. So as all of you know, the pituitary gland is a small gland that's on the brain. It is encased in bone at the base of the brain. When we shake our head, this little pendulous piece of material can become entrapped in its bony encasing. And when the head moves, the pituitary gland can become injured. So in 15% to 20% of TBI cases, excuse me, so because the pituitary gland can become injured, it is important to look at it. What we do see in head injury is that there is an overlap of chronic hyperpituitaryism, although I'm not willing to say that the head injury caused that. It is a common finding. There are no clear evidence-based guidelines for when you send neuroendocrine labs to assess for pituitary dysfunction, with the exception of if you've had an ICU stay. If you've had an ICU stay, you should do it at that time. Generally, when I do it, it's about 9 to 12 months out from the injury, and someone's not improving. And I'm really just trying to see, is something else going on? So what you should send to assess the pituitary gland is a thyroid-stimulating hormone, a free T4, an insulin-like growth hormone, prolactin, luteinizing hormone, cortisol, follicular stimulating hormone, and an ADM testosterone or an estradiol. So the important thing is that that has to be in the morning for the hormone, and so you got to make sure they do go in the morning to have it done, so that we can see the variation. Now, I have never, in all of the times I've sent neuroendocrine labs, I have never identified a true pituitary dysfunction that I felt was related to the head injury. However, I've discovered a bunch of other conditions that were very helpful. One, I actually discovered someone had an adenoma in their pituitary gland, and their growth hormone was off. And because we caught it so early, we actually saved her tremendous burden. But she'd had a head injury, and so we looked at it. You couldn't really see it on imaging yet, but we found it because of that. I frequently diagnose hypothyroidism when I do this. And I think that primary untreated hypothyroid, particularly in a middle-aged woman, can appear very similar to a middle-aged woman with concussion, meaning that they're tired, they're fatigued. And nobody's primary hypothyroidism happens around that age. And so if you're not considering it, you miss it. And so often what I'll find is hypothyroidism, we treat the hypothyroidism, and the concussion symptoms improve. All right, so return to work. So yes? You mentioned SIDH after head trauma? I have not seen a case of it. I mean, in theory, it is possible. I mean, but these are usually mild cases, mild traumatic brain injury, where I wouldn't anticipate SIDH happening. I have not seen it. You see this? Yes, my wife had it after brain trauma a few years ago. Oh, boy. But she had a serious brain trauma. Yeah. Yeah, OK. And so thank you for sharing. But no, I have not clinically seen that. Now, ideally, again, as I say, I'm often the chronic guy. So I'm seeing them at 9 to 12 months. If SIDH has not been picked up by now, we have a problem. All right, so return to work. I find that return to work is actually very difficult with this patient population. The literature says most people do return to work. I think returning someone to sport is way easier than returning someone to work. This is partly because the motivations are different. Athletes want to go back. Workers don't always, depending on the work that they do. So I wish I had some magic pearls to actually say how you do get people back to work. I do think it's easier to do it early than late, all right? And so I would encourage, if you can, the early normal restoration of activities is really best. Ideally, we do them time limited. But by waiting too long, then we sort of facilitate, I think, the disabled mindset, all right? And then it can be particularly difficult. A group I find very difficult to get back to work are mental health techs. Often, their head injuries are because they've been beaten up. Often, their employer will not accommodate light duty because you need to be around these crazy people. And to take someone like that, who is then fearful of return, is just incredibly difficult. Ultimately, you just got to push them and you say, look, we've got to try. You've got to jump in with two feet, and we see how it goes. I'll take you out again if we need to. All right. So some predictors of delayed return to work are lower education. This is partly because these are often in physically demanding jobs, and that they then can't really do it. I think mental health tech falls into that in particular. And our mental health techs then aren't well cross-trained to other fields. And they get paid pretty well as mental health techs, and so it can be difficult. A predictor of delayed return is nausea and vomiting at initial presentation, multiple body injuries, multi-trauma is, of course, a risk factor, limited job independence. I love this. When someone actually has control over their workday, and they're more autonomous, they're going to be much more successful with their return to work than someone that's being very directive of them. I do think another barrier is really the breakdown in the employer-employee relationship when an employee begins to think that you did this to me, and then you're not being very nice to them, and then you're creating a stressful situation because your work comp carrier isn't being nice to them. Stress does prolong recovery. Trying to limit stress during a post-concussive period is very helpful. But I find fear of re-injury and employer-employee breakdown are a significant risk factor for delayed return to work. All right, so non-predictors. I mean, the evidence is back and forth, I do think. But non-predictors, age isn't supposed to be a predictor. However, I did show, potentially on an earlier slide, where young people tend to recover faster. Female gender is not supposed to be a risk factor for having no previous emotional problems. It's not supposed to being a risk factor. And so I take them one at a time. I find that you have to treat a concussion patient as an individual. And we also have to be very careful about misattribution. All right, so misattribution is the concept of where we erroneously attribute symptoms to your head injury, right? I feel tired. Well, you feel tired because you didn't sleep very well. But is that really because of your head injury? Or I feel like I can't remember everything when I'm going to the grocery store. But you have your child there that's distracting you. And so we just want to be really clear. And particularly, I would say, in the chronic hypothyroid case, that it would be very easy to attribute those symptoms of hypothyroid to concussion. And so I really encourage people not to take off their thinking hats and really continue to say, is this symptom that we're experiencing related to the concussion? Or is there a better explanation? And we always want to keep looking for better explanations, particularly in our chronic cases. So there is also the good old days phenomenon, all right? And this is the concept of where I used to be great. Before this, I did everything. I was a superstar. Everything was great. My life was perfect. And we tend to underestimate our number of brain farts that we had before our injury. And we think that we never had them, where in reality, I still walk into rooms, and I can't remember why I went into that room. And then I go, wait, wait, what? And so when we look at it, there is an underestimate of pre-injury problems and an overestimate of pre-injury health in concussion patients compared to normal population. All right, so depression. 12% to 44% of people following a TBI do experience depression. And so depression is a very, very common symptom. I do want to have people think back to the portions of their brain that are potentially injured in concussion as to an explanation for it. Cognitive compromise, symptoms persisting, can also cause a shaken identity. When we're just uncertain about who we are and what's going on, particularly if we've been out of work for a long time, all of these things can contribute to loss of identity as well as depression. And then the interesting thing is when you're depressed, then you can perpetuate your cognitive symptoms. And this is also true with anxiety. If you're really having a lot of anxiety, then you get anxious about your cognitive symptoms, even though there may not be true objective cognitive symptoms, but your anxiety is such that it's presenting as cognitive or it's much more comfortable for an individual to say, oh, it's my cognitive issues from my head injury as opposed to it's my anxiety. But it does lead to fear avoidance. It does lead to worry in response to environmental stimuli. I think there's also anxiety about re-injury, particularly if there is a high risk of re-injury in your occupation. Then you have the anxiety of just being in the workers' compensation system itself as well as the possibility of losing your job. And so pay attention to early identification of the anxiety with potential referral for cognitive behavioral therapy or some other modality to help. So I want to be within concussion. I think we also need to be very mindful of iatrogenic disability. This is when it's us that create the disability. As health providers, I imagine we're not as big, shouldn't be as guilty of this as other providers potentially. But this iatrogenic disability really comes from these prolonged work removals, this prolonged messaging of, oh, no, you've got to rest, no, you shouldn't look at the computer, no, you shouldn't read, you should just nap. By a provider saying you shouldn't do anything and you should just stay home, this in of itself is a problem because we want early return to normal life activities. And the sooner you do that, the more quickly someone is going to improve. I mean, it's partly why I actually enjoy doing acute concussion over chronic concussion because if you do it acutely, you get on at the right end, then they're fine and they don't get into this negative spiral of just prolonged work removal where then no one's, everyone's afraid to then ultimately give them some work capacity and they say, oh, my head hurts or I can't look at the screen, the lights are too bright, and they come in with their tinted glasses on and they've got side blinders on. So be mindful, push people back to work, push them to their normal activities, and push them to exercise. I will talk about exercise here in a minute, but exercise, everybody that has a concussion should be walking every day starting on day one after their concussion, in my opinion. All right. So I've had the great pleasure of having a very good clinical psychologist who just retired. I do now have a new neuropsychologist that I work with. But I find utilizing a psychologist is very helpful for my chronic concussion patients. There is evidence that early referral for cognitive behavioral therapy, particularly this focus on education around head injury, can be very helpful. It can actually shorten the course of concussion. But really also being supportive and reassuring that people are going to get better, helping them understand what to expect, I find makes a big difference. But you've got to push people along. So let's talk about exercise. So acutely following concussion, you can get some autonomic instability, right? And so if you overexert yourself, it can make you feel bad and it can perpetuate your symptoms. This is why we make our sports athletes stay out of sports for one or two weeks. So however, noting, as I said earlier, we actually want to try and identify those acute symptoms of autonomic dysfunction through a stress test. If someone does really develop symptoms with exertion, part of their treatment then needs to be exerting themselves. But ideally, you only go to about 50% to 70% of your max heart rate, because acutely, you do not want to trigger symptoms, because then you can perpetuate symptoms. Chronically, you need people to habituate to their symptoms. So initially, what I encourage people to do is I say, just walk. You don't do it 15, 20 minutes, fine. But every day, you should be walking. Walk at a comfortable pace. You don't have to push this. You don't want to elicit symptoms. But you do need to establish where that symptom threshold is. And so encourage people to explore it. And they want to push that symptom threshold, but not exceed it, because it's the act of pushing that symptom threshold lets the symptom threshold rise up, and so that they ultimately have less symptoms. There is growing evidence on this. I do really want to emphasize it is something that within everybody's control, they should be doing some sort of cardio exercise. All right, where did I put this? Yes, and so rest seems like it's bad medicine. If someone's still doing bed rest more than just a couple of days out, that's wrong, and we're doing them a disservice. We've got to get them up, got to get them moving, got to get them socializing, I think, too, because it's really associated with social isolation. People forget names. But the reality is, I was going to forget your name anyway, I'm sorry, for when you talk to me later on that. But socialization, I think, is really important for these people. They become socially isolated. That then triggers their anxiety and depression. That then makes it harder. Then they don't have work because their employer won't take light duty, and it can really perpetuate. So encouraging them to exercise every day is important. All right, so the role of neuropsychologic testing. My thinking on neuropsychologic testing is evolving, and that's partly now because I work closely with a neuropsychologist. Neuropsychologic testing is not a perfect test, right? But what we would want to see is, are there inconsistencies? I sometimes find that neuropsychologic testing hurts my patients in their recovery. The reason I say that is because often the neuropsychologist says, there's nothing wrong with them. But they only assess cognitive. They didn't assess whether they're having a post-traumatic stress thing. They're not really assessing whether they're having the anxiety or depression. And so a good neuropsych can be helpful, but sometimes I find they're excessively used by sort of defense to close down a claim. And yes, your testing shows they don't have a cognitive, but they're still clearly struggling. Or maybe it's they've got more of a headache-based than a cognitive-based thing, or they've got more of an ocular-based with headache than they have cognitive. And so the neuropsych testing has mixed results. It doesn't often help me push the care of the case forward, although I do get it. Because it can be helpful, but it can be hurtful. You really have to have a good neuropsychologist that understands their role in the system. Because really, what I try and tell my neuropsychologists is it's really about the goal of where we're getting to. And the goal is always that return to work. And are you helping me get to that goal, or are you hindering me to get to that goal with this testing? Because if you're going to say this person is non-credible, and they don't pass their validity tests, and they're therefore lying, then that really compromises the treating relationship, and it's hard to then move that case forward. And if I send you to that guy, and that guy says that, and then it's reflective of me, well, you don't believe me, what's going on? I'm like, well, we still got to get to the goal of getting you back to work. So I do think that there is a role. Generally when I do it, I do it when I'm trying to get someone back to work to really see if they have the capacity to do it, and to see if there are any of the validation tests are inaccurate. Because if it's not a valid study, it limits your conclusions, but that's also informative if someone doesn't meet the validity scales for the testing. All right. A cognitive functional capacity evaluation, I don't know if folks are using this. This is a functional capacity evaluation that also has a cognitive component. They will do some assembly, they have to follow directions. When I've had someone that's been out of work for a long time, that's really continuing to report lots of symptoms and very limited, I will order a cognitive functional capacity, particularly if they're fighting me on going back to work. They do have mixed utility. Again, they are a one-day snapshot of how somebody is. They need to be interpreted with care. You need to have confidence in your FCE person, because they, I mean, again, you order these things, then you're left to interpret the result. But I do think that they can be helpful to really see whether someone can follow instructions and really get a sense of what their capacity is, or whether they're self-limiting, they're complaining of headache, oh, they can't do it. Because that person is then going to be really difficult to get back to work. But at least then you have an objective, well, as close as you can come to an objective indicator is what someone can functionally do. All right. So in conclusion, a little brain rest is OK, but early return to function, early return to exercise. And I think for return to work, what I often do is I do time return. So I will say full duty for two hours, full duty for three hours, full duty for four hours, and titrate them up that way to build their tolerance. Treat the insomnia early. Identify it, ask about it, and treat it. Treat the headache. Try and get on top of the headache early, because these are two things that are going to really create problems. Again, encourage the exercise, and really pay attention acutely after the injury to see how many of these things that you can identify so that we can really get people appropriately treated early on. So with that, I'd love to open it up to questions. The short answer is I don't use the term malingering and because for me the ultimate goal is return to work, I try and stay on that goal. For me, my goal is not just to get someone's claim closed, because I personally think the ultimate outcome of treatment success in workers' comp is the successful return to work, and if you haven't done that, they should still have an open claim, unless they're permanently and totally disabled. But in terms of red flags, I would say somebody who's very angry, somebody that reports a headache that's just, you're telling me this headache is this bad, I think someone that's had multi-trauma are predictors, I think low education, and then I think sort of the perceived level of cognitive disability that somebody has is often a predictor of them being in the system longer. But I don't use malingering, I understand even my neuropsychologist shouldn't use that either. Yes, back here. Sorry, then we'll move over. I think that that's a wonderful suggestion. I actually proposed it to my local psychiatric care hospital, particularly in professions with a high risk of head injury. I think doing something like a SCAT test, what they do for sports, or doing some sort of baseline balance testing and some baseline cognitive testing is a wonderful idea because then you can actually measure departure from that and you can measure return to that. I think moving, they've done it successfully in the sports environment, and I think that we could do that in high risk occupations. I think there's merit to it. My state psychiatric hospital didn't want to go that way. So we've got the guy in the back of the door first. Thank you. Well, secondary gains do clearly play a role here. I sometimes question the intent of the secondary gain in workers' comp because, you know, being out on workers' comp is not great. But to come to, and I don't see it as a reward necessarily, having your total life taken disrupted like that. But I perceive that getting paid to not work, some people might find that as a secondary gain. But to come back to the first one, where I don't, the frequency of cases I don't have objective findings. I think I need to differentiate that question between acute and chronic. But by the time they hit a chronic stage when I'm seeing them, generally there's, the findings that I'll see, are they still having convergence insufficiency and they'll still have some saccades? Those tend to be the most common sort of objective findings I see, as well as the balance stuff. The acute autonomic dysfunction should resolve within six weeks, and so you should no longer see the vital sign abnormalities that you would see when you stress someone after about six weeks. So but chronically, often they have nothing except telling you, I can't think and I've got this terrible headache and I can't see, and there are no great objective findings. But if you look very carefully, I think even on those, you will actually find they have some subtle eye findings. And they probably still, may still have some subtle balance issues. But if you don't look for them, you're not going to find them at all. And so if you just shine your light in somebody's eyes and they pull away or whatever, that's not actually looking for the finding that would actually, and assessing somebody's cranial nerves, I mean, you're not necessarily, if you don't look for the right clinical findings, you're not going to find them. And I think most cases, people just aren't looking for the right things is why they don't identify them. So I think if you look carefully, you do see them particularly in an acute case, and you really shouldn't call a concussion if you don't, in my opinion, then you just called a head injury or a scalp wound or something. So I've totally lost track of order. We'll come over here. So for the gradual return to work, if you have mainly computer workers, what kind of regimen do you recommend for like screen breaks, brainless, that sort of thing? Yes, I recommend them. So I think that screen work is incredibly difficult, particularly for someone that has predominantly ocular findings. So some things that I try and do is I get anti-glare glasses for them or an anti-glare screen on their computer. I will get blue wavelength blocking glasses for them. And I do encourage rest breaks. But often, if you're struggling with the computer, it's really hard to get those people back. It's just really hard. If they have to be on the computer all day, then it's just hard. And so I would say I will let someone do it for an hour, and then I'll give them a 10 minute break. And more what I want to try and do is just get them in the door initially so that they can build their confidence and realize that they can do it, because sometimes it's the anxiety and frustration. And then it's the pressure to produce. And then you're just adding the stress on it. And then you add that stress, and then it's like, ah, I can't, I don't want to think anymore. So my advice is you really listen to the person. You don't have a cookie cutter approach to it, but you do nudge them on. And I often look at it as a negotiation, frankly. I will throw out one number. How about six hours? And they throw out, how about two hours? And then we come to some sort of accord where I just want to get them to throw out something so that I can agree to it. Oh, that sounds great. We'll do it that way. Sure. Because once you've gotten their buy-in, then you actually can get it started. But until you actually can get that first jump with two feet in, it's really hard. Yes, over here. Yeah. I have a question. You had referenced in the difficulties you had with invalid results in neuropsychological trials. So, a good neuropsychologic test should be able to pick up a cognitive dysfunction. And ideally, it can point to the type. Is it a vascular type? Is it sort of an Alzheimer's type? Is it a type that would be consistent with a head injury? And so, meaningful testing can show that you actually are functioning at a level that's different than would be expected. Ideally, if they do the right selection of testing, you should be able to also pick up things like anxiety, depression, PTSD, and what have you. A failing I find with neuropsychologists is when I see somebody, I take my history, I do my physical exam, and then I start my medical decision making right then and there, right? I start suspecting what I think is going on, and then I do tests to specifically test for what I think is going on to confirm my clinical suspicion. In neuropsychology, I find they do do their preemptory interview, but they don't always come up with their differential diagnosis. And so, if they don't have an appropriate differential diagnosis, then they don't select the right battery of tests, then they're not going to actually answer the question you want to ask, have answered. Because, again, as I said, if they don't have a cognitive issue, but they have screaming anxiety and their anxiety is what's causing their perception of their cognitive issue, but the neuropsychologist didn't really do a screening battery for anxiety, they only did it for cognitive, it doesn't help me, right? Because it didn't really answer the right question, because the neuropsychologist didn't take the time to suspect the right list of answers. And so, I'm a firm believer in differential diagnosis, just to reminisce a little bit, when I went to medical school, my mom gave me a book of doctor's rules, and one of the rules in there was, if you cannot make a history based on, excuse me, if you cannot make a diagnosis based on your first history, take a second history. If you can't make a diagnosis based on your second history, take a third history. If you cannot make a diagnosis based on your third history, refer the patient to someone who can. And so, I try to employ that, and so, with my new neuropsychologist, I'm trying to get him to really make sure that he is selecting the right tests, so that we do get the necessary information to actually move the case forward, getting closer to that return to work. Yes, no, I mean, if they're invalid, they're invalid, if someone doesn't meet the validity scales, and it's not a valid test, and you cannot believe the conclusions, and then, you can suggest that maybe they're malingering, or they're intentionally flubbing the test, and that's often what the conclusions will be, that someone intentionally tried to make their scores worse. And so then, the question is, well, how do you, if you're the treating person, how do you help move that case down the road? If you're the forensic person, you just say, oh, they're at end, and forget about them. When you're the treating person, you've got to sort of pick out the things that are worthwhile. Yes, sorry, we've got so many questions. I'm like concussion people. So for full disclosure, I am really clear in the sandbox I am comfortable staying in. All right? And so I do not make diagnoses of anxiety, depression, or PTSD, or adjustment disorder. I clinically suspect it, or I have a high clinical suspicion that this person is having symptoms at least. And then because I have the great fortune of working with a psychologist, I will send them to my psychologist to make that diagnosis. Because I really don't want to be deposed and have someone say, well, how are you qualified to diagnose this PTSD? And I would have to say, well, I'm an internist and an med doc, and I am not qualified. And so next. Next question. Right? For me, it's just what I prefer to do is that I try not to make that diagnosis. And I try to encourage my peers, particularly the forensic ones, if they're not really qualified, they shouldn't be making the diagnosis either, especially if it's to try and shift, distract you with some clouds and mirrors or smoke and mirrors to really away from what's going on. And so I think we have to be very careful with those diagnoses. I think we have to let the qualified people make them. So I've got a guy in the very back here. Sorry, Ben, we'll go over. Do you see imaging? Of what? In terms of the... I personally find imaging serves a very small role in concussion. I would do... The times I would do injury imaging, excuse me, is on my chronic cases where a headache is not resolving and I really need to rule it out to make sure there's nothing else. I think acutely, I think the indications are really if you're having some focal neurologic deficit or if you're just in the ER and it's busy and you're just going to get it so that it's done. But overall, in acute concussion, imaging does not play a prominent role because as with the initial definition, you see it's usually normal. Yes? You mentioned a lot of overlap between mental health disorders as well as hypopituitary disorders. So if you find those, whether it's diagnosed by you or somebody you refer the patient to, do you find that those are typically covered under work response? I don't think that the pituitary injury or the association with chronic hypothyroid is related to the head injury. I think they cohabitate and have similar symptoms. So that person, I prefer to direct them back to their primary. I will make the diagnosis. I would strongly advise that they begin Synthroid, but so as to not confuse things with worker's comp, I do send them back. For anxiety depression kind of thing, if I really think that that was caused by or aggravated by the head injury, yes, and I would want that to be compensated in the worker's compensation system and the cognitive therapy that they may need should also be covered, as should the neuropsych testing. And so yes, if it arose out of the injury and we have a mechanism for why our brain chemistry would potentially become altered, then yes, it should be part of the claim in my opinion. Yes, I got to get this gentleman here. Sorry. Spectacular talk. Oh, thank you. Well, gladly we'll get you everywhere. I mean, concussion is hard. It's hard. But I do think this argues that we need more and better OCMED training programs. I think we need more occupational medicine people doing clinical medicine so that we can, I think our specialty is very important and we just need more of us, and I think having solid clinical ability is really very important, because I do think that's what distinguishes folks is how good your clinical stuff is. Because if you're utilization review, but you know not a good clinician, then how can you really do utilization review? So that's my thing I ask myself when I get that call. All right. I think that we're out of time here so that we don't, I'm happy to answer questions afterwards, but thank you all very much.

concussions

work-related setting

early intervention

cognitive disabilities

post-concussion syndrome

sleep disturbances

headaches

anxiety

depression

multidisciplinary teams