The Importance of Early Concussion Evaluation For Athlete Recovery with Dr. Brandon Eck, D.O. and PT, AT Michael Keenan [PART 1]
Season 3, Episode 7 | Podcast #43
Today, we will be discussing everything concussions with two of the best in the business: Vestibular certified Physical Therapist and Athletic Trainer - Mike Keenan, as well as Dr. Brandon Eck. Mike was on the podcast before to discuss concussions as was Dr. Eck in which we discussed his experience and roles in sports medicine specifically endurance athletes and the services he provides.
Dr. Brandon Eck
Let’s get into this Concussion Roundtable discussion. Dr. Brandon Eck is a sports medicine physician that earned his undergraduate degree at Villanova University where he ran track and field for the Wildcats. He then earned his medical degree at the Philadelphia College of Osteopathic Medicine. He completed his residency in family medicine. He also completed a sports medicine fellowship in Blacksburg, VA in which he served as a team physician to Virginia Tech and Radford University. Dr. Eck has extensive experience in treating athletes of many disciplines and is dedicated to the treatment of both athletes and non-athletes with orthopedic injuries, including sports injuries, overuse injuries, fracture care, and concussions. He is one of the Team physicians for U.S. Ski and Snowboard.
Check out our previous episode with Dr.Eck
Michael Keenan
Michael Keenan is a dual credentialed Physical Therapist and Athletic Trainer, Mike has been working in Sports Medicine and Rehabilitation since 2008. During this time, Mike has worked with patients of all ages and physical abilities from pediatrics to professional sports while with the Pittsburgh Pirates Baseball Organization. He specializes in vestibular and concussion-based treatment. I have had the pleasure of working with Mike Keenan over the past several years. I can say with the utmost confidence that he is the best I’ve seen at treating concussions – whether the patient was in an automobile accident, work-related accident, or as a result of an athletic trauma or injury.
Check out our previous episode with Mike Keenan
In this episode we cover:
3:30: What is a concussion?
A concussion is a Physical and Physiological injury to the brain that occurs when the brain moves inside of the skull and slams the wall of the skull and there's a reciprocal slowing (or swelling) of the tissue that can cause physical damage along with chemical and physiological changes in the brain.
4:40 What is the difference between a traumatic brain injury (TBI) and a concussion?
A concussion is a mild traumatic brain injury
5:15 what the most important thing Dr. Eck and Keenan have learned about concussions since their fellowships and training.
The number one thing is being able to recognize what is a concussion and the symptoms to look out for when evaluating for one.
6:00 Keenan is in the unique position of seeing concussions at the beginning and the end.
The beginning as an athletic trainer on the field and at the end as a physical therapist treating and facilitating recovery of a concussion after lengthy clinical evaluation.
7:35 How are concussions diagnosed and how have these practices evolved?
No matter the setting, evaluation is always based on a clinical exam.
Usually starts with speculation of a head injury from the athlete themselves, a coach, a parent, or an athletic trainer.
9:30 What does the Sideline concussion assessment tool - SCAT 5 test consist of?
The SCAT 5 consists of checking memory, balance, eye movement, physical evaluation of the head and neck.
This is the evaluation done in the blue tents or in the locker rooms in the NFL for example.
10:30 How soon should the SCAT 5 be administered?
This test/ evaluation should ideally be administered within minutes of impact and then assessed, but unfortunately can often go days unreported and unevaluated.
13:00 How often are we missing concussions or misdiagnosing with the SCAT 5?
14:00 Why serial reevaluation is necessary. If you suspect a head injury and results are unclear at first, do a reevaluation 30 minutes later then again an hour later, for example.
This is true across levels of sports, for example, the NFL now has spotters who serve as a second set of eyes during a concussion evaluation.
Dr.Eck served as a spotter for a game back in 2017.
16:00 What does concussion diagnosis look like in the clinical setting after the initial evaluation on the field?
When a patient first arrives, Dr.Eck assumes it is a head injury until proven otherwise.
The evaluation begins with the symptom evaluation that is in the SCAT 5 again to compare to the initial injury and determine how the patient is improving or not improving.
Then Dr.Eck determines what kind of symptoms is the patient having as a result of the concussion, for example, are they having light sensitivity, sleep issues, headaches, psychological changes, memory loss, etc.
Services and accommodations are then determined.
19:45 How does a physician dictate what the appropriate next steps are?
First, it depends on how long it has been since the initial injury and how they are progressing
23:00 If something like the Impact test is available from the school or sports team is available it will be taken into consideration.
24:30 Getting a psychological evaluation and treatment is especially important for student-athletes to determine care protocol and school accommodations.
26:00 The importance of having a good rapport between the physician, the physical therapist, and the patient.
28:35 How often are clinicians seeing a patient within a week of the initial injury?
Very infrequently, however, strong communication between the physician and pt will speed up the process and get the patient into treatment much faster which is a critical factor for outcomes.
The delay is usually in getting to a sports medicine doctor due to different factors, like not having a physician present during an athletic event, or going to a family doctor first for a referral, and then delaying care.
30:30 Dr.Eck shares a study from the Journal of Neurosurgery in Pediatrics about the association of time to a clinic visit with prolonged recovery in Pediatric patients with concussions.
Early presentation (less than seven days) vs late presentation (eight or more days) the odds ratio was 9.8 so close to 10 times the likelihood of having a prolonged recovery and prolonged symptoms.
31:45 Athletes with a possible concussion need to get help and the right kind of help as quickly as possible.
33:30 Average Symptom Severity and Related Predictors of Prolonged Recovery in Pediatric Patients with a concussion (2020) found that symptom severity along with delayed evaluation related to the prediction of prolonged recovery.
34:20 Dr.Eck states “2-3 days should be the ideal window for getting an athlete into a clinicans office”
34:15 “It can’t hurt to get evaluated”
36:20 What does Mike Keenan do to perform an assessment when he first sees a patient, once there is a referral from a sports medicine doctor like Dr.Eck?
39:30 What is symptom grading and how does Keenan use it as a flag system with patients?
40:20 Dispelling the old myth that someone with a concussion should be told to rest completely
“Don’t throw them in a dark room”
42:00 The importance of education at every step of the process. The gap in understanding between clinicians and the public when it comes to concussion recovery and accommodations.
Due to the gray nature of the injury, communication is essential with all parties.
42:00 - 43:00 The stress of having to make up extra work and how it can set back recovery
44:30 The value of Mike Keenan taking the time to educate the patient and the parents every step of the way, when treating a student-athlete.
“Education is our biggest weapon. If 90 percent is subjective history, 9 per cent is education and 1 percent is what I actually do”
46:00 Anecdote about how stress and outside factors can cause a set back in recovery adn education on that is essential to getting back on track.
48:00 The impact of the thoracic spine on the movement assessment and recovery.
50:00 Look, Listen, and Feel to complete a full evaluation. Pay attention to every detail of the interaction to make a determination of the best treatment going forward.
52:00 How is treatment then handled based on the deficits that were identified by the clinician?
52:30 The 6 subsections and presentations of concussions
Cognitive/fatigue.
Vestibular.
Ocular.
Post-traumatic migraine.
Cervical.
Psychological
55:00 Why staying really committed to the symptom rule is so important
58:00 The usual time span between initial evaluation by Dr.Eck and a follow-up.
59:30 What lead to the change in protocol and why is it no longer advised to put someone in a dark room for complete rest?
1:01:30 The research has proven that the psychological and cognitive impact of not following a gradual return to activity is often detrimental and prolongs full recovery.
Stay tuned for Part 2 of this concussion roundtable where we move into return to play protocols and more.
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