Return To Play Concussion | UPMC Sports Medicine

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– No sports-related injury has received more attention than the concussion. Concussions are complex injuries, which require careful assessments, diagnosis, and management for proper treatment and eventual return to sport. Experts at the UPMC Sports Medicine Concussion Program have spent more than two decades perfecting the diagnosis and management of concussions through active treatment. While a knock to the head may seem devastating to an athlete, concussions are treatable, and a return to play is possible if care is received early by a sports concussion expert.

– Hi, I’m Charlie Batch. Yes, that Charlie Batch, if the name is familiar to you. And I’m here with Dr. Micky Collins and Dr. Anne Mucha of the UPMC Sports Medicine Concussion Program. Parents, coaches, and even athletes themselves need to know what a concussion is and how to diagnose the signs and symptoms of a concussion. So how does one identify a concussion?

– It’s actually very difficult to identify a concussion. Concussion can result in either signs or symptoms of injury. Signs are what you’d see in an athlete’s behavior, and symptoms are what the athlete reports. Signs may include loss of consciousness. It may include balance problems. It may include confusion or vomiting. Symptoms of injury can include dizziness, headache, light sensitivity, noise sensitivity, nausea, feeling foggy or one step behind or detached. So, there’s a lot of different signs or symptoms that can be involved with this injury. The important point, though, is any of those signs or symptoms should result in immediate removal from play and very careful evaluation.

– And what are the different types of concussions?

– Yeah, we’ve now been able to identify that there’s different types of concussion. There’s 30 different types of knee injuries. Why do we think there’s one type of concussion? And now, through our research at UPMC, we’ve been able to identify there’s six different problems that we see after a concussion. Problems with cognition or thinking, problems with a system in the brain called the vestibular system, which is a very important part of the brain that allows us to interpret movement and stabilize our vision when we move our head, and a number of other symptoms that we’ll get into. The third type of concussion is ocular, which is your eyes working together as a team. We can see a lot of changes in your ability for your eyes to work together as a team. The fourth type of concussion is migraine, which is what it sounds like — headache with nausea and/or light or noise sensitivity. The fifth type of concussion can be actually neck issues that we see cervical issues. And the sixth subtype is anxiety, mood changes. Now, patients may have one of those types of concussion when they see us; they may have all six of those types. Obviously, if you have all six, it can be a longer outcome than if you have just one. But the key is, is we’ve now not only been able to identify the different types of concussions, but we’ve now identified targeted treatment for those different problems. And we can get patients better faster and get them back to play safely and as quickly as possible.

– Doc, you’ve identified what concussions are, but how can someone avoid a concussion?

– It’s hard to prevent concussion from happening, as it takes the brain moving inside the skull for it to occur. There’s been some research that neck strength may be beneficial. There’s been some research that rule changes that have occurred, both at the NFL, high school, and collegiate level, have certainly resulted in safer play and reduce incidents and severity of injury. But at the end of the day, collisions do happen, and they do occur. And when that happens, we can see signs and symptoms of injury. It’s important to get those patients out of play, get them to a specialist like the UPMC Concussion Program, where we can get the right treatments in place and get them back to play safely.

– If an athlete thinks that they may have sustained a concussion, how soon should they come in to see you?

– We’ve actually just published a study on that, Charlie, and the sooner we see patients after an injury, the quicker the outcome. You can save days to weeks of going through this injury by coming in sooner. We can actually get patients better faster and getting back to the sports they love.

– Concussions really are a complex injury, and it doesn’t seem cut and dry as to what treatment will work for everyone. So when you see an athlete with a suspected concussion, what is the first step of diagnosis?

– At the UPMC Concussion Program, we have a multidisciplinary team that helps to assess and diagnose the injury and also establish the correct treatment plan. We’ve developed a number of tests that help to quantify and objectify the injury. Tests like neurocognitive, computerized neurocognitive testing, tests that look at the vestibular and ocular motor systems. We have specific questions and exams that we utilize to understand if the patient’s had a concussion. We have a very high degree of sensitivity in being able to diagnose this injury properly. And once we identify the diagnosis and then we identify the type of concussion, that’s when we can implement the targeted treatment to get patients better faster.

– Dr. Mucha, now we get into the treatment portion of the program. When you see an athlete who sustains a concussion, is rest or activity more important?

– I’m so glad you asked that question, Charlie, because the old adage was you rest a concussion, and what we found at UPMC is that the opposite is true. In that, we really need to activate most concussion profiles or subtypes. We talked a little bit about the vestibular subtype, for example. We know that we actually have to use exercise and activity to activate that subtype. Same thing goes with ocular, and we know that athletes who are removed from activity start to become depressed and anxious, and we need to activate them. So one of the biggest things we’ve done is figure out how do we best create an active approach to treating these athletes, rather than allowing just rest and waiting for things to get better.

– Can you first off tell us what VOMS means? I know it’s a tool that’s designed by UPMC experts to detect signs and symptoms of a concussion. And then what are the benefits of that?

– Sure. VOMS stands for the vestibular ocular motor screening. Dr. Collins earlier talked about two different types of concussions are vestibular types of presentations and ocular presentations. The VOMS is specifically to help us identify those two concussion types. And it’s a very standardized battery of quick clinical tests that we do to help determine if an athlete is experiencing vestibular or ocular issues, and then that allows us to start treatment for those particular areas. So it helps us identify and then create an active approach for our athletes.

– Once an athlete recognizes that they have sustained a concussion and begins treatment, I am sure the first question you get is, “When will I feel OK to return to play?”

– I actually love that question. I love hearing my patients ask me that question. We do take a very active approach at treating, this very targeted approach, and the goal is to get kids back to play safely and as quickly as possible. We have very specific criteria that we’ve established through the UPMC Sports Concussion Program to define when they’re ready to return to play. We want the patient’s cognition to be entirely normal. We have ways of measuring that through computerized neurocognitive testing. We want their vestibular and ocular motor systems to be normal. We look at that through tests that Dr. Mucha uses, as well as an exam that we utilize. We also want to make sure that patients can work out strenuously and fully, and we’ve developed a standardized clearance exertion test, called the EXIT test, that we utilize as well. And once the patients are symptom-free at rest, symptom-free with exertion, all our clinical tests are normal, our exams are normal, we put them back to play, and we’re super confident when we do. The best way to prevent problems with concussion is to manage effectively when it happens. And if you manage the first injury properly, we should see kids return to sports very safety. We don’t see additive injury. We don’t see long-term problems from the injury. This is a treatable, manageable injury. It just needs to be treated and managed.

– And you are able to see that from a physical perspective and a mental, but as athletes, mental is the part that affects them because they’re not sure whether or not they’re ready to return to play. How are those conversations happening when you have to now have that conversation with an athlete?

– It’s really interesting, Charlie. When you see patients come through our clinic, we educate them on this injury. We educate them on this is the type of concussion you have, this is the treatment we’re going to do, this is what we expect in terms of recovery, and this is how we’re going to get you back to play safely. And once we educate patients, the mental stuff clicks in. We tell them, the last thing I say to a patient when you’re going back to play, play aggressively. Get out there, play your game. I want it out of your head. We wouldn’t be clearing you if we were concerned about you returning to play, and we mean that. And we love to see athletes here in Greater Pittsburgh and beyond get back to their sports safely.

– You mentioned we, and obviously, this is not all you. Who is on your team?

– Yeah, at the UPMC Sports Medicine Concussion Program, we have 35 faculty and staff completely devoted to this injury. We have neuropsychologists, primary care physicians, physiatry. We have psychiatry, we have vestibular therapists, we have exertion therapists, we have athletic trainers that are a part of this. It is a very large program. We’ve been doing this for two decades here in Pittsburgh. We have approximately 18,000 patient visits a year to our program. It is a program that we take a lot of pride in, in the fact that we’ve really worked together cohesively as a team. Our goal is to get kids safe, back to play safely and healthy.

– And how satisfying or gratifying is it for you when you see a player finally return back to the field and have the success that they are used to having?

– It’s why we do what we do. We love seeing people back involved in what they, what gives them joy, and it gives us joy to help them do that.

– Dr. Collins, Dr. Mucha, if you had to have one key takeaway, what would that be from today?

– Well, Charlie, I think the takeaway for me is that active approaches are the way to go with managing concussion. Waiting, just waiting and resting is not usually that effective, and finding the right level of activity to address the problems that you’re having from your concussion, we found to be incredibly helpful in managing this injury.

– Yeah, Charlie, my takeaway is that this is, concussion is a treatable injury. We can, by coming through our program at UPMC, we can accurately diagnose this injury, we can target the right approach to treatment, and get these kids back to the sports that they love.

– Dr. Collins, Dr. Mucha, thank you for joining us today and sharing this very important information, everything from how one sustains a concussion, to the signs and symptoms, to how active treatment can help get athletes back in the game. If you are a coach, parent, or athlete, remember that UPMC Sports Medicine is here for you. If you want to learn more about concussion diagnosis, management, and treatment, visit, where you’ll find a wealth of information and resources on concussions.

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