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Dr. Jones: There are many ways that women's brains are different from men's brains. But what about when brains get bonked like a concussion? Are they different? This is Dr. Kirtly Jones from Obstetrics and Gynecology from University of Utah Health, and this is The Scope.

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Dr. Jones: As a reproductive endocrinologist, I am interested in the sex differences in the brain and behavior between men and women. Sex differences are differences that are related to sex chromosomes and sex hormones. Of course, I'm also interested in gender differences. Gender differences are related to social and societal norms for behavior that are different between men and women.

When it comes to brain and behavior differences between men and women, there are sex and there are gender differences, and of course they're linked together in many but not all cases. For instance, the verbal part of the brain in women is generally comparatively bigger in women than men. We think that is probably related to hormones and early development, but we're not sure.

However, after babies are born, do moms talk to their baby girls differently than baby boys? That would be a gender difference. If women talk more than men on an average, is that a sex difference or a gender difference or a combination of the two? Women have significantly more migraines than men. We're pretty sure that this difference is largely hormonal, a sex difference and not gender, but it's complicated. Women are more likely to complain of headaches of any type than men are.

Okay, let's get to concussions. Men are more likely to have concussions than women. This may be related to the sports that are prone to concussive interactions: American football, hockey, boxing, you know. It may be related to the fact that men are more prone to risky behavior: cliff jumping, motorcycle riding.

Some of these are sex differences. If a women could get as big and as muscular as a defensive tackle, could she play high school or college football? Unfortunately, there are social situations in which women are much more prone to head injury than men such as domestic violence. So this makes it hard to study differences in closed head trauma in women and men. So if you pick a sport where the rules are the same for women and men and the sport engages a lot of women, then you can begin to study differences.

Soccer is a good case in point. In studies comparing concussion rates in soccer players, women have more concussions than men. Not a lot more, but a little more. Now we get to the interesting sex and gender issues. There are sex reasons why women might be more prone to concussion than men in soccer. Men have larger and more muscular necks so they can brace their head better, less snapping of the neck and shaking of the brain. Women may be slightly more likely to verbalize their symptoms after concussion, therefore they're more likely to be reported and counted. There is evidence that men are slightly less likely to report concussions. Studies show that both male and female athletes will lie about symptoms after head trauma to stay in the game, men about 79% of the time and women about 70% of the time. Actually, these numbers are really terrifying if athletes are so willing to cover up potentially dangerous symptoms.

Now, the hormone part is very interesting. One study of women who were hospitalized for concussion looked at women's hormonal status at the time of concussion. Women who were hurt in the early part of their menstrual cycle when there's just estrogen around, had on average longer times to recovery than women who were in the second half of their cycle or on birth control pills when progesterone or progestin hormones in the pill were around. This was added to some research in rats that suggested that rats that were given progesterone, a woman's hormone, immediately after head trauma, had less adverse brain effects. In the rat case, you can control for sex and gender, and the degree of head trauma.

This led to an early study of giving head trauma patients, both men and women, progesterone after head trauma to see if the brain was less damaged and recovered faster. The early studies suggested that progesterone was somewhat protective, and that was really exciting to me. Of course, most all of us are exposed to truly horrifying head trauma during a normal vaginal birth, but our brains are swimming in progesterone from our placenta so maybe that's protective. That aside, a larger randomized trial of progesterone treatment in head trauma didn't show a difference in outcome.

So what should we do about this? Of course, the National Brian Bank is looking for brains after death of men and women who've been exposed to concussions and is hoping for more brains. Of course, we're sad. We don't want people to die early, but if you do and your brain is useful, that would be something you could do. This bank has made news in their work on chronic traumatic encephalopathy, CTE, in the brains of athletes who died who were exposed to multiple concussions. To date the Bank in Boston University has detected CTE in 236 of 377 brains donated to the research lab. But only four of those brains belonged to women, and none of those women's brains had CTE.

There are more and more studies of women and concussion, and that's encouraging. There's a website and national non-profit organization called Pink Concussions to raise awareness of concussion in girls in women. Most importantly, if a girl or a woman has a head bonk and sees stars or has a temporary change in consciousness, not necessarily losing consciousness, she should stop what she's doing and be evaluated. Any sport that encourages using the head as a tool or a target: heading the ball in soccer, hitting the bead in boxing, should have the rules changed to protect men and women and boys and girls. And don't get me started on football.

To search The Scope website by putting concussion in the search box, you can learn more. Thanks.

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Interviewer: Are you struggling with the decision whether or not you should let your kids play sports because of the danger of concussion? Dr. Greg Hawryluk is a concussion expert and neurosurgeon. Give us your perspective.

Dr. Hawryluk: The first point is that we don't want people to be overly concerned about concussion. There are so many benefits to sporting activities. We're seeing very high rates of childhood obesity. Sports are good for you. We don't want people being pulled out because of fear of concussion.

The second point is that we really want to encourage players to respect their own bodies and the bodies of their competitors. We don't want them using their heads as a battering ram. They need to be using proper tackling technique.

The third point is we really want the coaching staff to have the proper training and experience where they can recognize concussion, they understand the importance of it, and so they know how to take the right steps if concussion happens to one of their athletes.

updated: June 10, 2021
originally published: April 18, 2019

Interviewer: You think you got a concussion? Go see a doctor, and here's why. Dr. Greg Hawryluk is a neurosurgeon and a concussion expert.

Dr. Hawryluk: One of the big things that we need to do after a concussion is to make sure that it's not something more serious. A lot of times, we think that these are pretty minor injuries, but the reality is, and fortunately it's rare, but these can be sometimes very serious. Sometimes there can be bleeding in the head. Sometimes you need to see a neurosurgeon so we really want to make sure that you don't fall into that category.

And the other thing is that there's this thing we call second impact syndrome. And this is more common in young patients, where they get a second injury a short time after the first one and it can lead to fatal brain swelling. Another major benefit of seeing a doctor is that we can help to guide you through a pretty well established six-step process that has been shown to really achieve symptom resolution and a return to normal activities as quickly as possible.

updated: June 21, 2021
originally published: January 16, 2019

Dr. Gellner: It's common for active kids to bonk their heads, but when should you worry? I'm Dr. Cindy Gellner and I'll tell you all about head injuries today on The Scope.

Announcer: Keep your kids healthy and happy. You are now entering "The Healthy Kid Zone" with Dr. Cindy Gellner on the Scope.

Dr. Gellner: We've all been there as parents. You see it happening, but you just can't get there fast enough to stop it. Your child falls or gets hit in the head. The first rule: don't panic. Remember there are three main types of head injuries.

The first and most benign is a scalp injury. Most head injuries are scalp injuries. It's common for children to fall and hit their heads at some point while growing up. This is especially common when a child is learning to walk. Falls often cause a bruise on the forehead and sometimes black eyes appear one to three days later because the bruising spreads downward by gravity. Big lumps can occur with minor injuries because there's a large blood supply to the scalp. For the same reason, small cuts on the head may bleed a lot.

One head injury to worry about is a skull fracture. Severe head injuries that you can't see on the outside of the head could be a skull fracture or a concussion. Only 1 to 2% of children with head injuries will get a skull fracture. Usually, there are no other symptoms except a really bad headache at the site where the head was hit.

The one that everyone worries about is a concussion. A concussion is a mild injury to the brain that changes how the brain is normally working. It usually is caused by a sudden blow or jolt to the head. Many children bump or hit their heads without causing a concussion. Signs of a concussion can include headache, nausea and vomiting, dizziness and confusion, forgetting what happened around the time of the injury, acting dazed, or being knocked out. Of note, a person does not need to be knocked out or lose consciousness in order to have a concussion.

If your child has a concussion, there may be some ongoing symptoms such as mild headaches, dizziness, thinking difficulties or behavioral and emotional changes for several days, two weeks, or even longer. All children with a concussion need to have a follow-up with their pediatrician.

So how can you take care of your injured child? For scalp injuries, simple wound care is all that needs to be done. If the skin is split open and might need stitches, have them seen right away. If there is just a scrape, wash it off with soap and water. Then, apply pressure with a clean cloth for 10 minutes to stop any bleeding.

For any small cuts, apply an over-the-counter antibiotic ointment twice a day until the wound has healed. For swelling, put a cold pack or an ice bag on for 20 minutes. This will help their pain as well. Encourage your child to lie down and rest until all symptoms have cleared or for at least two hours. Your child can be allowed to sleep. You don't need to keep trying to wake them up continuously. Just have them sleep nearby so that you can periodically check on them.

Vomiting is common after some serious head injuries. Only give clear fluids until your child has gone two hours without vomiting. For pain, you can give Tylenol or Ibuprofen as needed, but be sure to wait two hours after the injury to make sure your child isn't going to vomit up the medicine if they hit their head pretty hard. You also don't want to mask any concerning symptoms with the pain medications.

Although your child is probably fine, watch him or her closely for 48 hours after the injury. Awakening the child to check on the ability to walk and talk isn't really necessary unless his or her breathing or sleep pattern becomes abnormal. If your child does fine for 48 hours, go about your normal routine.

It's also not necessary to check your child's pupils to make sure they're equal in size. Unequal pupils are never seen before other symptoms such as confusion and trouble walking. Head injuries will happen for your child; that's a guarantee. Being prepared for when it does happen will take a lot of the fear out of this scary injury.

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Interviewer: Recovering from a concussion, what you need to know is next on The Scope.

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Interviewer: Dr. Greg Hawryluk is a neurosurgeon at University of Utah Health Care and a concussion expert. Help me understand what steps are involved for recovering from a concussion.

Dr. Hawryluk: It's important to know that any concussion needs to be seen by a doctor. These days even if there is a suspicion that you may have had a concussion, it's important to see a doctor. Some people have trouble recognizing the signs. It can be things like headache, dizziness, confusion, blurred vision, and just feeling funny. Sometimes those symptoms aren't apparent until maybe the next day. That's the first step is making sure you see a physician.

Interviewer: So don't self-treat. You wouldn't fix your broken arm. Don't try to fix a concussion.

Dr. Hawryluk: That's right. Don't try and fix your brain yourself.

Interviewer: Okay.

Dr. Hawryluk: The biggest advance that we've had in concussion over the last 10 years or so has been the recognition of the need for a gradual return to normal activities and the importance of rest. That's both mental rest and physical rest. This is one of the rare times where we'll counsel young patients not to do homework. In fact, even things like video games, we think can be a little too taxing for a recovering brain.

Interviewer: Really? When the brain is recovering it needs to rest like any other body part might to heal.

Dr. Hawryluk: That's what we are starting to learn.

Interviewer: Okay.

Dr. Hawryluk: That's really step one, it is to get to a doctor and get started on this pathway of greater recovery. We do talk about six steps in terms of recovery and it's really tailored towards athletes. Again, we start with complete mental and physical rest, and then if that goes well you can basically progress through these steps at one step a day. It means the very fastest you're going to get back to your sporting event is going to be about a week.
Once your symptoms have totally resolved or almost completely resolved, normally the next step is going to be resumption of light activities. That might be something like an exercise bike or a brisk walk or something that is not too taxing.

Interviewer: Let me back up. Step one, nothing, mental and physical rest. How many days is that?

Dr. Hawryluk: For sure, one day.

Interviewer: For sure, one.

Dr. Hawryluk: Yeah, it's really based on the symptoms. Once the symptoms have resolved, or almost resolved.

Interviewer: Then step two.

Dr. Hawryluk: Then you're ready to try step two.

Interviewer: Which is light activity, okay continue.

Dr. Hawryluk: What's interesting about concussion is that symptoms can . . . even though at rest your symptoms are gone, once you push your body a little bit it actually can bring on the symptoms. Really the goal of step two is to see if you can do some light physical activity and see if any symptoms happen. If that goes well, we step it up. Step three would be a return to sports-specific activity. For instance, if you're a hockey player, well, we'd say okay, you can go back and skate at this point. We certainly wouldn't want you participating in regular drills. We wouldn't want you participating in body contact. Step three would be return to sports-specific sort of activities.

Interviewer: At this point, could you start feeling those symptoms again?

Dr. Hawryluk: What we want to see is if at any one of these stages, you do have a recurrence of symptoms. We say well, we need to back up. Some doctors would recommend starting back at square one. A lot of people like myself also advised just taking one step back and seeing where you can get to with no symptoms and eventually trying to work your way back up the six steps.
Once you can do sports-specific activity without symptoms, the next step is going to be to participate in practices without body contact. If that goes well for a day, usually we will give the green light to participate in practice with body contact. Ultimately, the last stage is return to gameplay and normal activities.

Interviewer: This is very sports specific. What about someone that has suffered a concussion for some other reason that's not an athlete, and doesn't have practice. Do they go through the same steps?

Dr. Hawryluk: They do. This six-stage process is really built for athletes that most of whom are really keen to get back to playing. It's designed to get people back as fast as we think is safe. We apply the same principle to people that aren't athletes. The principles of rest and greater return to normal activities has been associated with the most efficient recovery, the least chance of setbacks. We think it may be associated with a reduced chance of the so-called post-concussion syndrome.

Interviewer: For an athlete, what is the danger of returning to full gameplay before you go through these steps?

Dr. Hawryluk: To be totally blunt, one of the biggest things we worry about is death. I say that with a bit of drama on purpose because as physicians, that is the biggest thing we want to prevent in concussion. Some very sad occurrences over the years has taught us that players that return to the sport while they're still symptomatic, in fact, even players that return to the same game, you're at risk of for something called Second Impact Syndrome. We don't fully understand what that is. Fortunately, it's rare. But there's something about an injured brain that it's quicker to swell. We've seen patients that get hit a second time that have dramatic and fatal brain swelling and there have been a number of deaths
So that's the single most important principle for us as physicians in managing concussion. The biggest principle we need coaches and players to be aware of is that if you're concussed, you can't go back to play that game or in any other games until you've been seen by a physician and you work through that greater return.

Interviewer: When it comes to the recovery process, what is the most important piece of advice you would have for somebody?

Dr. Hawryluk: What I often find is true both of athletes and people with jobs and things like that. People are dying to prove to themselves and they want to prove to other people that they are okay. They want to shake this off and they want to be normal. The challenge is that for a lot of patients, that's not a good approach because what happens is you find that you actually are having trouble. And getting back to your activities, if you do it too soon, it doesn't go very well. It kind of becomes a negative experience. Ultimately that can delay an ultimate successful return to what you're doing. The importance of going slow really is key here.

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Interviewer: You're wondering if you should let you kids play contact sports that could lead to concussion injury. What are some of the things that you should discuss and think about? We'll find out from concussion expert Dr. Colby Hansen next on The Scope.

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Interviewer: Dr. Colby Hansen is a concussion expert at University of Utah Orthopedic Center's concussion clinic. Ultimately, I think the question that every parent would want to know given the stories and a lot of talk about concussions in the media, is it still safe or is it safe for my kids to play sports? I suppose you get that question a lot know a days.

Dr. Hansen: I do. I would say, yes, it's totally appropriate for kids to play sports.

Interviewer: Even football.

Dr. Hansen: Yes.

Interviewer: Which seems to be . . . is that the highest risk of a concussion, that sport?

Dr. Hansen: Football is right up there. There are others that are near it - hockey, things like rugby, soccer not too far behind, wrestling.

Interviewer: So it's still safe in, your opinion, for kids to play sports.

Dr. Hansen: I think you have to ask yourself the question, "What is the value of my kid in playing sports?" which I think are numerous.

Interviewer: Maybe basketball would be a better option than football? Where should a parent stand on that?

Dr. Hansen: If we talk about football specifically. Yes, football has some risk to it. Might there be an appropriate age where it's best to start to engaging in football and maybe a younger age where they shouldn't? I don't know. I am not really going to comment on that or try to pretend to be the expert or sounding board for that.

Interviewer: Is there research going on right now or research that would point to an answer to that question?

Dr. Hansen: Well, I know that some groups are interested in taking measures to reduce the number of impacts that people sustain playing a contact sport, like football. There are visible things that people who watch football might see as being measures in that regard - reducing the number of kick-off plays, increasing the number of touch-backs that occur, rules to prevent helmet-to-helmet or targeting types of collisions.

In the background there are lots of efforts to try to educate athletes, and coaches in proper tackling techniques. There are even rules now that are coming down limiting the number of contact practices in full pads, in full gear, to reduce the amount of contact that's sustained over the course of the season.

Those are, I think, appropriate measures. I don't know that we know exactly what's an acceptable amount of collisions to sustain. I think a lot of it eventually comes back to educating coaches, educating parents, educating athletes.

Where I see, perhaps, the biggest problem is when the initial injury may occur and it's not recognized. Instead of taking the kid out of play and observing them or even just making them sit out the rest of that practice or game, there is a tendency to, I think, brush it off. Whether it's on the part of the coach or the athlete, I think, sometimes both at fault, and just rush them out there, and say, "You're okay, let's go at it." That's where you're at risk.

Interviewer: Is that one of the most dangerous things that can happen? You sustain a concussion type head injury, and you go get one immediately right after that?

Dr. Hansen: Exactly.

Interviewer: That's where problems really start arising.

Dr. Hansen: Yeah. There's a saying that goes around in the concussion world, "When in doubt, sit him out." I think that is totally appropriate, there's nothing wrong with that. Is it, perhaps, on the conservative side? Sure. But I think it may well prevent some of these other complications that arise when it's not recognized and then what you have is a situation where kids are, perhaps, sustaining multiple, subsequent collisions over the course of a game or perhaps a few practices. It starts to add up.

Interviewer: Let's go down that path for a second. Are there lasting effects that can occur from those multiple sustained injuries if enough recovery time in between doesn't happen?

Dr. Hansen: I would say yes. From animal model data, and what we see from following players over time in some studies that have done that over the course of a season, if not given adequate recovery time, I think that certainly is a huge risk factor, maybe one of the biggest, for prolonged problems and symptoms that, unfortunately, in a few instances, may not go away.

Interviewer: What's your advice to a parent that has a kid in a sport that can lead to concussion or multiple concussions? Do you have children?

Dr. Hansen: I do.

Interviewer: And as a parent and an expert on concussions what's your strategy on this? What's your thought?

Dr. Hansen: My kids aren't, frankly, interested too much in those types of sports.

Interviewer: Does that make you a little happy on some level?

Dr. Hansen: So that takes some of the pressure off.

Interviewer: Nobody got a concussion in band.

Dr. Hansen: Exactly. I would say it's appropriate to allow kids to play in sanctioned sports, if there are sanctioned leagues and things out there. I think it's appropriate to make sure that the kids have the correct and correct fitting safety equipment. I think a lot of it comes back to the education piece. If an accident occurs, which there is often times not much you can do to prevent an accident, that you manage that appropriately.

Now there gets to be a point where if somebody sustains a number of injuries where you many have to re-think that. Unfortunately, we don't have the magic answer to what's acceptable. How many is too many? We frankly don't know the answer to that question. It should raise some concern if you're starting to have repeat injuries and cause you to re-think that whole issue.

That too, I think comes back to where it may be helpful to talk to a specialist in this area to help you think through those types of questions. Even understanding that even we may not have a definitive answer based on absolute proven scientific research.

Interviewer: And that's something you do at the concussion clinic here at University of Utah Health Care. You'll have consultations, you do some base-line testing, I saw. You consult with sports teams, that sort of thing to help. So, information, knowledge really the most powerful thing right now.

Dr. Hansen: Yeah, I think that's a huge, huge part to what we do. When is it okay to get back to playing? What's appropriate to kind of think about or do we need to maybe think about maybe switching sports altogether? Or any number of things.

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Interviewer: The Will Smith movie "Concussion" focuses on a condition called Chronic Traumatic Encephalopathy. Dr. Colby Hansen is from the University of Utah Orthopedic Center Concussion Clinic. Dr. Hansen, tell me about this condition.

Dr. Hansen: Well, I think in general there's still so much for us as a scientific community and as a medical community to understand about this entity that is highlighted in the movie, chronic traumatic encephalopathy. I mean, it seems pretty clear that trauma is a common denominator, but we don't know to what degree genetics may play into this, to what degree other types of issues may play into it, either mental health disorders or whatnot. We don't know at what amount of exposure to trauma people are put at risk. Just frankly, there's a lot to tease out before we start being over-reactionary and pulling the plug on sports and things of that nature.

Interviewer: The condition that they're talking about in the movie, what exactly is that?

Dr. Hansen: Chronic traumatic encephalopathy is really a diagnosis that can only be made postmortem or after death by autopsy. What some of these researchers are seeing are abnormal collections of clumps of protein called tau that has also been linked to other degenerative diseases like Alzheimer's dementia. They've seen these under the microscope of some of these former athletes, and there's really no denying that they've seen this. So now they're in a phase of trying to characterize are there maybe certain areas of the brain where you get this kind of collection more than others, to what degree does this correlate with known behaviors or symptoms that the patient was experiencing while they were alive, and then ultimately trying to make the link back to the sport or the activity that they were engaged in. People would generally feel or believe that not every football player who progressed through to the NFL has this disorder, so who does and who doesn't and what are the differentiating factors between who does and who doesn't.

Interviewer: Do people that don't play football develop this disease?

Dr. Hansen: At least in terms of the case series, the group at Boston led by Dr. Ann McKee, who's a neuro pathologist there, has studied the most brains and they are not exclusively football players. This disorder was originally described many, many years ago, many decades ago, in boxers, and was termed Dementia Pugilistica which literally means "boxer's dementia." We would assume that the common denominator is trauma, but we don't know much beyond that. How much trauma, at what age the trauma occurred, there's even a lot of debate now not in just concussions, but just the repeated impacts that don't necessarily produce a clear, observable concussion.

At the end of the day there is so much for us to learn, to understand, about not only the impacts of a single concussion and how is the best way to manage it, how is the best way to assess it, but of course the long-term ramifications of concussions and repeated concussions in the health of our athletes and anybody who's active.

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Interviewer: Are concussions more serious than people think? We'll find out next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. Greg Hawryluk is a neurosurgeon at University of Utah Healthcare. It seems like there's a lot in the news and in popular culture about concussions nowadays, and we're starting to learn that maybe they're a little bit more serious than we first thought. It feels as though at one point, if you got a concussions somebody would go, "How many fingers am I holding up?" If you passed the test, great. You're okay. But it's a little bit more serious than that, we're starting to learn.

Dr. Hawryluk: That's exactly the case. First off, what I can tell you is that it's probably an epidemic. There's probably way more concussion out there than we've ever really known. We're only now starting to see a lot of people coming to doctors with their concussion.

Interviewer: So how serious is a concussion in terms of the damage caused to the brain?

Dr. Hawryluk: The problem there is that we really don't know. We don't think that a concussion implies a structural injury to the brain. We still think that it's probably sort of a chemical imbalance. But there's no question that we do think it puts you at risk for ongoing damage to the brain, perhaps over the rest of your life. We are seeing something we call chronic traumatic encephalopathy, changes consistent with Alzheimer's disease in the brain. It really is suggesting that athletes need to be a lot more careful in terms of avoiding concussions and having them treated by a doctor, than has been the case in the past.

Interviewer: So a concussion is when your brain actually hits your skull. Right? So it's not a physical bruise in terms of like what a muscle is. But it causes a chemical imbalance. Explain that.

Dr. Hawryluk: Yeah. There's a few misconceptions about concussion. So one is that you don't actually have to hit your head to have a concussion, and you don't have to lose consciousness. Really, all that has to happen is your brain sloshes around inside your skull. The hallmark is that there's at least a temporary change in brain function. But in fact, we don't see bruising of the brain. We think that probably it's a chemical imbalance that leads to the brain dysfunction. If it gets to the point where there's actually bleeding in or around the brain that is an even more serious condition.

Interviewer: What does that chemical imbalance look like? What's going on there?

Dr. Hawryluk: It's something we really don't understand. It's something that's hard to study. What's really funny to me as both a neurosurgeon and as a scientist is that we haven't made more progress in this field. We can put people on the moon, but we really don't understand what's going on. In some senses, we're sort of at square one with concussion. The important thing is that we're recognizing the significance of it. But there's an awful lot more work to do to figure out what's going on and how to best treat these.

Interviewer: If I understand correctly, a single incident can be bad, can cause symptoms and damage. But it's the multiple incidents without recovery time that you're really worried about.

Dr. Hawryluk: Well, that's absolutely true. We're concerned about both cases. One concussion is certainly a concern and has to be appropriately treated. These days, we certainly advise that every concussion should be seen by a doctor. But our level of concern as physicians goes up quite a bit when we start to see multiple concussions. The worst case scenario that we worry about as doctors is basically a repeat head injury before the first concussion is fully resolved.
The reason that that's so important is because we actually see people die from that. There's something called "second impact syndrome." So if a player, for instance, goes back to playing football before their first concussion is resolved, some of those patients have died. We know that there's a tremendous amount of brain swelling that can occur in that instance, and that's one of the biggest things that we're trying to avoid and get word out to both players and coaches. That once you've had a concussion, you need to sit out and be seen by a doctor.

Interviewer: Outside of football is that the case, say for example, I was skiing and took a hard hit and got a concussion. Could the same thing happen if I got a second concussion as a football player?

Dr. Hawryluk: That's absolutely the case. One of the challenges with concussion is that a lot more things can cause concussion than I think a lot of people realize. Football is one that we would all think of. But I always tell people, I remember a time when I was younger and when I was on a roller-coaster, and I'm pretty sure I had a concussion on that roller-coaster. So, really anytime that you're jarring your head around that's a big issue.

Interviewer: If I get that one-time concussion, whether I'm playing a sport or in an accident, or something like that, should I be super-concerned above and beyond seeing a doctor?

Dr. Hawryluk: Well, the biggest thing is to see a doctor. The biggest change of concussion management over the last 10 years has been the idea of rest and graduated return to normal activities. We do think that we've learned that that leads to the best recovery from a concussion. After any sort of a concussion, the minimum amount of time it takes to fully get back to what you were doing before in terms of activities is about a week.
Some recommendations say that in children it should probably take twice that long to get back to normal activities. So, that needs to be medically supervised. There's usually six steps that we talk about as people go back to their normal activities. The good news with concussion is that the vast majority of people have a resolution of their symptoms and ultimately do quite well. There are, however, a minority of patients, maybe 20% that even six weeks out from a concussion are still having trouble, something we call "post-concussion syndrome." But the good news is that fortunately that's a minority of people.

Interviewer: Are there long-term repercussions to concussions then?

Dr. Hawryluk: Well, there certainly can be. So we think that at some level there is a brain injury, and we certainly worry about the accumulative effects. We are starting to learn, again with these professional athletes that perhaps these seemingly minor blows to the head when they're accumulative can lead to depression and behavior change. In fact, we think that maybe even some suicides have been linked to this.

Interviewer: Which comes back to that chemical imbalance [inaudible 00:06:16].

Dr. Hawryluk: That's exactly right.

Interviewer: That makes total sense.

Dr. Hawryluk: Yep.

Interviewer: What's the future hold? What do you think we're going to find in the next 5, 10 years? You said it's in its infancy. Where are things going?

Dr. Hawryluk: Yeah. It's a time where the concussion field is advancing in a lot of different directions. We're learning more and more about the basic science of the condition. We're learning more about how to treat these patients and how to manage them in terms of their sporting activities.
One of the things that is something I think an awful lot about is people that are participating in contact sports. I'm hearing a lot of parents these days with reservations about having their children play hockey or football. I think to a certain extent that's reasonable. But if I look back on my own life, the lessons that I learned playing sports with other kids is so important for socialization and it's important to be active and to be healthy.
So I just have a bit of concern that the way this conversation seems to be going is should kids be participating in some of these sports? What I always counsel my patients and their families is that I really think participation in sports have so many benefits that I hate to see kids pulled out. I think really what's important is encouraging safe play. The reality is that most concussions we think are probably preventable. Teaching players to treat each other with respect, to obey various rules for safety, I think those are the key. Again, I just worry about kids not participating because of some of these fears.

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Interviewer: Going to find out what to expect when you go to the University of Utah orthopedic center concussion clinic. That's next on The Scope.

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Interviewer: Let's say something happened to somebody that led to a concussion, whether it's playing football or skiing and took a nasty fall, or maybe even an accident. I've gone to my primary care physician or it's pretty clear that I do have a concussion, and I make an appointment with the concussion clinic. What should I expect after walking in the door?

Dr. Hansen: You'll be evaluated by a specialist in traumatic brain injury. As far as what the evaluation entails it will include a comprehensive look at what types of symptoms you are experiencing, what were the circumstances of the injury, what other medical problems do you have that could contribute in some way to the symptoms you're experiencing. For example, if somebody has a chronic headache disorder already and then they have a head injury, that certainly can affect how they experience their headaches, for example.

We'll want to find out if they've had head injuries before and if so, how did they occur, what was the recovery pattern. Beyond that history gathering, we'll perform a physical examination that looks at a good balance assessment. We know that that is often affected after a head injury. A general neurologic examination which is typically normal. Then, an assessment of how your eyes and vestibular system are working together and maybe provoking or aggravating symptoms.

Those are the main components of our physical exam. Depending on the circumstances there may be other supplementary tests that we do. The ultimate goal is to document what might be aggravating symptoms, what maybe is not back to normal, because in the case of athletes or people who are wishing to return to sports, or otherwise potentially risky activities, it's really important to make sure that you're "100%" before going back out into harms way.

Interviewer: So a lot of basic tests, a lot of questions, some balance tests, but what about some sort of a brain scan?

Dr. Hansen: Brain scans typically aren't very revealing. If you have a severe injury and show acute signs or symptoms that there might be a more serious problem in the brain, people with those sorts of issues usually end up in the emergency room and those appropriate scans are done at that time.

Interviewer: So imaging is not something that you normally would do there at the concussion clinic.

Dr. Hansen: Not typically. Certainly if the story doesn't add up or we're concerned about something else, but I guess I would say that imaging tests don't diagnose a concussion.

Interviewer: What kind of questions should the patient be asking when they're in the clinic? Is there anything in particular they should be actively doing?

Dr. Hansen: If I could put myself in a patient's shoes or in a parent's shoes, and certainly I'm a parent, how do I know when it's safe to go back and play such and such a sport? Or if I'm having symptoms that aren't going away, what can we do about it? It's a tricky process to navigate.

One of the big things that we try to tackle in our clinic is providing adequate education into how to manage this, and adequate support they can then take back to their work environment, their school environment, their coach, or whatever so that they can educate them on what's the right things to do or not to do to help facilitate getting better.

Interviewer: What are some of the treatment options that you might give a patient after they've come in and you've done the diagnosis? You mentioned medications could be one.

Dr. Hansen: Most of medical management of concussion is geared towards symptom management. There's not a pill that cures a concussion. Medications have a role. There are times when the best medicine is just education and helping them understand the right balance between rest and activity, how to scale things back, and how to tailor their daily activities to facilitate recovery. Sometimes we'll get rehabilitative therapies involved, physical therapy if somebody is struggling with a lot of dizziness or vertigo, or even a lot of neck pain sometimes coincides with their concussion.

Interviewer: If I got a concussion it sounds like rest . . . is rest a big part of it? I guess what I'm saying is instead of coming in, why don't I just rest for a few days?

Dr. Hansen: Sometimes that is the trick. We know that about 50% of concussions will spontaneously get better on their own without doing anything particularly special. The important thing in those situations is just making sure that you're not getting back into harms way too soon.

There are however cases research would suggest probably in the ballpark of 20% of patients may still be having problems even a month out from their injury. Continuing to just rest and do nothing there gets to be a point of diminishing returns I guess I would say where that's not helpful and you need to figure out how to balance the right amount of rest with the right amount of activity.

Interviewer: Certainly somebody in that particular category is somebody that you would want to see, if a month has gone by and they've still got symptoms.

Dr. Hansen: Absolutely, yeah. Some guidelines would even argue that anything beyond two weeks may merit a specialist evaluation.

Interviewer: It sounds like if somebody has had no history of having concussions, and has received one, resting for a few days would be fine. They probably don't need to come into the clinic unless those symptoms persist.

Dr. Hansen: Yeah, they probably don't need to come into necessarily our clinic, but it is super important to check in with a healthcare provider.

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Dr. Troy Madsen: What's a concussion and how do you know if you or your young athlete has one. Plus today on ER or Not how bad does a headache have to be to go to the ER? I'm Dr. Troy Madsen Emergency Physician at the University of Utah Hospital that's today on The Scope right after Health Headlines.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Scot: Here are your Health Headlines. I'm Scot Singpiel. The FDA today approved [beep]. In other health news [beep]. Does life make it impossible for you to get a workout in three or more times a week? Well good news because a recent study says how many times you exercise isn't as important as getting 150 minutes of exercise every week. People that only worked out once for 150 minutes were just as healthy as those that worked out more frequently according to a study published in the Journal of Applied Psychology, Nutrition, and Metabolism. So even if it's just all day on Saturday to get in that 150 minutes get in any way you can.

Dr. Troy Madsen: I'm a binge exerciser myself so.

Scot: Weekend warrior?

Dr. Troy Madsen: Yeah exactly. So if I can just take three hours go out hike, whatever, happy to hear that. Speaking of weekend warriors I was a warrior in the ER this weekend. Not my favorite thing to do as a weekend warrior, but one of the patients I've been... you know one of the patients I've seen recently in the ER is a young girl who's a cheerleader and her worst nightmare happened. She was being lifted by one of the male cheerleaders, he dropped her from above his head she fell down hit herself right on the head. She was unconscious, knocked out. I mean you can just imagine the drama at this scene with 15 high school cheerleaders around this girl who had just got knocked out.
So that's what we're talking about today; concussions. So what happens in the brain with a concussion? So every one of us has fluid around our brain and as we're moving our heads around that fluid just kind of keeps everything so it's not hitting the sides of your head or hitting the skull. It's kind of like the cushion of the brain, but what happens in a concussion is that that fluid just doesn't do its job. You get hit so hard that the brain is shaking around, it's hitting into the skull, and from that you get potentially damage to the brain. It shakes things around, it causes an impact on the electrical activity, and that's what makes you lose consciousness.
In this girls situation obviously she had hit her head, she had gotten knocked out, when I saw her she looked great. You know she was talking to me; she was alert, appropriate, a little bit slow on some of her responses, but again all things we often see with a concussion. So the big question in my mind as an ER doctor when I see someone like this I want to say, "Okay was this just a concussion or when she hit her head and it rattled around in her skull did something worse happen?" And so there I'm concerned about bleeding in the brain.
So the number one thing I look for as an emergency physician is do I need to get a CT scan of the brain. Fortunately for her the CT scan was negative. So at that point you're kind of left with well you know what do we do, and at this point it's kind of a long process of getting back to normal often times. People can have chronic issues with concussions where it can cause chronic headaches, nausea, vomiting, confusion, things that can kind of come and go. We've seen a lot in the news recently about football players, and a lot of the repeated head injuries some of the chronic issues with that where it may even cause personality changes, difficulty with memory, even in some cases in some football players possibly contributing to suicide. So it's some really horrible potentially devastating things from you know what at first may even seem maybe even kind of a minor injury or maybe not too serious.
What do you do if you have a head injury then? Well first of all if you've lost consciousness that's a concerning thing that should bring you to the ER. Other things I always look for are confusion, nausea, vomiting, any dizziness, difficulty walking, and certainly any neurologic symptoms like trouble speaking, or numbness, or tingling in your arms or legs. So those are all symptoms of a concussion, and all things that should bring you to the ER to get evaluated further.
So let's imagine you're a parent or a bystander of this situation where the cheerleader fell and hit her head. She's lying on the ground unconscious what do you do? Number one most people are going to wake up fairly quickly from a concussion, or from a head injury. Certainly if she's not responding call 911 get help there immediately, but if she does respond, and she's alert, she's talking to you, you know make sure her spine's okay. Make sure she's not having a lot of tenderness on her spine, and at that situation get her to the Emergency Department to get evaluated.
So our take home points from today are if you hit your head, if you have a head injury, keep an eye out for those symptoms nausea, vomiting, confusion, any trouble thinking, difficulty speaking, numbness, tingling be sure and get in to see us in the Emergency Department, and once you're there we'll make sure everything's okay in terms of the brain itself, and then get you on the right track to hopefully get you back on your feet and feeling normal after a concussion.

Scot: Is it bad enough to go to the Emergency Room or isn't it? Find out now. This is ER or Not on the scope.

Dr. Troy Madsen: So Scot what's our question for the day for ER or Not?

Scot: All right are you ready?

Dr. Troy Madsen: I think so.

Scot: Rachel...

Dr. Troy Madsen: These are always tough questions.

Scot: Rachel from Layton wants to know if you should go to the Emergency Room for a really bad headache. Now she's talking about worse than just everyday headaches, is that a reason to go to the ER? Headaches, ER or not?

Dr. Troy Madsen: This is a great question, and this is one we get all the time in the ER. We see lots of people with headaches, and the question in my mind is always is it serious or not? If you have a headache that is different from headaches you usually have, or it's a very severe headache you should go to the ER, and our number one concern in the ER is bleeding in the brain. Now you may have a brain aneurism, a vessel in your brain that's kind of dilated, or just like ballooned out, and that can rupture, and that's the big thing I worry about.
If you've got a new sudden severe headache some people talk about it as a thunderclap headache, just feels like a thunder just hitting your head. That's where we really get concerned. When you come into the ER in that situation we're typically going to get a CT scan. A scan of your brain to look for any sign of any bleeding. If it's a headache that's different, or much more severe than what you've had before you really need to come in and get checked out.
Next week on The Scope I'll tell you what you can do if you see someone having a seizure, and if putting a spoon in their mouth is a good idea or not. I'm Dr. Troy Madsen, thank you for listening to The Scope.

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