Ask Us Anything About… Concussions

Description – The video begins inside a Penn State Penn State Health Milton S. Hershey Medical Center conference room. Two individuals are standing next to each other in front of a large screen showcasing the Penn State Health, Primary Care Sports Medicine program website. From left to right is, Dr. Matt Silvis and Scott Gilbert.

Scott Gilbert  – From Penn State Health welcome to Ask Us Anything About. . . Concussions. I’m Scott Gilbert. In recent years there’s been a lot of talk about concussion. The word concussion protocols heard on sports sidelines from professional sports to amateur sports and maybe to your children’s sports teams. Here today to tell us a bit more about concussions and their treatment, their diagnosis is Dr. Matt Silvis. He is Medical Director of Primary Care Sports Medicine at Penn State health. Thanks for being here today Dr. Silvis. Appreciate it. Let’s start with just the very basics about how a concussion is defined. Because not just any bump on the head is a concussion and not every traumatic brain injury is one. But tell us about that.

Dr. Matt Silvis – So a concussion is transient alteration of brain function after head trauma. So, transient is the key feature of this. The vast majority of concussions resolve uneventfully over time without any type of medical intervention. One other key feature is a concussion can be caused by both a direct blow to the head. So, if a football player is struck from the side — head-to-head collision, that can cause a concussion. But they can also be caused from indirect hits. So you’re playing soccer, you twist suddenly, your head spins or rotates suddenly, that allows jostling to occur inside your skull. Your brain can shift because it’s not fixed. And that’s enough to cause a concussion as well. So, both direct and indirect blows can lead to this injury.

Scott Gilbert  – Yes. Tell me a bit more about what’s happening inside your head during a concussion. You say the brain is actually moving because, like you say, it’s not in a fixed position.

Dr. Matt Silvis – Yeah. The brain is not seat-belted inside the cranium. So, it actually is a loose gelatinous structure. It’s fixed to the spinal cord which goes down a person’s back. But it allows for movement inside the brain. It’s surrounded by cerebral spinal fluid to allow for cushioning. We also try to remember or remind patients that the outside of the skull is smooth. The inside of the skull bone is bumpy. So, you take this gelatinous structure and you shake it across all those bumps on the inside of the cranium; you can imagine the forces that puts on the brain tissue that can lead to this damage.

Scott Gilbert  – Dr. Mathew Silvis is Medical Director of Primary Care Sports Medicine here at Penn State Health. And we welcome your questions for him about concussions. This is Ask Us Anything About. . . Concussions. Feel free to leave a comment in this Facebook post whether you’re watching it live or on playback. We’ll make sure we get an answer for you. What are some of the most common types of concussions? Because, let’s face it, in the media sometimes we would be led to believe the football is the only cause. In fact, there are many other sports-type causes and even non-sports causes.

Dr. Matt Silvis – Absolutely. So, we see concussions from all different types of sports. I’ve even seen them in cross-country where a runner was running by a flag pole marker and it snapped back and hit them in the head. So, you really can see a concussion in any type of sport. Certain sports are a higher risk. The number one risk for concussion actually for collegiate sports is women’s ice hockey. And I think that’s an important I think for us to remember. It’s actually not football. And men’s soccer, women’s soccer, men’s basketball, women’s basketball, actually have risks pretty close to American football when you look at high school athletes. So again, it’s can be common throughout any type of contact sport. And any sport that both boys and girls play together — both play. So, if you look at men’s basketball and compare that to women’s basketball. Girls have about 3 to 4 times the risk of boys when it comes to a concussion in a sport.

Scott Gilbert  – Do we know why that is?

Dr. Matt Silvis – We can — the idea is that girls neck strength tends not to mature as fast as a boy’s. And that neck strength can help reduce some of the torsion — neck torsion that occurs whenever you’re struck. And so, that’s one of the thoughts. Girls are more honest than boys with their symptoms. So, we think that reporting is different amongst girls. And that has actually been studied. And then the way girls land from a height. So, girls tend to land from a height whenever they jump with their knees locked. And boys tend to land with their knees bent. So, you’re more likely to fall and hit your head if your knees are locked whenever you land from a height.

Scott Gilbert  – That issue you just referred to is a big one. That is; of reporting your symptoms. Of being honest with a coach or the coach noticing things. Have we made progress with that in the last say decade or so with these concussion protocols they’ve gone in and has that resulted in more players sitting out when they should versus going back in with a concussion?

Dr. Matt Silvis – Absolutely. I think that’s been a fundamental shift. And so, we talk a lot about how many more concussions we’re seeing today then we were 10, 15, 20 years ago. Part of that’s because we changed the definition. Historically we thought you had to lose consciousness to have a concussion. When we made that definition change we were missing a lot of concussions. The vast majority don’t have loss of consciousness. The other thing is by education, kids are more willing now, and adults, than ever before to actually say that they’ve had a concussion or say that they have symptoms and they’re worried about a concussion. One thing I’ve noticed at the high school level, is seeing teammates pull teammates out of a game to have him evaluated by the medical staff because they’re concerned whether teammates may have a concussion. That to me is a real win. If we get kids looking out for other kids and taking it seriously, that really helps us identify these students, these athletes, quickly so we can take appropriate steps so that they don’t have any significant long-term sequela.

Scott Gilbert  – And some of the old thinking might have been, “They can just play through it and then we’ll take care of it later.” What’s the danger in that kind of thinking?

Dr. Matt Silvis – So, the biggest concern is very rare. And that’s a condition called second-impact syndrome. This is when an athlete that has a concussion continues to play in the game. They’re struck a second time. And for whatever reason, that second hit causes brain swelling. And that causes the brain to actual herniate into the spinal cord which is lethal. That’s very, very rare. What’s much more common to occur if you play with a concussion and you hit another time, is that your symptoms last a lot longer. You end up being a patient in a concussion program like ours for a long time. Much longer than you’d like. And the symptoms can be more severe. So that’s the main reason. We really want kids to be identified early and not play through these concussions because they just take a lot longer to get better and they have much more intrusive symptoms into their life if they try to play through.

Scott Gilbert  – You’re watching Ask Us Anything About. . . Concussions from Penn State Health. Dr. Matt Silvis is Medical Director of Primary Care Sports Medicine. We welcome your questions. Put them in the comment field below this Facebook post. And we’ll make sure we get you some answers. You are a team physician for the Hershey Bears. So, let’s use that as kind of an example. That if there’s a thought that a player on the ice might have sustained a concussion, what do you as the physician do to diagnose it? How can you tell? And is there a way to tell definitively?

Dr. Matt Silvis – So, we actually — we bring that athlete into the locker room. The first step is you get the athlete off the playing field whether it’s ice hockey or any other sport. We bring them back to the locker room where it’s quiet. We try to let some of the emotion of what just occurred pass. And then we just — we interview the athlete. So, we get through a variety of concussion symptoms to find out if they’re experiencing that; any of those symptoms. And to what degree? We put them through some memory tests. Do a physical examination to figure out — make sure that their neurological status is okay. And then through that information and knowing the player, we often times can make a decision whether or not they suffered a concussion. Not every head injury in any sport is a concussion. And so, if you get hit with a pop in the jaw, it’s going to hurt where you were struck. And you may have a headache or head pain in the location where you were hit. That doesn’t necessarily mean that you have a concussion. And so, it’s our job to try to figure out who do we think has a concussion. And we always err on the side of caution without just having a blanket statement that any type of collision leads automatically to a diagnosis of concussion. So, we really are very thoughtful about that diagnosis. There are different systems in place that are available to athletic trainers and doctors to make those decisions. Something that the viewers may want to look at online is something called the SCAT 5 card — S, C, A, T, 5 card. And it’s really an assessment tool that we have available to us that we can walk an athlete through to help us make the decision whether they had a concussion or not.

Scott Gilbert  – As you mentioned, the cognitive symptoms. I know there are also things like mood, can affect your sleep. So, there are a variety of things that you look at; right?

Dr. Matt Silvis – Yeah. It really affects all different types of domains. So, we kind of lump them into four categories; the symptoms of concussion. Physical symptoms like headache, dizziness, light sensitivity, sound sensitivity, nausea. You could have cognitive symptoms like you just referred to: poor memory, decreased focus and concentration, confusion. You can have emotional symptoms: depression, anxiety, PTSD. And then the last category we say is sleep. So, sleep is very important for concussion recovery. Some athletes sleep too much and some don’t get enough. And so, we kind of put sleep in its own category as another important symptom that you can have after a concussion.

Scott Gilbert  – Is that one of those myths we used to hear that if you think your child has a concussion — oh, my gosh! Don’t let them go to bed. That’s bad.

Dr. Matt Silvis – Yeah, absolutely. So, we want our concussed athletes or even if you’re not an athlete and you have a concussion, we want you to be able to sleep. The big thing is you want to make sure you have an appropriate medical evaluation before you make that decision. So for me; if I am concerned about an athlete going to sleep, that’s probably an athlete that may have needed to go to the emergency department to be further evaluated. If I’m not concerned about them going to sleep that night, I really encourage parents to let their child sleep the night. They don’t need to wake them up and shine a bright light in their eyes every hour or two to check on them. They really actually need that sleep. It’s actually helpful for healing of the brain after a concussion.

Scott Gilbert  – You’re watching Ask Us Anything About. . . Concussions from Penn State Health. This is Dr. Matt Silvis. He’s Medical Director of Primary Care Sports Medicine. We welcome your questions for him. Again, whether you’re watching this video live or even on playback — as so many people do — please add your questions in the comment field and we’ll be sure to get you an answer. You know, we were talking a bit about the various symptoms of a concussion. What about treatment? When do you know — let’s say a parent or a coach has, you know, really suspects a child has concussion. When is it safe to assume that you can, kind of, treat that yourself versus seeking medical help?

Dr. Matt Silvis – So, in the acute period after a concussion — the first few days — most kids actually do quite well. So, they may have a headache or something like that initially. Those symptoms tend to get better. If they’re an athlete and they’re going to back to a sport, they should ultimately go through a return-to-play process. And that can be guided through their regular doctor or certainly at a program like ours here at Penn State with the help of an athletic trainer. You get concerned about kids that don’t get better within the first few days after a concussion. So, most kids would get better within that first week. If they’re not getting better, certainly if they’re getting worse in that timespan, it really requires a medical evaluation. What we do at that point, is we do a complete intake and evaluation. And we determine what areas that student athlete may have concerns. Often times we’ll try to lighten their academic load. We put in school accommodations to try to make it better for them to be able to participate in school. There was an old idea that we do cocoon therapy. Which meant that you had your child sit on a couch, dark room, no reading, no video games, no cell phones, no talking to their girlfriend or boyfriend. There really is nothing left for that child to do. And we know that that’s counterproductive. It leads to a lot of emotional issues in kids. So, we’re not recommending that you become that restrictive. We just take away sporting activities and exertion initially. Try to make school better for the athlete whenever they go back in their school environment. We really don’t consider medications for concussion until they’ve been symptomatic for typically on the order of one month.

Scott Gilbert  – Again, you’re watching Ask Us Anything About. . . Concussions from Penn State Health. Dr. Silvis just referred to the Penn State Health Concussion Program. And the phone number for that we’ll put that in the comment field. But that number if you like it is: 717-531-6824. That’s 717-531-6824. Now, Dr. Silvis, concussions are in the news all the time. In fact, just last month in July, there was report noting that chronic traumatic encephalopathy, known as CTE, was found in 99% of deceased NFL players’ brains in one particular study conducted out of Harvard. I believe it was. This is a study in the Journal of the American Medical Association. So, it got a lot of attention. But it’s not considered settled at science; is it?

Dr. Matt Silvis – It absolutely isn’t. So, we’re definitely concerned about the long-term effects of repetitive concussion. So, everybody shares that concern. The — and while the researchers at Harvard are attempting to answer questions about CTE and what it means, there are still a lot of gaps in our understanding. So, these athletes voluntarily donated their brains to a brain bank at Harvard where they were analyzed. So, we don’t have any idea how many people are walking around with these changes that didn’t have a concussion history or they didn’t necessarily have symptoms when they were living. You can have these brain changes and actually die of natural causes and not have any symptoms related to them. We also don’t know the effects of drug and alcohol use, anabolic steroids, chronic narcotic pain medications on brain health. And that is definitely a confounder when you look at NFL football. So, where there’s a lot of questions that we don’t have an answer when it comes to CTE. I think what they’re doing at Harvard to address some of these questions is definitely laudable. But we certainly have a lot of questions and it does not settle at science at this point in time.

Scott Gilbert  – Right. And as with any study, more work is needed because there are limitations there.

Dr. Matt Silvis – Absolutely. So — and I know they had more planned work at Harvard. I know a lot of other institutions are looking at that including here at Penn State. Just looking at: what are the potential long-term sequela of repetitive concussion? I share concerns about what’s happening to NFL football players. But the reality is, I’m very concerned about youth sports. We have a lot more youth actually participating then we have people that are participating at the NFL level. So, they get a lot of attention as adults. But we share the same concern when it comes to repetitive concussion. What that means long-term for a young athlete. And so, there’s a lot of work to be done when it comes to concussion and understanding the long-term significance of, especially, repeat concussion.

Scott Gilbert  – So, one option is to keep your child on the sideline and never let them play sports. But as I know, Dr. Robert Harbaugh — he’s our Chair of neurosurgery — is fond of pointing out; that is swinging the pendulum in another direction and possibly feeding into another major issue facing youth today. And that is childhood obesity.

Dr. Matt Silvis – Absolutely.

Scott Gilbert  – So, I mean, really parents need to balance the risks of all these factors; don’t they?

Dr. Matt Silvis – That’s absolute true. You know, we’re big exercise proponents. None of these sports in and of themselves are injury free. There is no injury-free sport. But it’s far better to have your child active, engaged in sports. I do think it’s a false notion to think that if you take your child out of American football and put them into boys’ soccer, that you’re really sparing them concussion risk. I hear that a lot. We see an awful lot of concussions with boys’ soccer. And that’s been definitely shown. So, there’s also no way to protect from concussion uniformly. So, you can have the best helmet, the best mouth guard, the most neck strength; but there’s no way to 100% protect against this injury. And that’s also hard for parents to understand. But not being physically active; yeah, is far worse. There is one study that Dr. Harbaugh loves to point out. And it was a really cool study. It was done through Mayo Clinic where they looked at a 50-year outcome comparing the football team and the band at a high school. And they show that there was no increased risk in the football players compared to the band members in terms of long-term brain health. And that, I think, was really actually a very valuable study for us because that was certainly at a time where concussions were not something we were identifying. You were just playing through those injuries.

Scott Gilbert  – I know. He likes to say, you know — not to talk too much about Dr. Harbaugh. But in case he’s watching. I know he used to talk about how the risk of playing the clarinet can be pretty high up there as opposed to playing certain football positions. So yeah. I remember that. You talked a little bit about how — how long it takes for most concussions to resolve. But what are some general benchmarks on that? When should somebody who thinks that their child’s symptoms will resolve and they haven’t — when should they become concerned?

Dr. Matt Silvis – So, it’s a really unique injury. So, we think of kids being in general more resilient than adults. So, kids tend to get better from everything faster than an adult with the same condition. Think about the flu in your household. Kids tend to bounce back faster than an adult does. Concussion’s opposite. So, the younger the child; the longer they take to get better. So in adults, we expect most adult patients to be better within 7 to 10 days. And that’s true for collegiate athletes as well. And even for senior high athletes. It’s surprising to see senior high kids still symptomatic after two weeks. The younger you get, the more likely you’re symptomatic. So, if you have a young child — middle school or under — we expect them to be better by one month. If they’re not better by one month, then that might require some specialized expertise in dealing with their concussion symptoms and how you might be able to help aid in their recovery. You naturally recover over time on your own. But we’re able to try to help lighten the load. And sometimes use specific medications for certain symptoms to try to help a student athlete get through that natural concussion recovery that we want them to go through. So, two weeks for an adult, senior high kid. Middle school and under, you’re looking at a longer period of time typically up to a month is considered within the normal range.

Scott Gilbert  – You’re watching Ask Us Anything About. . . Concussions from Penn State Health. Dr. Matt Silvis is Medical Director of Primary Care Sports Medicine and providing answers to our questions and to your questions. Here’s one from Amanda. She’s asking, “Do you recommend that youth athletes get a baseline evaluation?”

Dr. Matt Silvis – So, I — baseline evaluations were very popular 5 to 10 years ago. At current State, baseline evaluations are not considered to be essential prior to a sport season. And typically, most schools in this area provide the impact test which is a neurocognitive computerized test. That may be what Amanda is referring to. You typically get that screen done as a baseline in 9th and 11th grade. You can’t — you can’t just do it in 9th grade alone because as a brain develops, you might do better on that test as you get more brain maturity. It’s been thought that it’s — there’s no better way after a concussion recovery than to compare back to your baseline since you are your own control. However, we found that that actually doesn’t really add much to the mix. And so, if you wait and get that neurocognitive test done at the end of your concussion recovery, that actually is okay. So, if your school has it; great. If you don’t have it in your school district or a way to have that done, it’s not essential for appropriate concussion management.

Scott Gilbert  – Yeah. So, yet another way in which the thinking is evolving around concussions.

Dr. Matt Silvis – Yeah, absolutely.

Scott Gilbert  – And so, this is something where we still don’t know everything about this; do we?

Dr. Matt Silvis – That’s totally true. So, we’re — we learn every, every — I give talks on concussion pretty frequently in the region. And I have to update my comments every time I give the talk because the literature is changing constantly. And what we thought was clear-cut in the past, has been challenged over time. And that’s what we all should want. We want to follow the science on this so that we know we’re doing the best that we can for our kids and our athletes.

Scott Gilbert  – Right. Especially if you’re a parent or if you’re a coach. Even — I mean, adults get concussions too; of course. And I even — I’ve heard that seniors are a risk of getting concussions as well. Especially, say, those on blood thinners. And I’ve even seen it reported that if a senior who’s on blood thinners falls, bumps their head, they should definitely seek medical attention. Can you talk about the risk in that population?

Dr. Matt Silvis – Right. So, certainly fall risk the older a person gets becomes more of an issue. Your sense of balance changes with the aging process. So, especially elderly folks, it becomes much more of a concern. When you’re on blood thinner; you add in the variable that whenever you fall, you may not just have a concussion, you can actually get a brain bleed. And that is something you don’t want to miss. And so in that particular circumstance, it’s probably most prudent to make sure you’re evaluated immediately if you’re on blood thinner and you fall and hit your head to make sure that you don’t have a brain bleed. That would definitely — that can be a life-threatening situation that you certainly don’t want to have a delayed diagnosis with.

Scott Gilbert  – Alright. Dr. Matthew Silvis. He’s Medical Director at Primary Care Sports Medicine at Penn State Health. Thanks a lot for your time and the great information today. We appreciate it.

Dr. Matt Silvis – Thanks for having me.

Scott Gilbert  – And we appreciate your questions here. Feel free to add your questions. Again, even if you’re watching this video on playback. And if you do want more information about the Penn State Health concussion program that phone number is 717-531-6824. That’s 717-531-6824. Thanks so much for watching Ask Us Anything About. . . Concussions from Penn State Health.