Transcript

0:01

Good morning, everyone. Ray Castle. Moderator today for another fantastic session. We're on session. 7 of the Sports And Merchandise Care symposium 1.0.

0:13

Great to see everybody coming on board. We've got some we've got a great session this morning. On concussion management and also what goes on the side inside the sideline and then the tent with Jeremy Gazelle, who's the director of football rehabilitation at University of Alabama. Before we get started, just want to go through a couple of quick highs I mean, housekeeping items so that you know how we're gonna if you're new for the first time on here, this week. If if you saw some yesterday, we did some things a little we did some things differently.

0:44

So first off, you let us know that you're on where you're from, great to see everybody, and there also is So you can put some comments there if you like, but also there's a q and a session q and a button. Click on there. Put your question up. Also, when we get into the end of the session, a discussion with with Jeremy is if you'd like to, we're gonna go just raise your hand, the little icon, and then I'm a put you on audio, and then you can ask your question to Jeremy. So we can have that real conversation, not this just a text conversation where you're texting the message in, but you actually have a dial log and and maybe have 1 or 2 questions there.

1:29

So Kurt did do that. We had a lot of fun with that yesterday with our previous speakers, and we'll continue to do that. So Without further ado, I'm gonna go ahead and let's go ahead and get started. So once again, good morning, Jeremy. Great to have you here on the on the presentation today.

1:46

Morning. Ray, thank you so much for allowing me to come on and and speak a little bit on how we do our concussion management on the sideline and what that goes on that tent. Great. You and Maximus and consultants for letting me do this.

1:59

Yep. Great. I'm glad to have you here. So You know, we're talking earlier, and I I just complete I I kinda forget through this. So Jeremy's been just kinda give a quick bio on or background in Jeremy.

2:10

Jeremy's been with at Universal Alabama for the last 18 years now. He is not only in charge of rehabilitation, but he also works in coordinating the EAPs as well. And that's really what we're talking about today is how we how we have protocols, how we put those protocols in motion, and we follow them. And I know that just similar at my time at LSU and you know, you there you as at Alabama and other other institutions that, you know, following protocol with regardless of size institution is very critical, especially in concussion management. So in addition to this role there, what I didn't know, I I I meant to mix.

2:50

I forgot about this. Jeremy, we're talking before the call is that you and I are both Southern Mist work at Southern Mist. I was there I finished there in 2000, so he came in 2005. He but he's worked but, anyway, Jeremy's worked at, you know, Southern Mist, He's been also, he worked with also been with Indianapolis Coach for several years, and then also is it being a frequent speaker at various conferences, including the SEC, athletic, Turner Association, various state meetings, etcetera, on his expertise on a number of different areas, including and cushion management and rehabilitation. So without further ado, Jeremy, I'm gonna hand this over to you, and thanks again for being on on the presentation today.

3:31

Absolutely. Thank you. Well, good morning, everybody. Again, thank you so much for taking the time to to listen to what I have to say today. This is something that is kind of an up and coming topic.

3:45

Obviously, it's it's been in the in the media a lot here. Let's talk about it a little bit later. But The interesting twist on this is is kinda utilizing the tent. So I will say this. I apologize in advance.

3:56

I'm on the back end of a cold. So I'll try my best not to cough in in in your ear. But if if I'm pause it for a minute and and you see me looking like I'm about to die over here, that's That's all that is. So just bear bear with me. I appreciate that.

4:16

First off, I have no disclosures or conflicts of interest to report. Although I do work at the University of Alabama, and do work for the the guy that invented the the Sideliner. I do not have any direct affiliation with any Sideliner tents, the Sideliner working at Max Sports. So just to kinda get started, this is one of those you never know slides. I'll say this in advance.

4:40

Maddox's mom knows I did this and she's okay with it. You're expected. You're you're ready to to to get this situation on a sideline of a football game. With your doctors there and kind of in a game. But where you're not necessarily ready for this, might be on a Saturday morning when you're at your son's 8 youth basketball game.

4:59

And excuse me, Mister Max here decides he's gonna try and catch a a line drive at 3rd without his glove. So You can see the the the mark there on its forehead, but you never know when when you're you're gonna have to change hats from dad to to athletic trainer and and and run on the field and make sure that that that this young man's okay. And thankfully, you know, a couple inches below, and we probably would have been dealing with a much bigger situation. But know, you never know when you're gonna have to evaluate somebody for a compassion or a head injury like Mister Max here. So the agenda for today kinda what we're gonna talk about.

5:33

In order to to kinda go through this whole thing and and and whittle it down to what goes on in the tent and and the kid's side lock and question management, which is really a pretty straightforward topic. To give you some some kind of meat potatoes to this. I wanted to kinda add some things from a ten thousand foot view so that all makes sense at the end. So You're gonna see a couple of detours here where we we may go off on a little tangent, and I know that's not what the topic's about, but I wanna lay some ground work so that when we get to the end, it kinda all makes sense. So we're gonna start off with some some current recommendations and and literature review and kinda what's what's in the what's in the meeting and what or not meeting, but what's in the literature and what people are talking about?

6:15

How how does this being implemented in different areas? And then we're gonna kinda go into, you know, what our general concussion management plan is here, what we use at University of Alabama, and how we came to that. Gonna kinda take the first little detour there and kinda go into the evolution of the tent. Obviously, the tent is the main focus of this this conversation and how we utilize it on the sideline with really all of our evaluations, but specifically with our head head injury evaluations. And then we'll kind of find our way back to the to the line here and go with our own field, kinda evaluation progression, how we do this, and how how it kind of starts and where it comes from and all that kind of stuff.

6:56

We'll go into the 10 again and and start start talking about how we we do our intent concussion evaluation where that leads to. And And that's gonna come from from our team position. You know, I I thought, you know, who who better than to get that information from than than the the man that's gonna be doing it. So, you know, that's coming from his mouth and his brain as far as our, you know, how how our protocols developed. And then post game management, you know, what do we do after we've We've said, okay.

7:21

This is a this is a concussion or this is something else. Okay. What do we do now? And then we'll we'll finish up with some some discussion and questions. Hopefully, hopefully, I can continue to shed light on some information from there.

7:33

So this is as I kinda said before, this is a extremely hot topic right now. In the media, there's a lot of every time you turn on the TV, even so more so with this past NFL season with with the likes of our our dear friend here, Mister Tuatunga Balua. He was obviously near and dear to our heart here in Tuscaruso. The concussion management and sideline and how it's handled on the field is is obviously a a big deal, and and it's it's come under scrutiny. Because of situations like that and and, you know, how how things are get handled and and, you know, the the concussion injury itself is is really, really upfront right now.

8:13

So we'll talk about that a little bit. So what is everybody saying? You know, where where is all this stuff coming from? And when I when I decided to to do this talk and and started looking into to things. I wanted to know, you know, is everybody doing the same thing?

8:30

Is everybody recommending the same thing? Is everybody saying the same thing? And and for the most part, They're they're similar. They're very, very similar, but there's some differences. Most of the similarities are in the recognition, the education, stuff like that.

8:43

But the return to play and the rehabilitation right now, they vary a little bit depending on depending on what you're looking at and who who you're who you're reading. So it's more best practices. There's no real hard and fast. You know, this is how it needs to be done. It's more, you know, we're recommending this and that.

9:00

And, you know, I wanted to to kind of focus on the the groups that affect us the most and and kind of branch out from there. And and most people in, whether it be high school or collegiate professional sports, one of these are gonna gonna affect you in some way, shape, or form. So We're gonna kinda take take the time to go through all these different entities and and kinda what they're recommending and what they're saying. And the the Internet interesting thing here is that the the 6th international consensus statement is about to come out. So and I believe it's coming out the end of this month, if not the beginning of May.

9:34

So I anticipate that there's gonna be some convergence here. So, you know, where these differences are. Excuse me. Where these differences are coming into play, I bet that that we're gonna see some some realignment, some some changes to some some programs and protocols and recommendations and things like that. So it's gonna be interesting to see what what happens with that.

9:57

So the first one that I chose, obviously, was the NETA, which is obviously the one that I I see the most. And something popped out at me that that was very, very interesting. If you go on the NETA's website right now, there is a a when you go into the educational part of it, there's there's position statements on certain topics. There's official statements on certain topic. There's consensus statements on certain topics and there's support statements on certain topics.

10:24

None of these links currently have anything that talks about a current, you know, recommendation for concussion management. So that was interesting to me. And I think it's just because of the the the most current position statement that we have as athletic terms is is too old to be. You know, to still put up there. I really anticipate again after this the 6th update that that's gonna change.

10:52

But right now, that that was interesting to me. So I went back and looked to the journal of athletic training and found, you know, how long ago because I knew there was a position statement. So how long ago was that position statement? In print. It turns out it was published in 2014.

11:07

And I believe that there's obviously been some more positions statements or different recommendations put out since then from other bodies. So it's probably why that's not there. But it was just interesting to me that if you go there and look, we don't have you know, something going on that, it should be there. So the 2014 version of this position statement you know, it it it really focused on the definition of education of concussions. And that is probably the most overlapping theme in all of these different different groups and organizations, and and what they're recommending is is the heavy push on the the hard definition and the education about the the management itself.

11:49

And then it went into evaluation and a safe return to play, which I think is probably a little updated at this point in time and and could be updated, which is probably what's gonna happen. An interesting thing about the NCAA of the NCAA Sports Science Institute doesn't necessarily have a recommendation or a best practice of a more of a protocol checklist. So they they have things that they recommend that that and I think their recommendations for all their member institutions are it was a way that they weren't trying to tell you exactly how you need to do it. They're just giving you recommendations of in some way, shape, or form, you need to have some preseason education. In some way, shape, or form, you need to have pre participation assessment, baseline testing, recognition, identify somebody preferably a medical doctor that is the person that diagnoses and Clear is essentially your your student ethics for a turn to play.

12:50

And then how are you you managing these people post concussion and an additional planning as it needs to go through. So that that was pretty pretty interesting to me that that they give you more of a checklist versus more of a management plan. And then going into looking at the NFL, and obviously, this is in my opinion, probably the where this is the most scrutinized and and most visible is in the NFL, especially kinda going back again to the 2 attempts of LOS situation. You know, they're under a microscope, I would argue more than anybody is on us. So and it would make sense that with the NFL Players Association involved in this and their medical that this will be the most detailed and most stringent return to play in diagnosis and education plan, and it sure is the head and neck and spine committee.

13:38

Has a plan. It's it's less than a year old. I would I would believe that when the 6th statement comes out, that there's gonna be some changes to this too. But, again, education and a and a plan to educate these people was in there as well. And then the management protocol, they broke it down into preseason versus in season, you know, who's involved and and, you know, obviously, it's it's well known that they, excuse me, really push for unaffiliated medical people to be involved in this so that people that are away from the team that are not associated with the team have a say in the diagnosis and and essentially the clearance to return to play or not.

14:17

Obviously, it differed from side of back to the locker room and and really where this had the the most meat in my opinion was the return to play protocol. It was very, very specific, multiphase. You know, they had to reach this before they got to this, and then it had to be, you know, a step by step clearance process. And they even had some some examples included in their in their protocol as as far as how to progress these people and and who's involved and that kind of thing. So very, very detailed management plan and very probably one of the more current plans.

14:50

And then one of the interesting things that I I I like to look at too is, you know, where I I think more athletes are involved in this than anywhere else in the country is the high school level. And interestingly enough, all the 50 states in in the United States have a law on the books. But the laws very, very wild widely. A couple examples of this, you know, in in in our state of Alabama, you know, concussions must be confirmed and cleared by by doctor whether it's an MD or a DO, but they're the only people that can return these these athletes once they've been diagnosed. Nobody else can do it.

15:26

You go to look at New Jersey. You know, they require all of their student athletes to have impact baseline testing. At least based on this. So at the bottom of this page, there's a there's a kind of a a a link to this this website that that kind of reports all of the the high school information. South Carolina and Arizona allow same day return to play.

15:51

Nobody else does that. So all the other states didn't allow that. There's 8 states that include Alabama. That have those standards about the doctors, you know, being required to return them to play 18 states, doesn't necessarily have to be a doctor. You know, it can be a selected provider that's approved by the state to return their athletes to play.

16:09

And then 24 states said anyone that was trained in concussion management. I'm not sure how that training goes, but and maybe somebody on here kinda like me on that. But anyone that's trained in concussion management and deemed by the state to be trained can essentially clear somebody to to play. So those those laws and those regulations very very wobbly or widely, not wobbly. Sorry.

16:32

But they they they're different. So, you know, there's no standard there. But as long you know, the good thing is, I guess, deposit to that is is that every state has something on the books. So it's being regulated and it's being monitored, but but how it's handled varies drastically. So just something to follow there, especially if you're in in the high school world, you know, I would say you need to make sure that you're up to date, especially if you're moving one state to the next, you know, your your state, you're in now, may have one set of management regulations, but the next stage you're going to may may be harder or easier on it depending on how you're doing.

17:08

And then one of the the most surprising things to me, and I guess it shouldn't have been considering how how up you know, up close in in the forefront this this topic is nowadays. You Google Scholar, concussion management sports. You get 54,000 matches. So there is a ton of information out there research literature about this this topic. Pubmed has 38 systematic reviews 11 random controlled trials, all in the management of concussion.

17:37

So there's a ton of information out there. And I and I guarantee you when the next consensus statement comes out There's gonna be a lot more. So interesting to see that if you're if you're interested in this, there is no shortage of of reading material. And then one of the the more interesting articles I found, it's linked on this page here, but I took a lot of the statistics out of it, and it was just interesting to me to see how prevalent this is. 1 to 1,800,000 sport related concussions per year Approximately 400 of those are in 400,000 of those are in high schools alone.

18:12

And and I really think that number could be higher. You know, they talked about that the the numbers come from the way that the high school and the collegiate athletes are tracked. So if you think about recreational sports or just the the kids that ride their skateboards or the amount of concussions. I I was 18. We were all 18 at one point in time and did some dumb things.

18:32

I'm pretty sure I've had a concussion too in my life. So you it's hard to to really put a number to that. But if if this is how many numb you know, how many concussions are reported, from sport. I can only imagine how many kids are dealing with this coming up as they're growing up and getting older and and whether it's sport or not sport. So let's kinda go back a little bit and and kinda pick up ten thousand foot view on the concussion management plan.

19:02

So so everybody should have some form of of of plan as for for when this happens. Not if it happens, but when it happens. If you're taking care of athletes, this is going to happen. So we need to have a plan in place. We need to make sure that it we're following that plan.

19:17

And we need to make sure that plan holds water. So, you know, that we're doing what is recommended to us to do or in the case of an athlete having a concussion. And these can be very challenging. The guidelines and the recommendations, they change, and they're gonna change again. And they will change again after that.

19:34

So and that's really a good thing as as more eyes are on this and more people are kind of evaluating this. That just means that we're gonna get the best possible outcomes and the best plans as as far as how we can most accurately take care of these athletes. So make sure that they're and then we're not putting them in harm's way. And that to me, that's the the most important part of this. It's in the spotlight more than ever.

19:56

We have got to get this right. We can't complicate it. The more complicated we we make this, the the more likely we are to mess it up. So, again, I I I put an emphasis on the fact that We just have to get this right. So what do we do at Alabama?

20:12

And I'm by no means am am I saying that what we do is is the right thing, the best thing. I feel like it's a good thing for us, and and we have put a lot of time and effort into how we manage our our sport related concussions here. Right now that our our protocol management situation is is based off of the 5th inter international consensus statement. Obviously, we'll take a look at the new one when it comes out and see if if we need to make updates or changes. But right now, it's in 3 phases.

20:41

We have a baseline testing phase. We make sure that everybody Excuse me. That is on our team is baseline tested. So God forbid, something happens to them. We have what their normal is.

20:53

Excuse me. So that we know in the event of an injury, what we need to do to get them back to normal. Once the injury has been diagnosed, we have a concussion management plan. And it's a phased plan. We'll go over that in a little bit more detail.

21:11

And then once they're technically cleared by our physician to return to play, they're not just thrown to the wolves. We have a step by step return to play protocol or program. And it's not hard and fast. It doesn't say this step, this step, this step, this step, it's every one of these head injuries is gonna be different. And we we we follow us at a guidelines, but they're gonna be you know, progress differently depending on what, you know, we don't progress every knee injury the same way.

21:38

We don't progress every shoulder injury the same way, but this is no different. We're gonna manage each person differently depending on their personality and their mindset and and their symptoms and and kinda go from there. So what we're currently doing now is something that we decided to keep I don't wanna say keep simple, but we wanted to keep it effective and efficient. And we have a 135 to a 140 guys on our team and wanna be able to do this easily, somewhat quickly, inefficiently, but accurately. We want to be able to repeat it.

22:17

So right now, we typically are going to use the SCAT 5 form, and we're also going to use a balance system with the Biodex. It's we do the modified CTSIB program. We're gonna repeat this test every 2 years. The only outlier there is if we have somebody that has a significant concussion, and we feel like Once we've gotten them back to normal, it takes a long time. They're they're out for a little bit.

22:45

It was a pretty good injury. We're gonna baseline test them again. Just to get the most accurate baseline that we have. Something else we're doing, you know, we we we realized that The the SCAT 5 and BIOX is not the only way to do this. There are other technologies, and we are constantly evaluating what's coming out and what's out there and what's available.

23:07

And and making decisions between our team positions and us and and different sports. What are we gonna use? There's sway impact log impact 3 c 3 logic. There's a lot of different things. There's some stuff coming out with virtual reality.

23:21

We're big on virtual reality here with our rehab stuff. But there's also some virtual reality components coming out that we can, you know, as far as, like, bombs and things like that that we can use that we're kinda you know, looking at to see if it has any validity to where we can add this to our programs. But right now, we're in the CAT 5 program with robotics balance. System. That's that's what we're doing because we can replicate it pretty efficiently and pretty easily.

23:49

Will that change? Maybe we're we're like I said, we're looking at other things. Currently, we're looking at Sway to see if that's something that we we could use. But just I would my takeaway from this would be, you know, know what's out there and and see what works best for you. And as long as you're covering best practices and and and taking care of your athletes I I don't necessarily think that one is a bad thing and one is a good thing.

24:11

I think as long as we're doing something and we're accurately following our athletes and taking care of them and make sure we're clearing them in the right way. I'm not so sure. It's it it necessarily matters which one we're using. And we're going to our concussion management. So this is what happens for us once once somebody has had a concussion or been diagnosed with a concussion.

24:35

We're gonna we're gonna start with just simple serial, simple checks. So the first thing we wanna see is that their their their complaints or symptoms are going down. Right? And based on how that progression happens with our with our serial symptom SCAT 5 sheets plus our our doctors are gonna see these people repeatedly that will return that will kinda tell us how we're going to return to learn, and I don't want this being returned to learn for a school. You know, for us, there's meetings involved with football, there's meetings, you know, there's things involved outside of football.

25:13

So we're gonna use our symptom check first as long as they're progressing the right way to decide when and where we're gonna return these people to different aspects that have nothing to do with sport. Nutrition, supplemental considerations are huge for us. Our nutrition department is put on notice for everybody that has a head injury so they can, you know, change their diet, change their supplemental intake so that we can use to the vitamins and the the fish oils and things like that that are gonna they've been designed to to help with brain health and hopefully get those people back feeling better quicker. And then before we ever technically return this person to play, We're gonna do some type of non football related progression progressive exertional exercise type thing, get their sweat a little bit, get their heart rate up and see if you know, that progression can still continue. And then we're gonna talk about return to play.

26:14

Again, this is this is how we we do this based on, you know, how our docs are interpreting the consensus, the most recent consensus statement of the 5th one. Obviously, this may change with the 6 We're going to repeat that baseline testing protocol and see if they've normalized all their testing data to back to their pre Taste baseline testing. Our physician is gonna have the the ultimate NSA as far as his exam and clearance And when he says they're cleared to go, it doesn't mean I you can go play Saturday. It's gonna be a continued progression just like it was in the management portion of it. So we're gonna start out practice with our whales having their pads and their shoulder helmets on.

26:57

We're gonna do some non impact exertional activity and see what that does. If that does well, We'll clear them to do some contact in practice, certain drills, progress them up to a normal practice. They do well with that, then we're gonna return them to play. It's gonna be a staged process, but just like I'm sure most people are doing. But we're gonna be really careful to to not set these people back and and have to start this all over again.

27:21

So be very careful about how fast we progress. Alright. Here's a detour. To understand, you know, where the tent came from and why it why it's useful and and the benefits of it. I figured we could take a little dive into the history of of the tent and and the tent that we use and most people are using now isn't the first tent that was ever available to sidelines.

27:49

Obviously, we've been around for a while. There's a couple of pictures on here of some some different ones. You know, most high school games that I've been to. There's several of these ones on the right side of your screen, you know, maybe not the most practical as far as privacy, but, you know, they do provide benefits to the teams. And then some different variations of of ones you see under different college side lines, but the tents have been around for a while, but nothing new.

28:16

Our our tent obviously was created by Jeff Allen in the the engine College of Engineering here, and it started as a senior project. You know? Jeff says that The problem was there was a lack of sideline medical confidentiality. And necessity is the mother of invention when he he presents on this. That's a quote he uses.

28:38

But we came up with a a problem. You know? And and you can see in his first picture, you've got a person who could potentially have any kind of injury. It doesn't have to be a head injury, but Maybe they just blew their knee out, and and they know what's about to come, and and they're they're in the worst position of their life. They're they're, you know, they just got hurt.

28:56

They can't play. And There's a hundred thousand people staring at this kid cry on the sideline. And, essentially, it's it's imagine walking into your doctor's office. Okay? And you sit in the waiting room and the doctor comes out to you and and decides to evaluate you right there in front of everybody else.

29:14

There's there's no privacy there. There's no confidentiality there. And it's a nerve racking experience. And and you gotta imagine for the doctors and for the patient, this is a extremely awkward situation. It's been going on forever.

29:29

And and, you know, one day, Jeff decided, you know, there there's gotta be a solution to and and I'll tell you a story. This is when I knew that I was not gonna be a capitalist mindset, you know, as far as creating things that you could market. You know? He he brought this tent to the the backdoor of our athletic training room, and and he said, take a look at this. This is what I got in mind.

29:50

This is what we're kinda doing. I'm like, my mind, I'm like, this is the dumbest thing I've ever seen in my life. This is never gonna work. Nobody's gonna buy this. This is and then I walk back into my office and 10 years later or so, every college has got 1.

30:03

Every NFL team's got 2 or 3 of them, and I see them on high high school sidelines all the time. So that's when I knew that I needed to stick to rehabbing knees and ankles and not worry about trying to sell things because I didn't know what I was talking about. So, again, created in 2015 by Jeff and the College of Engineering. Turned into a a company that obviously is going stronger today, selling a lot more things than just tents, but Canada exports started in 2016, and and the rest was was history. So why this is important is, you know, again, initially, the driving force was pay patient privacy, but what we found out too is that it's a it's a better quality side on evaluation.

30:47

It's a more efficient way of getting things done, whereas before No. We may have had to take this person inside for everything we wanted to do. Excuse me. We have a we have a portable X-ray machine now. That we keep on the sideline.

31:01

We can do x rays in this tent. Normally, we'd have to take somebody in. As far as a football game, that is that is unbelievable about how how much that changes our time frame of of either clearing or not clearing somebody for any kind of injury. When we would have had to walk inside to do that before. So it it really changes our efficiency on the sideline.

31:21

Think about how distracting that could be with you know, in SCC school, for example, you're you're looking at up to a hundred thousand people on the sideline watching you, not to mention that the TV camera is right behind you. And there's a microphone there and trying to listen to everything you're trying to do. High schools, you know, there's some high schools that there's just there's no there's really no limitation to access to the field. You can come right down on the stands. A parent can come running down and see what's going on.

31:46

It's just it's just hard to get a a quality evaluation without distractions at that point in time. So having this available, just just makes sense as far as allowing us to do our job better and and and kinda to to take this into to the sideline and to concussion management injuries in general. It just made sense, and and I think that's probably why in hindsight, it's it's why it's taken off so much. It's just in the world of of being sensitive to our athletes and to their their needs and their privacy, it just it just makes everything better. So kinda going back to the sideline now, and talking about how how we're gonna manage our injuries.

32:27

So to me, it's it's important to understand you know, where where are we gonna get this information from? How did how is this injury? Whether it be a injury or not is is brought to our attention. Is the player down on the field? Are they in distress?

32:40

Does does that phone ring on the the back line that never rings? They're telling us that the spotter saw something that he didn't like he or she didn't like. It it was a sideline personnel told us. It was a coach or another player, hey, to go check on Jimmy or Joe, you know, something's wrong with him. What is it in the locker room, half time?

32:59

All these ways that we get this information you know, have have something to do with how we manage them and and how quickly we have to make a decision. So we get somebody down on the field. You know? We need to figure out really, really quickly what are we dealing with. You know?

33:17

Our philosophy here which is different than other people. And I'm not saying we do it right and they do it wrong. We just do it differently. If we can get this person off the field expeditiously, we're gonna do it. So we need to to triage very, very quickly and find out, you know, what's going on.

33:32

Okay? Is this person safe to move? Are they not? Is this something that we need to package and get to the hospital? Is this something that we obviously know that we have a serious injury, do we need to get them into straight to the locker?

33:44

Is this something we can get to the sideline and take a breath and see exactly what's going on? Is there an injury there or not? Did they just get the wind knocked out of them? Is there something going on? That we need to follow-up further with.

33:53

And then if we do, that's when we're going in the tent. We're not gonna we're not gonna evaluate anymore on the sideline for you know, prying eyes to see and for them to be nervous and anxious about we're gonna get in the tent where we have a a quiet environment in a in a private environment, and and we're gonna gonna start our process from there. We get to the sideline and this happens. This is decision time. So every way that works, a score can attest to this, you you have to obviously, 1st and foremost, the the the athlete's health is the most important thing, but but you're working a football game.

34:28

And and decisions that you make on the sideline by not by informing or not informing a coach or something about what's going on. Can cause a ripple effect. You only have you have a player on the sideline that nobody knows is out, and there's 10 guys on the field, and they or touchdown or somebody throws an interception or or it can have real life ramifications to your game. So so timely notification is hugely important. So luckily, you know, for us, we have a big enough staff.

34:54

We can do that, but in my mind, you gotta have somebody telling people what's going on. I'm not minimizing what's happening with this person's injury. Are they okay or not? We need to figure that out. But we also need to take this time to to make sure that everybody knows that we're dealing with help him with this person.

35:09

Went in to output him in the dent. And then this is not necessarily just specific to head injuries. This is specific to all of our injuries. But, obviously, you know, we're we're talking about how we're gonna take care of head injuries on the sidelines. So this this is applicable.

35:25

So then we're gonna get make a decision that we have a suspected injury suspected head injury. We're gonna put them in the in the tent. That way, we can do a quality evaluation. Ideally, for us, it's going to be done by our physician because we want to make sure that at the end of the day, we're we're doing what's recommended to us and and then a physician taking the lead on whether this person does or does not have a concussion or head injury is is is how we wanna do things. And the tent comes into play here because think about working at a high school and you may have one doctor on the sideline with you.

35:59

That doctor can't go into the locker room with one person. And and leave this I nine exposed. So having something like this available allows for a a more expeditious process, and that physician can still be there kind of monitoring the sideline for anything else going on while he's taking care of that injury. But it just minimizes distractions, gives us some more quality evaluation and allows for a a a large team with minimal resources to do a really quality job taking care of these suspected head injuries or these concussions. So now we're gonna go to kind of the the the we've got a guy.

36:40

He's he's made it off the sideline or from the field to the sideline, and and we're really suspecting we're worried that this guy's got a concussion. Okay? So now we're gonna make the decision, let everybody know what's going on. Everybody's on the same page, docs taking this person into the tent. So when I started to get into this part of of the presentation, I wanted to get I'm not the one doing this.

37:02

I may be in there with them. Somebody else on our staff may be in there with them, but I wanted to make sure that I get this from the horse's mouth. So so this part comes directly from our team physician. And what how they're gonna go through this process. So we don't need to complicate this evaluation even though the injury can be complicated.

37:24

Which kinda sounds weird. But we wanna make sure, you know, that this is what it is and it's not something else masking. For a head injury or something like that. So we have to get this right. Even though know, the biggest problem I keep going back to that to a situation.

37:42

You know, the the biggest argument that was had there was was did they do this the right way, and I'm not I'm not here to say they did it. They didn't. That's one thing I try really, really hard not to do is I was not on that sideline, and I'm not on anybody else's sideline, but ours. So you never know what truly went on there. I'm not trying to judge anybody.

38:02

But in the media that that just got hammered about whether that was done right and and all that kind of stuff. And and I think that's gonna happen regardless, but we wanna make sure that at the end of the day, like I'm sure they did, but they wanted to make sure that they could justify what happened on that sideline when it came down to it. Because regardless of of the outcome, you're gonna you're gonna have that situation. So we wanna get it right, and we wanna make sure that we have the the the most accurate up to date current sideline tools, including that tint. To avoid distractions, to get us a a really, really good thorough evaluation and and to make sure that it's accurate.

38:38

You know, years ago, they didn't have any of this stuff, and you had to do this stuff in front of all these people or you had to walk them all the way inside. So thankfully, This has evolved to the point where we can do this on the sideline in a in a well scripted, really accurate manner. So as doctor Stuart would say, you know, when he's doing this evaluation, the first thing he's gonna is a is a physical exam. You know, head injuries can mask a lot of things. It can be other things going on that aren't necessarily concussion.

39:10

So do they look okay? You know, is there any obvious external injuries? The biggest thing that I I've learned in my time of on a football sideline is when somebody's gotten their bell rung and got a pretty good concussion, it it is pretty obvious. The lights are on with nobody's home. I I the first time I'd ever seen it, I concussion in person.

39:29

I was playing high school across, and and I still remember the kid's name was Taylor. And and he got he was a defensive long stick mid filter. And he got hit from the side. And, man, you would have thought he had had a whole bottle of vodka or something. He was just you it you could just tell.

39:46

He was there wasn't something there was something going on there. And, obviously, now years later, having been educated and the stuff I I realized that you know, he got a concussion, pretty bad one too. But they don't look okay. The lights are on, but nobody's home. But we have to roll out other things.

40:01

We need to make sure that that's what we're dealing with, and we're them with something else. Is there an obvious external injuries or broken nose or or bidders or an eye problem? Is there something going on inside that head that's more than a concussion that we need to deal with and get them transported somewhere else. So we need to make sure that we're rolling out all the more I'm not trying to minimize the concussion thing, but I'll make sure we're not overlooking some potentially life threatening situation. Once we feel confident that we know what we're dealing with, we're gonna do an initial symptom assessment just like we would do in our baseline or just like we would do we're on the practice field, we pull somebody off because we think they got a concussion there.

40:38

It's gonna be the same. We're just doing it inside the tent. Then we're gonna go Doctor Stewart's gonna go to a neurologic assessment. So he's gonna do a cranial nerve assessment, reflexes basic sensory and strength, testing. This is gonna be the point where we we know.

40:56

Okay? This person's got it or they don't. And we're gonna know whether we need to hold this personnel. And maybe we're on the fence, and we have to to administer some another round of our our concussion testing, our our our Scott 5 or something like that to get just to get more evidence one way or the other to make sure that, hey, they're cleared to go. This isn't an eye injury that's giving them headache or or, you know, something other other than that, they got hit the nose and their nose broke, but their head's okay.

41:24

You know, we need to make sure at this point in time that we're doing the right thing. And and and when all else fails, we're gonna be we're gonna be cautious on this. Whenever we talk about things here that we're not gonna we're not gonna push, we're not gonna be aggressive with. It's the head, the heat, in the heart. It's through 3 agents we like to talk about here a lot is, those are nonnegotiable.

41:48

Now if we have somebody with a hamstring and we're we're we're we're judging whether how bad that hamstring is and what can we wrap it or put a strap on it and and they wanna try and go, you know, there's some negotiation there. But those three things, head, heat, and heart, we're we're not messing with. So there's a there's a no go every time, and we're gonna make sure that we're doing these the right way because Somebody's life is potentially at risk there. Somebody's longevity, their their quality of life could could be impaired, and and we're gonna make sure that we're doing this the right we're gonna hold these people until we know for sure what they've got. We're gonna move these people to a locker room.

42:25

They're obviously disqualified from the event. Keeping them on the field doesn't do us any good, doesn't do them any good. So we wanna give them some rest from the stimuli that's potentially gonna aggravate what's already going on, the lights, the crowd, the game itself, the interesting environment has never been on the sideline at Friday stay even for concussion, but I can imagine it would probably be a very overwhelming feeling. Plus, we can get them inside and and give them a little bit of time to rest from the initial injury. We can take them inside, do a do a more accurate test, repeat our our questions, and just just kinda see what the progression is of this.

43:01

Is it getting worse? Is it getting better? We can see kinda where they're at now. The dust is settled a little bit. And then the docs are gonna do some of their testing, like like, this is of the stuff that Ray likes to do the bombs and near port convergent, repeat the balance testing, and then serially repeat these if necessary.

43:24

We wanna make for sure that we are in a situation where we know we're dealing with a concussion and we're not dealing with something that could be progressing. So the symptoms could be getting worse. Something could be going on that we need to to transport this person for observation or for scans or for something else to make sure that we're not missing something. Again, we gotta get this right because the the the consequences of getting it wrong could potentially be catastrophic. And then post game, you know, what are we gonna do after the game?

43:55

We diagnose this person with concussion. We're still managing this thing. For most people, a home game versus in in a way game, there's there's a very big difference in how we're gonna have to manage this. There's time limitations. If they were at a home game, for example, you know, the amount of time we have to watch this person depending on how long how early it happened in the game changes.

44:21

So we wanna make sure that if if we're gonna let this athlete leave the stadium that We know who they're gonna be with. We know we feel comfortable that we know what they're dealing with, and we can educate him and for her and the people with him on what to look for and what to monitor because we don't want them to leave and go home and something bad happened. Who call in the event that something happens, what to look for, to recommend transporting them to the hospital or something like wanna make sure that they're in a good spot before we let them out of our site. We're traveling, obviously, our time limitations to leave the stadium go up we we gotta we we only have as much time to get on the bus or get on the plane. But that travel situation allows us a window of time to continue to monitor that person.

45:08

So maybe one of our staff goes and sits with them on the bus of the plane and just kinda see, talk to them every once in a while, make sure that they're they're symptoms are progressing in the right way. Things aren't happening that concern us. So they have their pluses and their minuses. Plus, you gotta think about at least in our situation in NFL. Do they have postgame responsibilities?

45:28

Do they do they have to meet with a coach? Do they have media? Do they have things that typically happen? And do we need to address that and minimize that or get them out of that kind of stuff. And then either way, we need to make sure that they're educated on what to look for, what to do, and what the follow-up's gonna be.

45:43

Down the road as far as coming back in the next day for treatment and follow-up testing and things like that. And then from there, we're typically gonna do our our typical standard, you know, post op, it turns into a, you know, 3 stage testing protocol for us. So from there, we're going to continue to it turns into just a regular confession, which we have our plan for. And we're gonna address and attack those the same way every time, whether it was in a game or whether it was not a game. So in summary, for me, I would say no good literature.

46:26

Stay current on what the best practices are. Again, that 6th international consensus statement is gonna be coming out soon. So make sure you know what that says. And if if it requires or recommends that we we change how we're doing things, We need to do that and then make a make a change to our plan so that we can, you know, make sure we're we're we're following our best practices. Have a good management plan, make sure it's consistent with the current machinations, and and don't overcomplicate.

46:54

We there's that we could we could be doing a ton more stuff that we need and we're doing right now, but we we feel like, you know, this is a a a test that we can repeat a 150 times. Is it is consistent with what's recommended for us to do. Our doctors are comfortable with it. And at the end of the day, it can be replicable, and it can be something that is available to us to effectively progress somebody back from an injury and make sure that we're not putting them back on the field too early. Evaluate your sideline.

47:25

Make sure that you have a sideline situation that's conductive or conducive to a quality effective quiet which we're looking for. Just a way to do a a private, you know, evaluation so that this person's, you know, information and and and businesses and out for everybody to see. Just just whatever situation you're gonna financially field wise, space, just, you know, evaluate this to make sure that you're doing it the best way to you can. And and if you if something comes up down the road that you feel like it could change it, don't be afraid to change it. We're always looking for new waves around here to to make sure that we can provide the best care to our athletes that we can possibly.

48:09

And as far as concussion evaluation, that's no different. And then be proficient in whatever you decide to do So whatever you die, you decide to go with, be proficient in it, practice it, make sure everybody and your your management team, your medical team is on the same page. If somebody gets a concussion or somebody gets an injury, this is how we're gonna handle it. And then practice it so that when when that happens, you know. This is okay.

48:31

This happened. This is what we're gonna do. That's all I got.

48:41

Jeremy, thanks. This is fantastic. I know we've already got some questions lined up. I think the one of the things that I've got from this, and I think, you know, I think everybody else you see as well, and you definitely emphasize this in the last slide as being consistent. And, you know, one of the things I I'm a I know, you know, who this is is Mike Malliston, Doctor Malliston, who was at Southern Mischief Surgeon, one of the things he said probably this was, like, 20 something years ago.

49:04

They sold me and that's always stuck with me or and our staff was, whatever you do, be consistent. And concussions is so I mean, you I think y'all seen this. It's so it's almost like the Wild Wild West, so to speak, and I think you did. You more than emphasize that is you have a you have a plan in place. It's a model.

49:24

You you practice it. You rehearse it regards to the setting. To be high school. And I think the one thing I thought just a minute ago is, you know, if you're to high school and you don't have the have it's hard to get resources, we communicate with EMS and say, hey. They have a closed area in that in that EMS unit.

49:40

I cannot borrow a unit a couple minutes. This is due to quick assessment off the field. That way, you know it's there, but also doing those vital sound assessment. So let's go ahead and get to some of the questions. So if you like to, ask your question in person on the on on the on the call or exit on your audio.

49:57

Just hit a thumbs up, and I'll I'll add you I'll grant you audio access and get you on here. So let's go ahead and get started. I'll give a second or so so you might have us do a thumbs up and talk to see 1 or 2 here. Let's see here if I can get this correct here on the think I could see this, I guess. I'm I'm learning this a little bit if how to use the the thumbs upside.

50:29

But sorry about that. We'll go ahead and get started with this from a minute ago. So here's one question from Sean is University of Georgia's release concussion research looking at driving post concussion driving post concussion. And if if you can answer this, does Alabama limit driving post concussion for any patients?

50:50

It's a it's a case by case. If if we have a concussion who is struggling, then, you know because, obviously, they're they're coming in different different levels of of severity. So if if we have ones that are they're obviously impaired, Yes. We're we're gonna take precautions. You know, we have but we're fortunate enough that we can do that.

51:16

We have enough people that we can have somebody take these people home or ensure that somebody's gonna be, you know, family members gonna be coming to pick them up. We don't have a affiliate protocol in place for that that every concussion does. But I'd be interesting to see that research because, obviously, like I said before, we are always willing to change based on the things that we see. So I'll make myself a note of that and and look up that research.

51:43

Okay. I just dropped in. Eric, if you would, you can turn your audio on and go ahead and fire away your question.

51:53

Can you hear me?

51:55

Yes. We can.

51:57

I guess I have another question. On the university level. And if you guys are doing anything of education on your athletes wearing helmets, when they're on their bikes or their scooters across campus because we've seen some concussions coming to us that way. So I was curious if you guys have implemented any requirements?

52:20

No. We haven't. That's a that's a really good thought because we these electric scooters, and they all buy them, and they run around campus here. And and there's some kind of service here at University that has these these It's like a bike, but it looks like a scooter. It's but you can swipe your phone and drive this thing around campus, and and nobody's wearing helmets on them.

52:41

So that's that's a good that's a good thought. We we do not, but we probably need to look into that.

52:48

Great. Thank you. Thank you, Eric. Excellent question. Excellent question.

52:53

Next question, I've got I'll move this around a little bit. So Aaron asked, I've heard about complications. It may or may not be caused by air travel shortly after sustaining concussion. Have you seen this in any of your athletes or heard of this and know anything or the validity of this concern?

53:11

We have not, and you know, thankfully, we, you know, we we don't have a ton honestly, we see more concussion problems in our preseason. I think that just goes to volume. And I'm not saying we don't see them in games, but if you look at our statistics on concussion, the large majority of our concussions come in in the preseason, and and we've, you know, implemented the the the Guardian caps and things like that to try to try to curb that. But I have not seen anything. We haven't had any complications for flying when we do have somebody with concussion to to knock on wood to this point.

53:48

But I'd be interested to see that research as well and see if there is some validity to that. But for us, we have not seen that.

53:54

Okay. So as a follow-up question to what Aaron had the same kind of a question here is and I'm well, what her on her question, do you look at specific symptoms to determine what school modifications are needed and for how long or so with symptoms, what is the threshold to know they are ready to turned to full school or no additional help with their studies.

54:23

I don't have a hard and fast answer for that. Typically, what we're gonna do is we're gonna follow-up our symptom scores with our team physician, and and we're gonna allow him to to kinda make that determination. You know, once they once they reach a certain threshold, and it's not certain symptoms. I think it's just a when a level gets to a a a certain place where we feel comfortable and just how they're acting and how they're complaining about or how they're reporting their complaints and their symptoms, then we're going to determine about when they can go back to class and go back to meetings and things like that. But it's not we're not specifically looking at at at at number 2 on the headache scale.

55:03

We're letting them back to class, or do they have to have it's more of when we see things trending in the right direction over the the a series of days and certain symptoms are going away. We typically have our guys follow-up with our physician in season, especially daily because they're they're here every day. And and make sure that that he's comfortable, like I said, here our physician drives majority of our decisions as far as when to do what and we let him kind of dictate when we feel comfortable. Talk about how they look to us and what he sees and and usually allow allow them to go back to class based on that. We don't specifically hit it.

55:43

We're we're hesitant to to put it into specific thresholds because, again, each concussion is different and each situation is different. So I hope that answers your question.

55:58

Great. Fantastic question there. Another question is, what are you all doing as a baseline test for 1st tier participants? And then what baseline test you perform for turners every year.

56:10

We're using SCAT 5, and that's the test that we're using right now. We're we're looking at Sway to to get something that's a little bit more current digital type deal, but we use CAT 5. We we have discussed at at at length, whether we wanna do something additional. But SCAT 5 covers us as far as everything that we, you know, our best practices recommend that we do, and we can we can cover every portion of of management based on that test, and it's it's fairly easy for us to duplicate, and it's sufficient for us to do. So that's where our physicians want us to go.

56:51

Okay, great

56:52

question. Here's another one in the give me a a minute to read this. So during a recent discussion with my high school principal, a former a d, he stated to me that concussions are most overdiagnosed injury in healthcare and that there are cases now where athletes are suing providers and entities for withholding them from activity due to this time law their time loss hurting their NIL bills, scholarship opportunities, and or bonuses. I've not been able to find any articles or cases supporting this but wanted to ask if you have ever heard or seen this. And also thank you for your time and presentation.

57:28

We we have not, and, you know, I hate that that, in my personal opinion, we're we're such a overlitigious society as it is. I hate that somebody would sue people for for keeping their best interest in mind. I mean, for 1, I could see it the other way. You put me back in the game too soon. I've got an injury because of it, but I would really hate to see somebody get sued because they they were trying to do the right thing by you and make make sure that your your head is healthy and you don't have long term effects because, you know, starting to see the long term effects of these head injuries down the road with with athletes when they get older and it's I would I would hate to to see you know, a decision made on my part the wrong way that could could lead to that.

58:13

So If if I've got your best interest in mind, I would hate to see that you're getting you're trying to sue me for that, but I would take that. So

58:23

Yep. That's excellent. So that's a hard question to answer. I think one is doing doing your best. And if they know you care and you do the things that show you care, those things would work out.

58:33

I think the other side is making sure you're communicating. You know, they're having a clear communication plan. You have to tell them everything, but you need they need to understand what the journal process is. And I know that you all do this because we did this when it was LHC. We have, you know, the hoping the the education side is really critical just not for the adults, but for the coaches, and for the parents, everyone involved, and you they see that consistently throughout, not necessarily for themselves, but they see that for their teammates and other athletes.

59:00

They see that already regardless of your setting, and they'll see that consistency, and they know that they're Alright. Let's move forward for a second. So another question is from Eric is, are you integrating low intensity exercise prior to clearance to start their RTP? And what do you look at to monitor intensity,

59:21

if so? We we do. When we get to a low threshold, when they're when they're when we're we're pretty close to baseline, maybe within 20 to 10, 20%, we'll start implementing some low low intensity type bike riding, things like that just to get their heart rate up. And see what that does. We don't do anything exertional as far as, like, we may institute some light lifting into that.

59:54

But as far as sport specific, we don't do anything until they've officially been cleared. But we do We typically do it. We do it based on car rate. So we have car reminders that some of our bikes have. It's not I'm not saying it's a high-tech version of of a way to do it.

1:00:12

But we'll we'll get them into a cardiovascular range on their heart rate and see what that does. And then we can implement longer periods of time in that heart rate. And see how it goes from there.

1:00:24

Great. Thank you. So we've got 2 of the you you have time to answer 2 of the short questions.

1:00:28

Sure. Okay.

1:00:29

Alright. So Larry Brown asked is ocular vestibular screening a component to the RTP screening.

1:00:39

No. We we went back and forth about that. We don't screen it because there are norms. So when we do VOMS testing, there are are diagnosed, not diagnosed. There are research and published norms as far as VOM scores.

1:00:54

So we use the norms versus a baseline.

1:00:60

Very good. Excellent question there, Larry. And last question is if someone took a ball to the face and they have a small headache, but no other concussion symptoms, are you still ruling it as a concussion and pulling them?

1:01:18

That's a that's a you know, that that first slide that I I showed you, you know, that eight year old kid. Yes. But in our situation, I'm I'm turning that over to the doctor. I I'm I'm fortunate, and I I know that that I don't have to make that decision. But if I have to make that decision, I'd rather be right the other way and and hold them and deal with that situation, then not hold them, and then they go out there and get hit again, and something catastrophic happens.

1:01:53

So I I don't I can't give you a certain specific answer on that question, but I'm gonna I'm gonna make sure that I'm not in my situation, I'm not going to make sure I'm the only one making that decision. We're going to have our physician involved and deciding whether that only symptom is enough to hold that person out or not.

1:02:13

I think to add to that and I've got one of the questions with oh, minute. I'm waiting for them to get a clarification on pipe it in. Is and we'll wrap things up. But I think it goes back to the initial assessment. You have to go through a for the referral assessment and make that you know, do vital signs, do those things.

1:02:29

And when in doubt, you are on the side of caution. I mean, concussions act I mean, you know, my electronic brain is actually pretty easy to I found since that, you know, when Zach Lifestyle law out in Washington came into play in 2009, it really just made things really kinda crazy in terms of all the places state laws. You you you alluded that state laws coming in. And even doing that, it's just a matter of just really being consistent in your evaluation. If you doubt and if you're in doubt and they're presenting with this and you aren't quite certain, it's facial trauma.

1:03:03

So I think it's another example. So until otherwise proven that if you aren't certain, get someone else to look at it. They may not like it, but, you know, I think, you know, Jeremy, you alluded this is, you know, it's just a game. There's we don't know what's gonna happen 15 years from now, and And I can tell you that 20 years ago so 30 years ago when I started, we didn't we were doing the right thing, but not knowing what they as much as we know about concussion. Now, we really don't know a lot.

1:03:30

We don't know what's gonna happen. We're trying to make those effective changes there. So let's see here. I think we had a question about, I guess, about this SCOAT or this scope instrument. And I'm not sure if let's see here if I get coming in.

1:03:49

Is are you aware of the scope instrument tool as a sport concussion office assessment tool, and it's discussed in international sport concussion conferences in Denmark. Are you familiar with that?

1:04:02

S c o s c o t I am not.

1:04:05

Yeah. I haven't heard of that either. I know Scott's the predominant one. It's a it's office tool. So I'm assuming it's kind of similar to that.

1:04:11

It didn't I don't think it's I haven't seen it get traction at least. That's that's the first time when I had seen that. Not that that means anything other than just not familiar with that, but using Scotts, the that coming out of that international conference is the one that's we've been using it, you know, pretty consistently.

1:04:28

Yeah. We're fortunate here. There's there's a there's two folks here that are in our education department that are very involved in in concussion research. And one her name is Lizie Elder and and and Ryan Maureen Maureen. Ryan actually helped me with this presentation a lot, so I appreciate him for that.

1:04:47

But I'm gonna go to him and ask that question because if if anybody here is familiar with that and it's something that, like I said before, we're obviously looking to make sure that we're using the best thing for us. So if if that's something that, you know, could help us down the road or something we need to change to, I I at least wanna be, you know, versed in it and educated on it. So we'll look into that.

1:05:10

Yep. So fantastic question there, Jeff, as well. So We're we're out of time now. We're running commitments over. I wanna appreciate everybody staying online for the last minute or so.

1:05:21

We had some excellent questions today. And again, Jeremy, thank you so much for your time, your expertise, ensuring what you all do at Alabama. I know that this is a it's always an evolving process and especially in in concussion management and best of luck moving forward.