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Um my feet, I think that's, um, I mean, that's the golden question, isn't it? And, uh, so I'll try to be as diplomatic as possible because we've got a definition that's been defined um, in the latest Amsterdam consensus statement of what is a concussion or what is a sport related concussion. But the way I understand and the way I like to put it, er, to my players and patients is that it's a traumatic brain injury, it's caused by a direct blow to the head or indirectly to the neck or body and that results in impulsive forces being transmitted through the brain. And I think what's really key to, to notice is that, or to note is that concussion is a disorder of function? So that's how the brain works rather than actual structural damage, like a skull fracture or brain bleed. Um, what then the sort of impact results in, is it triggers a chemical reaction, then you get blood flow changes, inflammatory changes in the brain as well as what we suspect now as possible, nerve cellular damage sharing and stretching of neurons. And then as a result of all of this, you get signs and symptoms and as the nature of concussion is variable, they may be, they may present immediately or they may evolve over minutes or hours. But most importantly, is most of them will resolve within a couple of days and players and patients will go back to their baseline and be completely fine. However, you do get some that are persistent, um whether that be persistent symptoms or just persistent difficulties with day to day function. Um and then you get some others that are slightly more complicated. But I think what's really important to note is that the majority of concussions will completely return back to baseline as long as it's picked up early and treated appropriately. Thank you, Doctor Tadmore. Um, Doctor Combs, just to put in the same question to you from a um neuropsychologist point of view. What, what is concussion and what is the physiology kind of involved into it elaborating on uh what Doctor Tadmore said? Yeah, I'll, I'll try to, to add to that because doctor doctor was already very comprehensive and a absolutely correct. So the only thing that I think is uh might be helpful to add is like he said, um we do expect most concussions which are classified as mild traumatic brain injuries to go back to their uh baseline and to fully heal about 80% of concussions, um will do so with without major complications, the 20% that don't, can have what we call a protracted recovery. So it will take a little bit longer. Um the average time of recovery, like for, for example, teenager and young adults like seems to be around the 21 day mark. So um three ish weeks is absolutely considered normal. But um even up to six months, some texts even suggest up to two years, it all kind of depends on what we're working with. And that's kind of what's also where we get into the nitty gritty with concussions because they're not a one fits all injury. So I conceptualize concussions as basically a profile injury. And there's five major profiles that the symptoms can kind of cluster into. We have the vestibular system. So the people that struggle with balance and equilibrium and feeling dizzy, then there is um what's called the ocular profile where they have trouble with their vision. So it's not the eye itself that has trouble. It is more the brain coordinating the eyes appropriately. There is the headache, migraine type predominantly, obviously the most common one. There's also the anxiety mood profile. We see a lot of concussion patients that struggle with emotional changes, um post injury that weren't present prior to it. And then there is also the cognitive fatigue profile, which is um typically difficulty concentrating, difficulty remembering all those kind of things. And we also have two modifiers which are neck and sleep. If there's an additional neck injury, obviously, that can mess with stuff. And then if the brain doesn't get enough rest, get enough sleep, that can also um impact recovery specifically. And I do wanna add that these profiles are not mutually inclusive. So when I evaluate people for this injury, we always wanna find out what, what is driving the bus, but they can have one profile, they can have all of them or any combination of them, which makes it such a unique and individual injury. So it's not a um everybody that has a concussion looks or feels the same type of injury. Thank, thank you so much, Doctor co that was um very comprehensive. I mean, I it did add, it did, it was good from a different point of view. So it did add quite a lot. Um So thank you um Doctor Tadmore. So I think you're alluding to it with your first answer with uh what is concussion? But what are the main causes um with maybe some examples of concussion? Yeah, I think um probably um because I'm quite specifically working with sport related concussion, I'm gonna keep it quite contact sport related and then maybe doctor Combs can add some there. Um So for my day to day job working in sport, primarily rugby. Um So the number one injury within rugby union as well as rugby league is concussion, which I think is quite concerning. Um and we've been doing some research here in the UK. Um And what I, the way I've sort of divided it is that you've got 49% of all concussions are caused by contact to the player's head. Obviously, you get other contacts. So, um, like I mentioned earlier, if you get a whiplash type injury where the body gets hit and the head flings back, that's one and as well as we get, um, sort of slightly other sort of subtle head knocks within a tackle that may not be directly to the head. But really important is that 49% are with direct contact to the head. Um, with 20% of them being head to head. So the head, both p tackler and the ball carrier being in the same space and their heads colliding 17%. So just slightly less than 20% you've got the ball carrier shoulder to the tackler's head and then 12% we've got tackler's shoulder to the ball carrier head. So, just slightly, um, swapped in. And if anyone's been doing some reading around concussion or sport related concussion right now, what's quite topical or controversial is the law changes that have been coming into rugby, um, to try and mitigate these risks. And as you've seen what I've just said, 50% of all of all concussions are in that space of head, head on head. So if we, our aim or our goal is to try, remove players from being within that space, cos then that will lessen the chance of having a head on head collision. Um So that's mine with, with rugby related football less. So another contact sports less. So, um, but just from a sporting perspective, um, you've got, uh basically as long as the heads are in the same space, you've got almost a double chance of, of uh, of having a concussion. Um So yeah, that, that's my more rugby specific take on it. Th thank you, Doctor Tadmore. Um Doc Doctor Combs, what are the main causes you've seen? Um, maybe in clinic out sport, um, of concussions. Yeah, so I'll, I'll talk about sports first since doctor, er, kind of got us started there and then I'll transition to some non sports things that we deal with quite frequently. So, um, yes, we, we definitely see very similar trends, right? Like any type of contact sport, obviously, it has a way higher risk, um, than non contact sports. That being said, I, I can't of a think, think of a sport that I haven't seen unless we're counting chess. Um, you know, even swimmers, I've seen golfers, tennis players, you name it. So it can literally happen anywhere. But yes, contact sports are um much, much higher in terms of chance and risk. So, for example, for in the US, um, obviously American football is more prominent and luckily through research, we've seen some changes, like for example, now it is illegal to uh talk an opponent's collar back to stop them, which uh 10 years or so wasn't. And so they, they're trying very much to utilize research that's coming out that is, um provides more insight into this injury to help inform uh rules and regulations to make the sport safer, to make it um better. That being said, uh contact sports always have a higher risk for women. Um Cheer tends to be the highest risk followed by soccer or football. Um And then for males, it is, uh, American football, at least in the US and then followed by ice hockey. Um, and obviously, you know, very different forces at play. Um, injury wise, uh, uh, the mechanism, at least I find in clinic does not alter necessarily the trajectory unless we have a lot of neck involvement. But those are very typical. And then obviously, youth tends to be, uh, gets to get, tends to get injured a lot more in sports simply because, you know, kids play school sports, they have club sports and then as they enter the adult world and have, you know, full time jobs, obviously, those kind of things tend to become more hobby unless we're talking pro sports level. Um, and so with adults, I see a lot more work accidents, uh, slip and falls or car accidents that result in a concussion. So for the adult population, especially for my older adults slip and fall, bad weather often is kind of the culprit that, um, causes that concussion like we pointed out earlier. It doesn't even have to be a blow directly to the head to the body. If the force is big enough, can certainly put people in that position as well. Thank you, Doctor Collins. Um, so Doctor Tadmore, what are some of the symptoms you would see in a, a con causes patient? Yeah. So again, um, we'll go with some s symptoms. So Doctor Combs also mentioned some of them earlier and I think what's quite important, I think maybe Doctor Combs will, will agree is that the mental health symptoms are, are often the ones that are most neglected by, by patients or not realize that this could be a concussion. Sometimes just an altering mood being more irritable, being slightly more sad or more anxious. These could be the only signs of a concussion. Um but it's important to note that they're there. So sort of the main symptoms, you know, that that I get from my players or, or patients will be headaches or feeling pressure in the head, feeling dizzy, feeling photophobic or, or or noise sensitive, difficulty concentrating. There could be some confusion or feeling slow. Um or sometimes they may describe their brain as being foggy. So not being able to really um be able to do everything that they normally do, feeling uh nauseous. I'm not sure if I mentioned um more emotional um tends to be the one of the mental health symptoms that's slightly higher as well as low energy and low energy is a difficult one because if you're dealing with athletes, they're often tired when they come off after the field. Um, so those are just some of the symptoms. But what I also wanted to add was you also have signs. Now, if you're working in a clinic setting or in an A&E you don't always have those signs because it'll be a retrospective assessment of what has happened to them. But if you're working in sport, there are specific signs that are indicative of a concussion and what we call criteria one symptoms, sorry, criteria one signs. So these would be definite sign of a concussion. So if it's observed, you can observe a confirmed loss of consciousness. But the, the patient or the player can also actually tell you this if there's any suspected loss of consciousness. So if someone's lying on the floor for, for more than five seconds with no purposeful movements, so no movement of the feet, um or anything like that, the other thing of no protection when they fall. So often players will get a head knock and fall unnaturally, um or in a way in which you wouldn't expect them to fall. Um There's also tonic posturing, which is a type of seizing. Basically, it's a short stemmed hypoxia and you get tonic posturing of the limbs, um which you'll often see if you watch NFL or if you watch rugby, the arms go rarely stiff when the player falls down. Also, there is potentially a seizure. Um This is when you're thinking a more serious injury because often if you're having a seizure, it's more likely you've got organic brain injury, then there's also ataxia. So if they stand up and they look like they're either drunk or basically balance disturbance, that's another clear criteria. One sign for a concussion or, and probably the last one I would say is, is a dazed or vacant look on their face. Um It's something that you will see in clinical practice. Um But a lot of these signs, like I said, they, they're short lived and they often only occur at the event. So it's quite difficult to, to diagnose them using these signs in an A&E or a clinic setting. But on the side of the pitch, these are fundamental signs. Um and probably lastly some oculomotor signs. So if they have nous or any visual problems, those can be considered as criteria one signs. Um Yeah, thank you, Doctor Tadmore. That was very um it was very broad and it covered quite a lot. So thank you quite a lot of unique signs that um for me personally is very um like I haven't heard of. So thank you very much. Um As Doctor Tadmore was saying, Doctor Combs, um would you like to elaborate on some of those um psychological symptoms? Uh Yeah, I'll focus on the psychological pieces just because he already covered the, the physical and cognitive symptoms really, really well. So, um the, the signs and symptoms early on are kind of, you know, pretty good indicators and giveaways. The, the tricky part about the psychological or like, you know, more sometimes the cognitive symptoms too is that they often set in with a delay. So typically the, the emotional sequelae, we don't always see right away a lot of times that really kicks in, um, 23 weeks, sometimes two or three months after the actual injury and are exacerbated by kind of the situational things. Um too, for example, if you have a, a student, let's say a student athlete that was removed from their academics and now they can't go to practice, they can't see their friends that is really going to take a toll on their mental wellbeing and how they're feeling about it too. And if they already had some of that um underlying anxieties through that uh emotional securely from the injury, that's just gonna worsen. So um just kind of being mindful of these things always um looking out and uh also being mindful if there's any kind of drastic changes, right? Like, I mean, teenagers are gonna have some variation in mood, we all know that we see it, that's normal. But if there are things that are very uncharacteristic for them and then also what they're telling us, right? Uh like pe ty typically people are um you know, can put some words around us like I just don't feel right or something is off, even if they look um healthy, those are always good indicators that we wanna dig a little deeper and, and kind of assess for those emotional things because they don't typically are in the forefront simply because, you know, our, our brain is very survival driven and um we need to from a flight or fight response, kind of make sure that we get out of dodge before we can sort out how we feel about it. So that's often why with the concussion presentation, those kind of concerns aren't really on the forefront immediately. People are more worried about the headache, like um feeling dizzy off balance, nauseated, those kind of things. And then as that starts to get better all of a sudden like, oh, I also don't feel very good like emotionally or I'm much more emotional or um I have a lot of patients that is describe feeling like crying even though there's not a real reason, it just kind of comes on and those are all very, very typical um signs for that mood profile or, or type of concussion. Thank, thank you, Doctor Collins that um explained it very well. Um Doc Doctor Tadmore, can I just um going back to what you were saying regarding when you see the signs and symptoms and you kind of alluded to it um within the question? But how would you diagnose concussion and from your experience in A&E how does this differ with um, diagnosing concussion in sports? Yeah, of course. Um I, I'm still of the opinion that concussion is a clinical assessment. There's, um, and I think we'll discuss it a bit later that you'll have, there are tools trying to be able to diagnose a concussion, er, categorically without doing a clinical assessment. Um II still think a clinical assessment will be uh most important. So if I go back to those criteria, one signs that I mentioned those, those visions. So the way in A&E you know, there's two potential ways either the patient may come in still without with the loss of consciousness. Um and they may, you know, may not be fully conscious, that's a pretty obvious that that's a brain injury and then the different grades of which you wanna diagnose that traumatic brain injury. So that's, that's the one end of the spectrum. The other end of in A&E is players will be coming with either significant or persistent symptoms that we mentioned earlier. So severe headache, dizziness, irritability, um being nauseous and all these symptoms that may just not go away. Um and that will, you know, they may come and present and see you. And as a clinician, I think the first thing you need to, to rule out is, is there something more more serious than a concussion? I don't really like to say more serious than a concussion. Cos concussion is, is a serious diagnosis. However, if you are thinking of a, of a bleed on the brain or a skull fracture, those are the things you need to clinically assess. And if they have worsening neurology or progressive neurology, for me, that would be an indication for a CT head. And that will rule out if there's any, any bleed on the brain. And then you can, you can rule out a severe traumatic brain injury and then you can diagnose a concussion if they're still symptomatic, it, it's a lot more challenging in A&E because you don't have as much time, you then don't get to see the patient again after it's pretty much you see them, you diagnose them and you send them home. Um and that's, that can be quite difficult. So basically for me in A&E that's how you would, you would, you would do it, but on the side of the field there is the SC A which is the sport concussion assessment tool. Um And every player will have a baseline or if they don't have a baseline, you just manage them as a recognize and remove. So any sort of indication if you're unsure, the safest thing to do is to diagnose a concussion a and keep that player off the field and safe. Um I think we'll get into it a bit later but um we will, the SCAT six is what I use in sport along with the clinical assessment and the criteria one sign would be, I wouldn't even necessarily need to do a SCAT six cos that's already diagnostic. But anything that I'm unsure of some subtle symptoms, I'll sit with the player and do a SCAT and then that will help me diagnose if they've got a concussion or not. Thank, thank you, Doctor Tadmore. Um, would you, would you, do you want to elaborate on the, er, SCAT assessment and just what are the pros and cons of the, the tool? Yeah, absolutely. So, um, different sports have different ways in which you can do the SCAT. Um, but basically the SCAT is a, is about a 10 to 15 minute assessment. That's a paper based tool where you look at the players baseline symptoms. Um, and then you'll look at their post post injury symptoms and you'll compare whether they are more symptomatic than their baseline or often they'll have new symptoms compared to their baseline because sometimes some players and patients may have a higher symptom burden at baseline. So it's just looking for a change in symptoms. You look at the, the players, er, ability to concentrate their memory, their attention, their balance and it's essentially just a tool like that, that you will do all of them together if everyone can just, if you can just note down the SCAT six, and you can just download a PDF version. It's a, it's a brilliant tool because everything is in there, it tells you exactly how to conduct the tool uh um how to conduct the test. But basically you sit with the player, what I do in sport is they sit for about five minutes, let them settle, get down to their baseline and then you've got about 10 minutes to, to do the SCAT six. which is what I said. You look at some symptoms, you do very simple examination. You look at the orientation, immediate memory, concentration, balance and delayed memory or recall memory. Like I just mentioned the other thing with the SCAT. So if we're looking at pros and cons II often can see an absolutely normal scat. But to me, the player still is concussed and and whether that is just a clinical decision or something just doesn't feel right, that's the way I operate. I don't like to say that the SCAT is either a pass or a fail. Um because often players and patients will be like, oh well, I passed my scat. Why are you still diagnosing me as a concussion? So to me it's a hi a which is a head injury assessment of which includes the SCAT as well as a clinical assessment. Um and then also just your clinical acumen and and what you think along with video. So like I mentioned earlier, if there's a category one sign like a a brief loss of consciousness or amnesia of the event after 1520 minutes, 30 minutes, they could be completely back to normal and their scat will be fine. It still doesn't mean that they're not concussed. Um, so in, in rugby or football, what if we look at the scat, I'd like every player to have a baseline because then when you do it after they've been injured, you can compare and then you do one at the time of injury, ideally within another three hours after the game and then you'll do Serial Scats. So you'll do one at 48 hours or, and 72 hours beyond 72 hours. I feel the scat sort of loses its, its clinical benefit. And even after I would say the initial scat, I still prefer to, to use the postconcussive symptom score, which are those symptoms we mentioned because for me, the symptoms are a higher indicator of the, the level of the concussion um rather than doing the full scat. Um but yeah, I don't know if doctor Combs may have some more on po potentially the SCOT, which is another office assessment tool that we do. Um But yeah, that that's the, the scat science. Thank, thank you, Doctor Tadmore. Um That was great, especially the way you um showed the different ways you can use the tools and when they're um successful doctor co um what, what, how would you diagnose concussion? And do you think um timing as cos do as Doctor Tadmore was alluding to different uh tools are better with different timings? Do you think timing makes a difference in, um, diagnosing concussion. Um, yeah, I mean, I guess it, it really, II can only, um, emphasize a lot of the points that Doctor Tman already made. II kind of think of concussion diagnosis as on the sideline in the action. It really is the go no go decision. They either are ready to go back to play or they're not. And if they're not then we can worry about more in depth things later on. Um But I definitely agree with at TED month, like we don't think of these assessments as a pass or fail kind of things. They're simply data points that help inform your decision, whether that individual is safe to continue or whether they need to come out. And we have this little catch phrase we always like to use, which is when in doubt, get out. So it's much better to kind of like he already talked about give it five minutes sit, let it, let us look at it simply because when we think back to earlier, when we talked about the kind of underlying pathology that metabolic cascade kind of that neuronal stretching, that movement can really take anywhere from 24 to 48 hours. So there's a lot of examples where people don't have symptoms right away, especially in a sports situation where a lot of adrenaline is going, they're, they're ready to, they want to be out there. It's important to them. They care about sport, they don't wanna let their team down. All these kind of factors can kind of aid in, um, not being able to feel the symptoms that for the athlete themselves. So we definitely wanna, um, make sure that we do right by them and even if they might think they are ok, we wanna make sure that they're safe, um, to be, to continue their sports. Um, not just in that moment but also in the long run. And so uh sightline assessments, that's kind of where the SCAT is really helpful. I do agree with doctor Tatman that it is not a long term assessment. And that's kind of where my specialty with like the nurse like um assessment and the batteries come in because now if you have someone, let's say that has been removed and we're following up, typically, I don't do sideline assessments anymore cause I currently don't have a team, but I see clinic patients all day every day and they um kind of vary. Some are within 24 hours or you know, some come straight from the ed. Um some are two weeks out, some are two months out and some even further than that. So for those type of um situations, a more in depth assessment is definitely uh helpful which is not UNS similar to the SCAT or the scope if you will. Um because it kind of touches on those similar domains, but you can kind of think of it as on steroids because it's just much more in depth. Um because we're not looking just for a quick decision of like you need to come out or you can go play. We're looking at like what are the deficits, right? Like I talked earlier about um kind of that profile concept of like it's not a one fits all type of injury. So the better I understand their symptom presentation, the more I can target their treatment approach to them and thereby speed up their recovery. So we always want to make sure we assess the vestibular and ocular domain. Um There's an assessment called vs that is really handy for that. Essentially, it's a cranial nerve screen. Um There's other ocular tests that, that are available like for example, a king divic, if that means anything to anyone. Um we've definitely progressed like it used to be all paper pencil testing. Now there's a lot of more uh computerized versions available like a famous one is probably the impact. Um there's other um tests that are computerized and they're just really handy because they allow for a more timely assessment and a more standardized one. So um they've, they've kind of taken over um the market but uh you know, depending on their presentation, especially if we're already a couple of weeks out, I always like to account for preexisting concerns. So for example, if someone has a learning disability that um is well established and obviously, we might tweak that battery a little bit to accommodate their needs better. Um But essentially we're still scanning for those same domains, like I said, vestibular ocular, we assess their cognitive functioning. Um I always uh assess their emotional wellbeing as well. So we screen for anxiety and depression and um look at those kind of things as well as any other concerns the patient may have. Um in terms of doctor Taman mentioned the scope. Um that kind of was recently updated. It's basically a sports concussion office assessment tool. So it it moves off the sideline and it's designed for individuals in office in clinic. Um It is a very helpful, especially if you don't see concussions on a regular basis. Um It is very nice cause it's structured and you can just kind of it guides you through the questions you need to ask as a provider to make sure that you cover um the main domains just like any other concussion tool. It, it has um a symptom evaluation of like basically self rating scale. Um It then assesses immediate memory for individuals as well as um some verbal cognitive tests. It looks at digits backwards, so very very typical um concussion signs, it does ask for those initial signs as well. So like it asks them if they fainted or if they had blurry vision, if they, you know, felt lightheaded, all those kind of things, obviously, the best they can report. Um or if there's witnesses as well. Um, it also asks for other neurological findings. Um, if there's any kind of weakness or, you know, those kind of things, it assesses balance which, um, I in clinic do through a computer program and a force plate, but there are ways where you can do it non tech, um, through, you know, tandem stands and those, those kind of things. So the code is a nice tool, especially if you don't have fancy computer programs or like a force plate or something in a nonspecialty clinic, just kind of, you know, it, it provides a very nice and structured approach um as well as some resources. W what does a return to learn? What does a return to play look like? Um And how can we help our athletes get there faster? So, yeah, thank, thank you, Doctor Combs. I thought you described, well, the difference between the early onset with the kind of late uh pre presentation in clinic. Um I was gonna ask so when they present from your experience kind of from sport as well um With, in regards to clinic as well, have you seen um like a worse progression or outcome from those that maybe present later rather than um those that present earlier? Yes, absolutely. There's research um actually a growing research body that suggests that time to clinic matters. Um So especially for individuals that don't, that might not have the luxury of having someone like Doctor Tedman on the sideline with them, um or if they have an athletic trainer that's also very helpful, but a lot of people um don't necessarily have the same access. So we found, um and the, like I said, a growing body of research that suggests that time to clinic does matter in recovery. People that um take longer to be evaluated, become more prone to having potentially protracted recoveries, not just because um treatment is delayed, but also um communicating the right messages, setting the right tone. I don't know how it is for doctor T but I still have a lot of that come in um potentially from their primary care or is just not having, you know, discussed it with anybody and they just kind of did the like, well, rest is best. I just wait it out. I just wait for my symptoms to go away. I lay down, I do nothing. Um That is a very outdated, that is a very old school approach and unfortunately, it simply does not work very well, like, especially when we consider like the different, you know, types of concussions that we have talked about. And so um being able to set the stage early on communicate realistic expectations and give them tools and ways how they can already navigate the early phase of their injury sets sets them up for much better success. So, yes, II definitely encourage people ideally to be seen within the first week, um, whether that's their primary care, the athletic trainer, their, um, team physician, if they have one or a specialty clinic, if there's one around, um, anything beats nothing honestly. And from there on that can also help, um, ideally, they don't need a whole bunch like we talked about, right, like approximately three weeks is normal. But, um, if, by two week, if, by the two week mark, we, we still haven't made good improvement. We definitely wanna see somebody because otherwise it just is gonna become more difficult to overcome. Thank, thank you, Doctor Collins. Um Just staying with me with one more question. Um II just wanted to ask, I think II heard you on a podcast previously and you said you experienced a concussion yourself. Do you mind just given what that experience was like from the other side, from the patient side? And um like how it, how do you think it like maybe possibly helped your clinical practice yourself? Sure. Um So II would like to preference that, that um it wasn't sports related. I was in a car accident and I will also say that I already was on my fellowship. So I already had an unfair advantage to the average person because I was already doing a lot um in the realm of concussion, obviously working with that day to day. So I knew exactly what it was when I felt it coming on. Um But it, yeah, I mean, knowing something and feeling something are always very, very different things. And so it, yeah, it's, it's, it's an interesting injury for sure because people cannot see it right? Like they look at you and they say you look great, like I'm glad you're fine. You like uh but I'm not something is still off. I don't feel, feel good versus if you have an oro injury, you break your foot, your arm, something there's, there's visual representation. And for some time for some reason that often makes it easier for people to just um conceptualize that better versus with a concussion, it is very much internal, right? So when you look fine, they people assume you're fine too. And so from a, from being on the flip side of it as a patient, um I think the thing that surprised me the most was the fatigue aspect simply just being exhausted by simple tasks um that normally wouldn't take much at all. But uh just uh because if we think of it, um conceptually what a concussion really comes down to is an energy crisis and just having that deficit kind of carrying over, not being able to do your normal your day to day, even if your headaches aren't debilitating or you're so dizzy that you're tipping over having this constant fatigue and just feeling like everything is an uphill battle was a very interesting experience um that I don't think I appreciated or saw the same before it happened to me. Thank you for sharing doctor co um so Doctor Tadmore back to you. Um I just wanted to ask so how would you manage and um treat concussion and how does this differ across um different sports that you've worked in? Yeah, sure. I just wanna quickly add just to doctor Combs there, I think. Um It's so true and often you need to get that to um through to your patients or your players. Is that, yeah, there's still, there still seems to be a, a stigma around concussion or, or this sort of um feeling of, of being weak if you report these symptoms because you can't see it. Um And often you need player advocates or patient advocates that have been through it that can actually, you know, advocate for why it's important, why we do what we do. Um So often I'll tell any of my players that have been concussed, you know, to talk to their, to their colleagues and co that just helps with the, the, with the understanding and sort of the better reporting of concussion. But that, that's a separate note. Um but just in terms of, of recovery, um this is my, probably one of my, as I call a pet peeve in, in the UK or at least um in international sport is that concussion is managed differently across different sports, um depending on their governing body, which is really frustrating because it's the same pathology. So just for, for argument's sake in football, er, or soccer. Um, so not, not NFL. Um, they can return within eight days from a concussion in rugby, they can return within 12 days in Taekwondo. It's the minimum, a minimum of a month. So why these are all deeper questions and po for policymakers and things like that. But essentially each governing body still decides their return to play depending on their, their medical teams. Um based on the consensus statement, that's essentially a guideline from, from the latest er, sport concussion assessment statement. Um Also the same, if we're just looking at sport, you've got community sport and you've got professional sport. So in community sport currently, um where we are here in the UK is that players are sat down for three weeks, which means which isn't always the best because they're just told, ok, you can't return for three weeks. Um So that's one way, the other way is for two weeks of rest. So like in my academy, football players, if they're under 18, um we're more cautious with their time away from, from uh contact sports, so they'll be out for two weeks and then start what we call a graduated return to play. Um And then the over eighteens have a slightly longer initial period, but basically the way in which we treat concussion is a graduated return and this can be applied to, to school, to learning to work to sport. Uh The policy I work with is, you know, you need to be able to return to learn before you can return to sport. Um And it's, it's graduated, which means every day or every couple of days you progress in a stage. So you will start initially with, with relative rest, what we call now as doctor Comb says, no longer locking yourself in a room for, for two days and not, not um switching on the lights, it's relative rest. So giving the brain just a bit of a, a break. So avoiding screen time, alcohol, um, any sort of triggers that can stimulate the brain unnecessarily driving. Um, and then after that, you start returning them with, with a bit of exercise, low level cardiovascular exercise and then they progress through different stages and then they get to returning to contact training and again, that depends on each sport. Um, I was going to say something and I, now I've just completely forgotten. Um, but it will, it will probably come back to come back to the, um, but yeah, that, that's it in a, in a little nutshell of, of how we manage it in sport. Um And yeah, Doctor Combs, I think. Do you want to add to that? Yeah, I'll take it back off you and then I'm sure um, it will come back to you and you can just bounce right back in. So, um, yeah, II agree. I think one of the things none of us are prepared. Um when we enter or when we start to work with concussions is the differences in politics and that, that can very much influence how things are managed and um handled. Like even like I said, um, you know, I'm in the US, but the NFL has very different requirements than for example, the NBA or the NHL. So, um it, it can be frustrating as a provider to have to kind of juggle these different um requirements when it, it is, you know, the same etiology and the same quote unquote thing that we're dealing with, even though obviously, it's a highly individualized injury. So, uh my training was actually fairly progressive. Uh We've been, we've been working with active behavioral activation and, and getting people moving quite early on for quite a while and the, the research um keeps growing in that direction and, and so we're, we're definitely on to something and that's also why um I think it's so important to, to get evaluated early. So we can avoid that like kind of long inactivity because research shows that um initial rest, the 1st 24 to 48 hours is very helpful. And then we're looking at modified activity, right? Like it's not about doing nothing, it's about doing something as much as you can wherever you're at, that's where we wanna get started because research suggests that prolonged rest, especially post the uh like uh pa day five, can lead to significant protracted recovery. So movement is not the enemy. Um, symptoms aren't the enemy. It's just about doing, you know, modifying that kind of stuff. And uh just like the frustration with the different governing bodies and different types of sports, I think, um especially for me, it's equally frustrating to also have a big uh discrepancy when it comes to non sports injuries because they, I don't know how it is in Europe. I'd be very curious to, to hear about that from Doctor Tatman. But the trend that seems to be perpetuated here and I can't give a very good reason is that there's a distinct difference between sports and non sports concussion. When again, the etiology, I mean, whether you get hit by, you know, a piece of wood uh in a workshop versus um uh a ball flying at very high speeds, right, like at the end of the day, it still comes down to the same um metabolic cascade, the same uh physiology. So I have uh great frustrations and often have patients that travel from very far because they cannot find providers that are willing to see non sports concussion because they deem them more complicated or more difficult. I don't know why because to me it does not make a difference. Um, treatment wise, we have the same successes with uh non sports related concussions that we do with concussion. The only difference really I think to me is that and when you have people that aren't athletes, you have to get a little bit more creative with their activation, right? Athletes I can send to practice and have them do modified activities through their coaches, through their athletic trainers, those kind of things versus, um, with people that are working, you might not have a pre made schedule of like, ok, I've practice on Tuesdays and, uh, Thursdays or training or whatever. Um, so you might need to get a little bit more creative. But once you explain it to them, like almost all of my patients are very willing to give it a try and they all come back and like, oh, this has helped so much. This is amazing. So as long as you can kind of be open to that creativity and then also um we're trying to formalize this as a type of treatment. There's uh what's called exertion therapy now, um kind of on the horizon and, and the growing body of research to help exactly that population that doesn't have organized, practice, organized training to kind of compensate for that and get back to normal more quickly. So, um yeah, thank, thank you, doctor. Yeah. What are some of some of um doctor? I think I'll just let you jump in because I think it came back to you. Uh What you were gonna say? Do you wanna just jump? Do you want to just say it was, it was basically what doctor said So how, how new research has shown that earlier return to activity, um, will have a sort of better impact on their return, sort of long term recovery. Um, and that's exactly like you say, it's a lot easier to monitor and modify within an athletic setting, um, because they can be supervised because now we're also, the research is showing that you can train with symptoms as long as the symptoms don't become too high or too debilitating. But that can still have a really positive impact on the recovery and less chance of persistent symptoms. So, absolutely, I find it rarely frustrating. Cos in A&E again, you don't know where you're discharging them to and it's just go home and rest and there's no real follow up and it's a frustration of mine that primary care, it doesn't really know how to manage um concussion. And I think sport is, is lucky that there's been investment in, into developing a really easy to follow guideline where I think primary health and public health need to probably step up and, and develop a, a community based recovery plan. And I think each country and each province has their own slightly different one. But I think we, we should be able to move to a more uh community based uh recovery plan. So, yeah, that, those were, that was my uh the point that I had forgotten. Sorry to just, um I just wanna tag on to that again. Um you mentioned the return to plague, right? Like there's protocols that we can utilize for that. It's not that hard to, to modify them for a working individual because I feel like especially with work injuries, there's a lot of stigma of uh people don't want to get back to work. They're gonna try to like ride this out, get more time off which probably not Europe has better um vacation time than the US does. But um II actually don't see that at all in, in clinic. I mean, you know, there's always a black sheep or whatever, but the majority of patients are very motivated, they wanna get back to their job, they wanna get back to their life. And so having simply taking that premise of the return to play protocol and being able to kind of modify that to their job in day to day life. Um I think is kind of the way to go. So what I will do is often I'll make them, I, I'll acquire like a, a job description for them like what does their responsibilities look like? And then we kind of taper them into what would be the equivalent of light exertion, moderate exertion, um sport specific, those kind of things. So it, you know, with a little creativity, you can actually get quite a long way. So, so I to interrupt you, I just wanted to type that on. Thank you, Doctor Co. No, it's perfect. How um both. That was my next question, the difference between um the sports side of things and to a, to a normal regular um, person in the general public, um, in terms of some of their, um, in terms of some other advice you would give to them other than like the tapered return and the rest, um, how would you treat some of the symptoms that are persisting? So, um the vomiting headaches and things like, like how would other, some of those other symptoms, how would you manage? Um those in a like in a multidisciplinary approach? Do you want to go first? Doctor Tman, I'll, I'll just, yeah, I'll just comment from a, from a medical side. So that, that's a really good question because I think as like a clinician, your immediate thing is, is you want to treat what the problem is. And I think it's understanding that the symptoms are coming as a result of, of what's happening within the brain. Um So I don't particularly like medicating concussions, obviously, if, if someone is suffering or in a lot of pain, um II don't tend to go more than, than a pa two paracetamols because you don't want to give any medication that could one mask symptoms or to alter the sort of pathophysiology or the physiology that's happening in the brain. So, like I mentioned with that relative rest in the 1st 24 to 48 hours. Definitely, you know, II don't encourage anything more beyond paracetamol. Um, I don't often give anti sick tablets because again, if someone is developing nausea, vomiting as a result of a potential bleed or worsening symptom or worsening pathology, you don't want to delay that or mask that. So I don't, I really don't like medicating. Um, I try to stay away because we know that as long as, as the, as the concussion progresses and, and they do all the sort of appropriate rest and, and return to learn and return to play, these symptoms will get better once they, if they develop persistent symptoms, that's a separate issue. Um And that will be neurology and, and you know, neuropsych and all those things that doctors will be able to comment on. But from my perspective, um I don't like to medicate and it's more just educating so that it's not, I'm trying to torture you. It's that I'm trying to just have the best understanding of what your illness looks like. Um Because again, if you give anything that's sedating, one that will sort of affect the neurochemistry as well as change the symptoms and that could be potentially dangerous. So, yeah, that's, that's my comment on the, on that treatment. Uh Doc Doctor Collins. So how would you work in like a, a multi kind of disciplinary team? Um If those symptoms are, if those symptoms are persisting. Yeah. So ii wholeheartedly agree like um medications can be used as a support or like as a rescue, but just like Doctor Tman says, they're not the solution because it simply doesn't address where it's coming from. It's just kind of functions as a bandaid. In most cases. Obviously, you know, we cannot not say we can, we shouldn't say always or never, those, those kind of things. But as a general, that is a very, very good approach simply because, um, the other thing too is a lot of my concussion patients try to take some painkillers, some help with relief. And for most of them, it doesn't even touch it. It do at best kind of dulls it a little bit, but it doesn't make it go away because it simply isn't a regular headache or, um, you know, just a, just a small pain or something. So, so a lot of times these type of medications don't even do what we would like them to. And then the other thing too, especially if, you know, if you had mentioned sick medication, if someone is so severely symptomatic that they can't even engage in the treatment, then we might utilize some Zofran or Meclizine or like these kind of type of sick medications to help them get over that initial hump. But then we also need to wean them back off because especially for example, meclizine suppresses the vestibular function and therefore makes the rehab the appropriate rehab almost impossible. So, um, medications are a tool but they rarely are the answer Now, here's the caveat to that, especially for the more chronic cases, the uh what's what's often called postconcussive syndrome, which the terminology is changing now, it's more considered postconcussive symptoms, potatoes, potato. Um But generally speaking in those cases, then medication can become more helpful, especially if people have a preexisting history of migraines. They tend to struggle with migraines much more um while they're recovering from their, from their concussion. And there it can be helpful through, for example, an evaluation, pardon me, with neurology to uh choose proper medication, whether it's a board of medication for migraines or preventative. That kind of depends on case by case. But generally speaking, the average concussion will not need or benefit from a ton of medicine. It's the complicated ones where we then kind of draw on that to help. But like Doctor Tman says it is not the first line of defense simply because it's not very helpful. Th thank you, Doctor Combs. Um we'll come back to that definitely the post concussion syndrome. Um But II just wanted to ask, er, Doctor Tadmore. Um what is, so how do you, you alluded to it earlier? How do you make the definitive decision that um a player an in like a player or an individual like a patient that's come in is ready to go back to sport or um Doctor Combs as well to you as well? It, when are they ready to go back to their daily activities. Yeah, that's um that's brilliant. Um So again, in sport, it's easy in, in that we've got certain criteria for which the player needs to meet before they can return. So in, like I said that with the baseline, Scats, they, we want their Scats to then return to baseline, um or the same as baseline, we also do neurocognitive assessments, so, or online neurocognitive assessment like impact or cognos. Um and a player again, within their graduated return to play needs to meet or be better than their, their baseline assessment of that. Um And as well as now we have a scope. So all players will need to have a scope that is an unremarkable scope. They're at their baseline, you're not concerned about anything. Um So those I would say medically, those are the 33 things I would I would look at is clinically that their scat is ba back to baseline. They've met their cognos requirements or their neurocog assessments. And um three, they're just clinically well with no neurological um signs or symptoms. Now, at that point, once I've cleared them that way, I will then allow them to return to full or contact training. So that will be their sort of first thing they need to pass. So we'll introduce them into initial exercise. They need to complete those three things and then once they're there at their baseline, they can then progress back into normal training and each sport has different guidelines as to how many sessions they need to complete before they're fit to play again. So, for me, they need to then go through full training depending on which sport I'm in. If they're completely well, I'll pass them foot once they've met every criteria according to that sport. Um, and if another thing just to know for me if, if that at that stage where I'm doing the scope or, or, um, the, the cognos, if there are still persistent symptoms or if there are multiple failed attempts at the, at the cognos or neurocog assessment, this is when I I will access higher speciality. So, neuropsych and neurologists to assist at this point because this for me is then an abnormal recovery or just not what the normal public or players will go through and this then requires further speciality. So at this point is when I refer on um but otherwise I let them progress, make sure they meet all their criteria. Once they've done that, I'll officially sign them off and, and allow them to carry on playing. Well. Thank you, Doctor Tadmore. Um I think it's particularly important what you said about the time to escalate, knowing when to escalate because then you're just kind of delaying that athletes um and or it like enhancing the consequences of their concussion. Um Doctor Collins. So uh just over to you, how would you um what would you, what would your process be to say someone's ready to go back to, like, their daily activities or in Children maybe go back to school. Yeah. I mean, uh, honestly, it sounds very much like t and I are following the exact same guidelines as it should be because that's where the research is, um, pointing us. And so basically we kind of think of it as like there's four things that an athlete needs to achieve to be considered for clearance. Number one asymptomatic at rest, so they need to be able to just hang out, chill be a couch potato, feel like they're normal selves. Uh Number two, asymptomatic with academics or vocation. So they need to be able to get through the a normal day, either of classes or their work day, whatever that looks like number three, asymptomatic with exertion. So whether that is practice or like the walking program, I gave them whatever physical activity they were assigned, they need to be able to get through the non contact aspects of those things without trouble. And then the fourth thing is good numbers on all the assessments. So exactly like Dr Tman was talking about whether that's the scope, the impact cognos C three level projects, whatever um they need to have good numbers that are expected, whether they have a baseline or not, especially my working population often doesn't have um a preexisting baseline. So for those we work with gender and background matched norms. So we kind of know an an adult like this should look kind of like this and they either, you know, they meet it or they don't. And then we can talk about that. But those are kind of the big things and just like Doctor Tman was talking about, if they meet those criteria, then they're clear to go through a full practice without any restrictions. So going through the, the practice, like they normally would, if they can pass that, then we can look at um formal clearance for competition. And like he said, it kind of depends on the sport. Um How many full practices need to be completed? That kind of varies, but at least one. And for the for the working population, it kind of is very similar, like it is uh when they can get through their normal day without trouble, that's typically a pretty good sign that we've got those things that we were looking for. Um And like Doctor Tman said too, if someone is unable to pass their um scores, that's kind of where specialty care or someone like me can come in really, really handy because we talked about the emotion s of concussions earlier. So this is often something where an athlete can struggle because now this has become a longer process than they thought they're struggling with that anxiety piece and they might, I'm super nervous, like I have athletes that sometimes look horrible on the test because they're so nervous and they're trying so hard to do well because they want to get back to their game and then they don't do well because they're so anxious and nervous taking the test. And that's why it's helpful to have multiple tools and have that specialty care to kind of look at. Ok. What is really happening here? Where is the, the afferent signal signal basically coming from? Is this an anxiety problem? Is there lingering post concussion stuff that hasn't been um fully recovered that has not been addressed? What are the next steps? And that's kind of the beauty of um having th that next level step? Thank. Thank you doctors. I think you with those four A S, you really explain that in like a simple, easy to remember way. So, um thank you for that. I just, I just wanted to ask um also we piggy back on to what you said earlier about the post concussion um syndrome. Would you like to elaborate on that? Um So what is post concussion syndrome and maybe what are some of the long term effects? Who does it affect? Yeah. So um depending on the literature, you're quoting it, this is kind of um sometimes a little difficult because depending on what we're citing, there's some splitting hairs going on, like I mentioned earlier for a while, it was called pcs postconcussive syndrome. Now it's more talked about as postconcussive symptoms. So there's, there's some changes there. Um it it's ever evolving just like the injury itself, you know, we're always learning more stuff, we're always changing, which that's medicine that that's how it should be. Um, but essentially, um it kind of comes down to time honestly, um, concussion and in the acute phase, like we talked about anywhere from, I would say two weeks to six months can be considered normal. Um, after that, we're definitely looking at a protracted recovery. Some people consider post three weeks already uh protracted. It kind of varies. And then like I said, some literature will go up to like two years for a normal concussion. So it it it is a very, very big spectrum, but I think clinician wise and doctor Tman feel free to jump in. I think we're kind of thinking of the weeks to a couple of months as that initial frame for the concussion itself. And then once we're moving into the protracted recovery, then we're looking at what's called post concussive symptoms or syndrome. And essentially that in, in those cases, um a lot of times it is very much the symptoms we see early on. A lot of these people struggle with headache. A lot of these people are still dizzy or off balance. A lot of uh people have cognitive fatigue or, or feel like that brain fog feeling that we talked about, it's just taking longer to get better. And so as of to why it it varies sometimes, you know, like I said, about 80% of concussions take care of themselves. It could just be that it's in that 20% of people that are unlucky and will deal with it, um, longer than hoped regardless. Um I will also say that the delay of treatment, we talked about getting to clinic early if that matters. I will say that a lot of people that struggle with prolonged symptoms are often the ones that did not receive appropriate care that just kind of thought they could either, you know, muscle through it or it was completely missed. Um For whatever reason, those also tend to be in that category quite frequently. Thank, thank you doctor uh Doctor Tadmore. Would you like to add anything um on post con on post concussion symptoms? Yeah, I think um so I see probably 22 different sort of populations is you've got the, the patients that will have the symptoms that just persist beyond the sort of standard return to play period. Um And then that will be what's classed as persistent symptoms. But then I've also got another population which I'm unfortunately seeing quite a lot in rugby is, is, is players that get repeat concussions in a short time frame and their symptoms and signs can also vary. Um As so, cos II have a player just currently at the moment, one that had a head impact with persistent symptoms, doing really struggling and I've had another player with, with uh three concussions in six months and clinically appears fine. So it just shows you how variable they are, but both of them are on extended time periods um to rest. Um So yeah, the the concussion is just extremely variable and I think it's really important what doctor Combs said, how early early help and early treatment really makes a massive difference in just, just sort of um assessing and planning for for future. Thank you, Doctor Tadmore. Um, just going off what something you said you mentioned, um, briefly earlier, um, I think that could possibly play out into that early help as well. How important do you think it is to educate? Um, what, what role do you think education? So, patient education, um, plays in the role of maybe preventing and treating concussions. Yeah, I think that's, uh, massively important. I'll, um, I'll throw a Spanner in the works here and say that research has actually showed that concussion education doesn't necessarily change the way in which players report their concussions. Um, and I think what, what that means if you want to dig into it deeper is the standard sort of. Hello. My name is Daniel. This is a concussion. This is what it does. Uh, this is what you do. I think that's less effective, I think. And a lot of my, I've done research with this is in and maybe Doctor Comones will agree or disagree in, in looking into behavior change because I think there's different ways. I think there's a lot of, a lot of the concussion is self reporting symptoms, especially if you don't have those clear criteria. One signs, players may just sit and harbor their symptoms and not say anything for whatever reason. And I would say education around the importance of vocalizing those symptoms and reporting them and protecting yourself and protecting your team. I think that's better education rather than the stand of what it is, what we do. Um I think awareness is really important um and not necessarily just uh just concussion education, but you know, there's if and I set them out. Um like Doctor Comb said, there's also recognize and remove. Um and all these, all these terms just becoming more aware cos I've had games where I've missed because things just everything is so manic, I've missed the concussion, but the referee has come to me and said doc, I think this player was knocked down conscious, I think has a concussion and I think that's also really important. It's not just the players and the, the staff, the medical staff. I think it's all stakeholders within the game and within sport and within the community that are able to recognize and assist because it's a very difficult um condition to, to diagnose sometimes. So, yeah, that's, that's my piece on, on, on education. Um I would agree. II definitely think um awareness and advocacy is incredibly important. I'll share um because you talked about your research, I'll share something that has been extremely successful for me, which is, um, targeting the players and the coaches directly. So when I, um, when I, when we do baseline testing, I give them a little spiel ahead of time, why they should take a series, why I need the best effort. And then the other thing that has been a really, really big selling point is that concussions don't need to be scary. You don't need to be scared of reporting them because if you're, if we get on top of it quickly, your chances of turning around and being back out there are much, much better. So typically there's, um, research, I think this is out of the UPMC Pittsburgh group that has shown that, um, time played after the injury matter. So there is, um, you know, they followed mo many, many athletes, I forget the actual and, um, across multiple sports, uh, American football, soccer, um, uh, ice hockey, cheer, basketball. Um, you name it like it was a very diverse kind of sample. And the, the one thing that kind of stayed consistent, no matter the type of impact or no matter the sport was that the players that came out immediately had a much quicker, much better chance at returning in a couple of weeks. The ones that played 5 to 10 more minutes after the injury because no one saw didn't think it was that bad. Don't want to lose my spot on the team or whatever, they actually tagged on several weeks compared to the first group. And then the ones that played 10 to 15 more minutes because of whatever reason, um, actually ended were much, much more likely to take months and months to, um, to recover compared to that very first group. So that type of messaging to let coaches as well as players know, like, hey, this doesn't have to be the end all every time. If we are honest about our symptoms, our chances of getting back out there is much, much better. I rather miss a game or two than an entire season. And so these type of, you know, like do it for yourself, like you're doing yourself a favor and then also kind of try trying to take that pressure from the individual athletes because I have a lot of people that are like, I don't wanna let my team down, I don't wanna not show up and let them down and kind of letting them know like, hey, if you do this right, you can come back quickly and just as strong as you were before and that helps your team weigh more than you being, you know, struggling the rest of the season. So just kind of targeting the ones that can intervene. Um and, and just kind of letting a yeah, letting people know this, this doesn't have to be scary and good updated information matters, right? Like you don't need to sit in a basement. You don't need to miss school like there are ways to get you back on track. Thank, thank you doctor cos and Doctor Amo. Um I like the way you both kind of brought in the other people involved. So the coaches, the referees. So it's like a, it's like a group educ um effort on education. Um Just one final question for both of you um For so concussion moving forward in the future with the ever like evolving development of technology A I and things like that. Um How, where do you think um concussion needs to improve and will probably improve um in the future in terms of a under in any aspect. So in diagnosis management treatment, um do, do you mind if I go first because I actually have ap off in a couple of minutes? Um Yeah, I mean, I think uh there's a lot of stuff that we don't know about A I yet, but I um I definitely think it can help and streamline information and, and um the kind of help get it out there more timely that being said, um I think technology in general has been advancing tremendously. One of the, one of the really cool things that I personally am very excited about, which is not so much A I but I feel like it's gonna head in that direction is we're actually incorporating VR technology. So those like you know the Oculus or like those type of like more like video games things into ocular rehab and vestibular rehab from a concussion standpoint. So I think um that will help with access that will help with exertion. Um I think technology is an unstoppable force and uh the best thing we can do is go with it and find ways to help it. What the goal would just improve patient care, improve patient outcomes. And um I think medicine has always been on the forefront of that and I think that trend will very much continue what that looks like, I guess remains to be seen. But um yeah, like I definitely think there is application very possible and I will let doctor Tman talk about that because like I said, I have a patient waiting. So thank you so much. Thank you so much, Doctor S wonderful. So I will hop off and leave you guys. But if you have any other questions concerns or whatever, you can always e-mail me. Thank you, Doctor Combs, I'll, I'll get them in the chat and then I will send them to you after for many participants. Sounds great. Great doctor. Thank you so much for everything, take care. Have a great day. Have a lovely day. Take care. Cheers. Um Yeah, from my, my standpoint, I would um right now we're doing and there's been a lot of talk about instrumented mouth guards. Um I think that can be really useful. I think we're still probably about 5 to 10 years away of any of that, any of that data, meaning something. Um So what that is is basically there are accelerometers within a mouth guard that just sits um on the upper lip or on the upper teeth. Why they're really good is because the they're fixed to the skull. Um So you can get proper forces as to the way in which the head moves rotationally and linearly. So I think in intermittent mouth guards will be something that could potentially assist us. Um More of a, just a a warning sign. So if players are taking big impacts, but not necessarily look concussed, it could just mean, OK, let's check in on this player. He's had quite a few or she's had quite a few head impacts. What, what are they like clinically? How are they feeling? So, I think in terms of technology, that's probably the nearest one we'll get to um of it being an assistant in diagnosing. Um But I think once it can formally diagnose, I think we're still quite a bit away. You're gonna need loads of data points before you can categorically say it is or it isn't a concussion. Um There's also biomarkers like salivary enzymes, those as well, I think are incredibly useful and the techno and, and the research is really promising, however, their feasibility within the community and in sport, I think is gonna be a bit of a challenge. I think they're quite expensive and uh it can take a bit of time before the results come out. So also really exciting if it could be developed into like APCR or something like that, like what we developed really quickly with COVID, something like that could uh be really helpful. But for me, the instrumental mouth guards are, are where we're going to see the greatest um help in the concussion space. Thank, thank you doctor uh to, well, that was very informative. Um Hopefully they actually uh implement that and um the mouth guard, it will probably make a huge difference. Um So yeah, so, so thankfully they have now of the series and rugby union and rugby league, they're mandatory. Um and we're collecting our first data set. So yeah, we'll see what happens. We just need players to wear them but they don't want to getting through to them to, to wear them. Yeah, thank you so much, Doctor Tadmore. Um So in terms, so thank you. Thanks a lot, Doctor Smore for our whole er for all the questions. I think you answered them all fantastically. Um If has any, I, I'm going to play a quick short video um from our sponsors, the MDU. If anyone not to take any, too much of your time does t more, but if anybody has any questions, um just pop them into the chat while the video plays and we'll try and quickly go through them with Doctor Tadmore before he goes. Or if you have any for doctor Combs also pop them into the chat and we'll um try and send them over. Um, after so I'm just gonna quickly share my screen and play a quick video uh from our sponsors MDU. Hi. Thank you very much for joining us this evening. I hope the weather is glorious for you. Thank you for coming out. You feeling that mine. My name is one of the medical advisors for the MDU S by co present today. I'm joined by that procedure. Many of, you know, from the E MG where he is a, a subject which he also has a phd. On top of this, he's a banister with a particular interest in personal injury and clinical negligence.