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Hello, everybody and welcome to the Neuro transmitters podcast, a show about everything related to clinical neurology with a goal of reducing your neur a phobia. I'm Michael Ken Trees. And I'm very happy to be talking today with an old friend of mine, Dr Misty Woodburn. And today we're gonna be talking a little bit about concussion. Hey, Misty, how are you doing? Good. How are you so good. So I really appreciate you taking the time to talk with me a little bit about concussion and uh kind of what that involves. So would you mind starting us off with just kind of a, a basic definition of concussion? So it's um like a basic definition is a direct blow to the head, face or neck or elsewhere in the body that um with an impulsive force transmitted to the head. So it's not necessarily always a direct blow like it's like a jerking motion and you know, forces transmitted in the brain is moving that can cause a concussion, acceleration, deceleration sometimes like would you like whiplash can sometimes be associated things like that? Um And what kind of like signs or symptoms would we expect to see immediately after uh such an injury depends, depends on the level of impact. Um So you can have headache immediately or shortly thereafter within a day or two. some patient's feel cognitively slowed down. So they're short term memory is affected. They can be repetitive in nature and their questions. Um they'll have like some mood disturbances. So some patients will have like aggression or like anxiety, they'll become tearful, um gait imbalance. So like just standing up and, you know, having their basic coordination can be affected. Um Patient's will also like have difficulties in there like sleeping patterns. Um they'll have difficulties falling asleep or staying asleep, there's dizziness, um you know, not just lightheadedness but like a spinning sensation, like the vestibular system is affected. Um you know, they'll have a neck pain. Some patient will have like an occipital neuralgia. Um So those are like acute things initially that happens pretty large. It's all about the threshold. Yes, it's a, it's a smaller board. So, and so tell me about that threshold. So every patient is different. Uh not every hit to the head or jarring motion is going to cause a concussion, but everyone has like a symptom threshold. So you can see like a hit or a fall um or a drawing motion and you think that's got to be a concussion, but you have to do an evaluation to see if are they symptomatic and everyone has like a symptom threshold so some patient's thresholds are a lot higher or I've seen patient's initially, they'll have like, confusion, dizziness lasting from, you know, seconds to, you know, less than 15, 20 minutes and it goes away like, and then they're asymptomatic after that. Um, and some patient's immediately following a hit, um, they will become symptomatic and, and go from there. But it's, it's kind of like on a scale. And so there are some where they call sub concussive hits where, you know, you're not having a symptom onset, but the force enough was sub concussive, like it just didn't bring on the symptoms, but it was enough to last concussion, but you're not symptomatic. I don't know that repetitive sub concussive hits are kind of like, uh, would it be fair to say kind of the hot new area in some areas? Concussion research? It is. And it's, uh, one, a lot of things that they do is, um, just to kind of measure like the force of the head and, you know, how many in a practice or time they have a lot of helmet studies to see that and how that correlates. What is the, you know, the athletes symptomatic things of their nature trying to like, catch it immediately, um, to bring them out or to see like, okay, that was sub concussive, but they're not symptomatic and managing it over time throughout the season? Okay. So, in someone who, who had a concussion, let's say like an athlete on the field and they, you know, evaluated on the, uh, side of the field or the court's what, what goes into that evaluation immediately following, immediately following. So, depending on the sport, um, on the sideline in football, there's normally a spotter. So someone that actually saw the hit that can explain to you what happened. Um, but immediately following, like, if I'm on a sideline and I see an athlete go down and I'm concerned, um we or if they're down, the team goes out like that, the trainer goes out, um neurologist, if there's one there or the and then they come to the sideline to do a sideline evaluation, we normally remove the athlete from uh the setting because it's a lot going on for them. So like after, you know, compute confusion can come after one and you know, the heightened sensitivity, like, you know, they can get migrainous features and so you normally we remove them and take them back to the locker room. Uh Some, I think some universities have like a kind of pop up kind of tent to where like you can privately evaluate them to um to, to bring out some to decrease the distractions and you do a neuro exam. But you also have like other components to check the vestibular ocular system as well. So like, you know, you make sure cranial nerves are intact, their hearing, there's no facial cemetery. So you have them take off their helmet, you know, if you can, um, you have them, if there's no neck injury suspected, if they're walking, they can take off their pads. And so you're, you know, you're checking that like tone, you know, looking at their pupils, um, you're looking at their extraocular muscle movements and you're checking like sick assad's like, you're, you know, smooth pursuits and then you're checking vertical and horizontal. Saca's where you have them, you know, like you're standing in front of them and you have your thumbs, what, you know, six inches apart, maybe more than that. And then you have them look back and forth in a horizontal motion for a few things to see if they're, it's smooth as they go back and forth. Is it causing symptomatic dizziness? And you do the same thing vertically and then you also check vor where you have them, have their, um, thumb is at arm's length like, like this in front and you have them focus on their thumb and you, they rotate the upper body back and forth and then you see if symptoms come up and you check their eyes, if they're able to continue to track in that slow motion. A lot of patient's are symptomatic with that, you check convergence. Um, you know, if it's converging, like not within, you know, I think within 10 is normal outside of that, they have issues. Um, and then you check their strength, you check, uh, you know, upper body strength, lower body strength, you check their coordination, finger to nose that can sometimes be off. You have them do Romberg testing that we normally do. But we also some practitioners do uh Fukuda where they have them with their hands outstretched in front of them, standing up, you close your eyes and you march in place. And what happens is a lot of people will kind of veer off because they don't have that, you know, that's spacial awareness anymore that's been disturbed. Um And then you have them do like a single leg stance um where, you know, a single leg squat. So you have them stand with their hands on their hips, um one knee up and then they do a squat and they come back up and then you have them do a tandem walk as well and a lot of times this is done and you compare it to their preseason evaluation. So that was kind of like a quick and dirty of like a sideline or like in the locker room. But you normally, you know, you do a pre season. So you can see like they always had issues with finger to nose dysmetria or tremor at baseline. Do they have difficulty with smooth pursuits or psychotic intrusions? You know, are they have, do they have balance issues at baseline too with the Fukuda or, you know, tandem? So you're not basing it off of something, you know, if you've never really seen the athletes so long, you know, where I did my fellowship, we had pre season and so we had the book there. So you can go over like this is what their exam was like prior. Do they have a symmetric people that baseline? Are they sold to react? That's all there. So, you know, you have a baseline and then this is different. Yeah, and, and then you also do like the quick of, you know, orientation questions like, you know, where are we, who are we playing? What's the last score? You remember here? Five words. Can you repeat them back to me, you know, stuff like that. So um is there, is it more of like if there are any abnormalities like in that coordination testing in those eye movements, uh they're immediately like not going back into the game or is there like a threshold? How quote unquote, how abnormal things have to be before you? Yeah. So it depends. Well, I gave you like the neuro sideline evaluation of it. Um athletic trainers have their own, they have their standardize their sac where they asked like orientation questions, they ask concentration where they give a series of numbers and do it backwards, you know, they have immediate recall, delayed recall. Um and then they do kind of like a quick strength exam. And so what I would see because I was formerly an athletic trainer, what we would do is like if it, I think it was, if it was like, I can't remember the number cut off if it was a number cut off with the orientation and mental status changes, they were automatically not going back in what I've seen sideline wise. It's, uh, fairly obvious that they, if you're familiar with the athlete or say you did their preseason testing or you have their preseason and you see them in front of you, It's pretty, fairly obvious at times that something is not right. So you can, what I've seen with some patient, even behavioral eyes that they're normal, you can see um extraocular muscle um changes like you see psychotic intrusions when you're testing this a cods, you see they're having difficulties like there's like a drag when you do the vor their balance is off and these are, you know, running backs who are known for their balance. So it's the subtle things. Um some patient's will immediately have a headache and that is an indicator there. Yeah, or they'll immediately say I just don't feel right. I'm dizzy or, but you do have athletes, it'll be like I'm fine, I'm fine, I'm fine. And so in those instances, you really have to calm them down and I feel like I have to do this for your safety and, and once you like, slowly go through the test, they're, they're more app to be honest or like you can see things and what I was, you know, they teach you is if you are seeing abnormalities on the exam or you're seeing personality changes there, you, it's not like this huge where you're like, well, let's way that your, the safety is your, of utmost importance. And so, yeah, you pull and you're also talking to, depending on, um, if you, this is football or, or basketball or soccer, like someone that saw the hit to. So, did you see the hit directly? Do they have tape? And so you can see like, hey, it's something abnormal and then you can go over the play and then, yeah, it's really helpful to know the mechanism that makes sense. And just a quick thing for, for those who might not be familiar with the term psychotic intrusions. Um, what, what does that look like when you see it on exam? Uh, it's kind of, it's, I guess the first time I saw it was one of my, one of the concussed high school players. So when I was checking their cicadas where you have, I guess your thumb shoulder with apart and they're looking back and forth. So it's normally like a smooth pursuit quickly and then it just stops. It's like a jerk. Um, kind of like a, like a break in the, in the smoothness. Yes, it is. And it's quite, if you're looking, you're just like, oh, and then you have them, you know, do it again and some patient's, some athletes or patient's have it at baseline. Um And that's where preseason testing is helpful and you can get do it with, you know, when you check for vertical, sick odds are with the vor testing, sometimes you will see it. Um But you know, if that is not something on scene on pre season testing and you see it there, that's indication that, you know, the stimular system is affected as well. Yeah, so, so let's say you have someone, you know, they've, they've had an injury and you think they have a concussion currently based on your exam or the symptoms and you have to pull them from the game. So when would you go about like when, when would they be able to return to play? Like can they come back in that same game or are we usually talking a bit longer? So a bit longer if you're diagnosed in someone with a concussion, um, it's at least a week that they are not in, back in the competition. So, excuse me. So within, so it's about seven days standard. If there's a loss of consciousness, it's longer than that, right? So it can be like 14 to 21 days. And a lot of that is also based on the symptoms that they're having. So you, you put them in, I'm sure you hear when they talk about their in the protocol, the return to play protocol. Yeah, most institutions have it even at high schools, the athletic trainers, um, have it where they put them through like a kind of a system that they go through before they go back to immediate um competition. So it, you know, it starts in the acute phase, the injury onset. So it's kind of like a, like a grass. So you have it shoot up and then it slowly kind of goes down over a seven day period. So when you have the onset of symptoms like that symptom threshold is passed and they have like headache or they're dizzy or their lack of coordination, they're sleeping, right? Things of that nature, that acute phase within 1 to 2 days, it's you just normally have them rest, but it's not a we don't know, cocoon therapy is not something that is done done anymore. Like you got to have them in a dark room and no lights and no interactions. Can you imagine giving this is, you know, these are big life events if you're used to playing, used to being around people and you isolate them, that's not great. You know, especially, you know, concussion can affect mood. So you have them in like a rest period, they're not physically active, but we would tell patient's, you know, do what's comfortable to you if you feel like watching TV. And you know, your headache gets worse, like turn down the, the brightness of the screen on your phone. Uh use the blue light filter, you know, things of that nature, take a break. Um, and in that time you can use, um, insides or, you know, they, you know, the standard is like Tylenol within a 24 hours. If you're concerned for like, a bleed or anything like that. I think we're in a phase of care where if you think that there's a bleed, you just get them to a CT. Right. So, you're not really gambling in that. Yeah. Yeah. Uh, so within that, you know, those few days, if they have a headache, you can treat it with Aleve twice daily. Um, and then you just have them, you know, for several days resting and then you do like a graduated return to play program. So if it's in a seven day period, the 1st 1 to 2 days, you know, you have them resting, you know, making sure they're hydrating, you know, some athletes, you know, they'll either have difficulty sleeping or they'll sleep a lot and you just let them rest, like there's no, like waking up every two hours or three hours. And then as you go, you know, as they go through that acute phase or that relative rest, you can slowly do like a graduated, um, program where they can start to exert themselves. So you do like light cardio have them doing like, just straight ahead walking or Stairmaster treadmill is, and then you have to see if their neck is involved because, you know, that's going to be a part of it too. I wouldn't say that you immediately start doing trigger points. You know, you do stretching and, and exercises around that time and then during that time they're doing straight ahead. It's like 30 40 minutes at a time. Um, and then you can slowly bring in like the next day with agility. Um, one thing is some patient's, the headache or the dizziness will worsen. And so there is a thing where you kind of back off a little bit and maybe you don't go to that next step of agility, um, or sports related activity, you go back to like the straight ahead walking or running, but we would do it on like a graduated thing to where it's like one is like, you know, your relative, you're feeling fine and three is like, you feel awful. So as long as you stay within that 1 to 2 phase, you're able to continue to be active, it's, it's, I think people, as soon as you're symptomatic, you immediately have to go back to step one. You don't necessarily have to do that. Yeah. Yes. Yeah. With, with every athlete you have to. Yeah. And then you have to make sure they're hydrating. Um, some athletes, um, and regular citizens are notorious for not hydrating. So, are you feeling dizzy because you only drink five ounces, did it? And, and that's why you're feeling like that with working out. So that's a part of it. To eating and then, you know, you do the cardio the straight ahead and then you can do agility things the next day. Then you do sports related activity drills, like running back drills and then you do contact. So this is all, each day, it's a progression. And then when you are able to do full contact activity and your symptoms are well controlled, it's not, uh, that spike up in symptoms again and you're stable. Um You're able to determine at that time. Okay. Are they ready to go into full competition because they've done full contact, full activity and uh done well, then they go, then you determine, can they go back to full competition? Uh I know you mentioned the minimum is typically a week but in your past experience, what, what would the average be for most people who have had, you know, let's say a mild, moderate concussion. We don't even really use mild to moderate anymore. But yeah, but I mean, I do know that they still a lot of circles of mild, moderate severe. Um, but we don't really use that as kind of as it is or it isn't what I've seen with colleagues that I've interacted with. Is there any distinction with a concussion with versus without loss of consciousness? Yes. So a lot of times if there is a loss of consciousness, uh some of the symptoms are just more pronounced, um or they last longer. So, before you go back to activity, you know, did the headache go away? That's one thing the dizziness gotten better. Um, has, you know, the sleep pattern changed a little bit? Um, are they feeling better? The memory changes have gotten better? So, it's normally with the headache and the dizziness has gotten better and then you go into your activity phase with loss of consciousness, sometimes that symptom amount or time will last longer. So you're not ready to go to that, graduated to get to the cardio. They're still pretty symptomatic and you need to and how symptomatic are they, is the headache really bad, you know, and this is where the history comes in. Do they have a history of migraine? If they have a history of migraine, they're going to have migrants, you know, so you have to treat the migraine if they have a history of insomnia or sleep issues, it's just going to be exacerbated after that. So you manage it, same thing with like mood, um, dizziness or, you know, if they have a stimular issues or, you know, orthostatic hypertension prior it, that's, you know, those are things you're going to have to take care of post concussion just makes everything a little bit worse. It does. It does. Yeah, just shakes up the bottle of Coke. Yeah. Now, what's the overall outlook for, for people who have suffered a concussion? Like in terms, like, let's say the short and the long term, you know, are like people who have had like, let's say a concussion without loss of consciousness, you know, assuming an uncomplicated course there's no bleeds on, you know, or anything like that that developed in their brain. Um What like they have a mild headache and like maybe some coordination difficulties. Yeah, like due to most people recover spontaneously, are there people who kind of transition into a longer form? So most people like concussion is acute, by definition, it's not something by like three months later you're still suffering from, it's really the symptoms from it that you're still, you know, you're still having the headache, you're still having the dizziness, you're still having the sleep issues and so on. But, you know, concussions acute. So within like, you know, 7 to 14 days, those acute, you know, everything that's gone on has, has resolved. So it's just really like the symptom management of that. And so if you have patient's where, like, as you say, like uncomplicated within a week that they're doing better and they're returning to play, you know, the, it's, and I never looked, I haven't looked at in a way it's, it's going to be debilitating years from now because it's an acute thing and as long as you're managing the symptoms, so, you know, I've had athletes that are worked with athletes that within a week they're able to return to play and some athletes, it's within two weeks, they're able to return to play. Um, the, I guess the fear lies is, is if they are heard again before they, they're concussion has resolved. And so, and that's where you have to, you know, you understand that it's an acute thing and, you know, within that 7 to 14 days there's, you know, Gosha and, you know, I know we were talking a little bit before I hit the record button, uh, recent uh, sports events at the national level. There was a lot of talk about Second Impact syndrome, which I know is uh somewhat disputed in some corners. But I was wondering if you would be able to share your thoughts on that. So I'm unsure if your listeners know what like the definition of second impact is. So it's so it's like it's thought as if you don't recover from a concussion and you have another concussion and then the brain rapidly swells and it's catastrophic. That is what like, yeah, like cerebral oedema herniation. Yeah, events, life ending because oops, sorry because you didn't recover from your concussion. That was something that was thought or fear from before we have the research that we have now uh what it does is, you know, if you are say your in that phase of recovering from a concussion. So you have your injury on a Friday and say come Sunday, the symptoms, the headache or gotten better. And then Monday, you're doing like uh like cardio activity. And so it's in that time of like, symptom management and recovery returning to play, you mistakenly have another one. All it does is reset the clock. So, now we're, now we're back at day zero. So you're going to acute rest. And, and that's saying if it's uncomplicated prior, now, if you're, you know, you have a brain bleed, that's a traumatic brain injury and that's, that's a completely different realm. Yeah. It's certainly much more acute, more risks for various problems. Yes. Now one thing, uh, I've seen this a couple of times in the news, uh, not just recently but where people, mostly with like American football where they get like a pretty nasty that you said American football. Well, you know, we have some international listeners out there but, uh, uh, where people will, uh, they'll get hit, they fall and they kind of have like this abnormal posturing. Does that have any clinical relevance? Uh, 22 doctors on the sideline or in terms of the prognosis, what does that, what does that mean? The same clinical relevance is if you went to the, er, and you saw someone posturing, uh, I think we're neurologists. So we're like, oh, gosh, the red nucleus. Okay. Yeah. So, yes, it's, it's the same immediate, you know, reaction that there's initial fear. Have I seen an athlete do that before? Yes. Um, and so terrifying. It is. It is. Um, so, but you, you always have to remember um, that on the neuro aspect of it, it's just kind of us and sometimes you have someone else there with you that kind of, you know, understand, you know, the implications or what to do next. But yeah. Mhm The same feeling that you would get saying it. Yeah. So, so a spinal reflex essentially, right? So in this particular situation, obviously, you have to rule out like you said that there wasn't like a massive brain bleed or something like that that's developing acutely. But let's, let's say that, you know, there's no evidence of that would then be considered like probably like a spinal reflex, something mediated by either the midbrain pons, something like that. Okay. Gotcha. Yeah. But once you kind of, you got to go through the like the ruling out part. But yeah, write those patients are going to the emergency department. Yeah. Yeah. So what we, you know, with that sideline assessment you're on the field and your initially, it's not even a sideline, you're checking their pupils, you're checking, you know, their tone, you're, you know, you're seeing there really sensation before you even checked on like how things are and you're, you're moving them off the field, they're not moving themselves, go on, go on the gurney and get carried. Mm Yeah. And sometimes it, you know, it's different. Some patient's like pop out of that quickly and you know, you go from there but you want to be cautious athletes. I love, I love working with athletes, but I also know that you have to save them from themselves. So a lot of driven people, they are very motivated and it's, uh, they're great to be around because, you know, you want to be better right along with them. But you also got to like throwing the reins. But yes, and you can have seizure after concussion too. Sure. From my background, I would consider that usually an acute symptomatic seizure. Yes. So they don't normally wind up on anti seizure medications per say. Yes. So, um and it's very like clear uh for your listeners, like it's a seizure and it happens quite soon after the head injury. So I've had uh two patient's that have had that one was a car accident and the other one was, I think BMX. Yeah. Oh, wow. That I imagine they go through all the same work up that they would uh for anyone else with the first time seizure in terms of eg MRI of the brain, all that kind of. Yeah. So the first one was in residency, you were, you had left the first one? Yeah. Yeah. The first one was residency was came in as an emergency and the other one. Yeah, he, they actually saw me, I want to say within like a week or four days of having like the head injury and then the post traumatic seizure and they had already, they were immediately taken to the hospital and got imaging and things of that nature and they were coming to see me um, in training to see if it was safe for them to ever kind of ride again. Do the six months. Yeah. Yeah. Yeah. So we just, you know, we did that same kind of thing that we did who with um, like, you know, you do the slow return to play and you monitor them during that process and, you know, yeah, they're able to return activity but you're also making sure that they don't have another event. But it's, I think the, we're lucky we're attendings that had worked with, um, athletes or soldiers that had post traumatic seizures. So they were very comfortable with, you know, following them and taking care of them. Yeah, like, yeah, you have activity. We're just going to, you know, monitor you and you're gonna see us back at 36 months and go from there. Yeah. Absolutely. Yeah. Now, 11 last topic I wanted to touch on, I would see sometimes people who had sustained workplace injuries and they would usually have, you know, kind of these, these concussion symptoms. But, you know, I know you said there are more acute but these are months removed down the road where they're still having headaches, uh, you know, kind of sensitivity to like auditory visual stimulation, sleep impairment, mood impairment. Um, and I know it's kind of a nebulous term depending on what criteria are you using but like post concussion syndrome would be sometimes kind of like the label that best fits people. Remember one lady in particular she was like, restocking shelves and like, uh, like, it doesn't stand mixers fell and like, landed on her from like 10 ft up. Yeah, that's a pretty, pretty bad injury to. But what, what are your thoughts on the term post concussion syndrome and the treatment of patient's who might have it? So the term is a blanket term, it's kind of an umbrella like the symptoms that you have after, you know, that acute part of the concussion and the changes that have occurred with the jarring forces in the brain have already resolved. And now you're just left with these symptoms. So it's a, it's easier for patient's to grasp if you just say, oh, this is secondary to your concussions. So it's post concussive. There are, you know, people in our field that don't like the term, they prefer to split it up to what you are actually dealing with your dealing with post traumatic migraine, you're dealing with, you know, sleep disturbance or insomnia, you're dealing with mood or adjustment disorder. They don't like the blanket term because some patients' kind of cling to that, this is all my concussion. And so, and with those patients', you just kind of sit down and you take the time um to explain to them. Yes, you know, you likely had a concussion. Um, but that acute injury has resolved, you were no longer concussed. And that's, uh, you know, some patients get really mad. I've got, I've had patient's get really mad at me when I say that and I try to tell them I'm not discounting that you were concussed at one point. But you're, it's an acute diagnosis. You know, this happened three months ago, you're not still concussed, but you're having symptoms from that. And so what happens is in that acute phase. Sometimes the symptoms are not well managed and that's how they linger. And so, you know, people, I have heard providers that are fearful of treating headaches, post concussion because they're like, if I treat the headache, what if something else is going on and we miss it cause they're not in pain. And then I say, well, if you did a neuro exam or if they had imaging and it was normal, you treat the headache. And so, you know, you, the first, um, was it 2 to 3 days you have them schedule to leave, um, twice a day, uh, to help break the headache cycle and, you know, sometimes it gets better after that and you don't need anything else or you use predniSONE like it's the same way you'd give a predniSONE burst to treat a migraine. They're having post traumatic migraine. So you treat it like any other migraine, do any other migraine. So you give them that burst and taper over like seven or something, uh, providers like 10 or 14 days and then you go from there and I would still, with patient's that have had a workplace related injuries that they come in with a migraine that is still there for months on end. I would give them predniSONE. By the time they've seen you, they've already had imaging their exam. You're not finding anything on exam. So you're like, why are they feeling this way? They have a migraine. So you treat it like a migraine and you know, the same way you would, you know, in a lot of times that helps break the cycle and then once you break the cycle, then it's just like okay, intermittent migraines, this is how we're going to treat it. And so you go from there. And so I was, I've been very big on, you know, symptom management. You have to think about it in ways of how we manage symptoms with other neurological conditions to like sleep, we manage sleep with MS patient's neuroimmunology, epilepsy patients', we manage mood with them too. It's just the same kind of thing, the same thing. Yeah. And it's, it is very, I've seen with patient's that work in a certain setting that their symptoms aren't because they have a neuro exam, their headaches aren't believed or their mood complaints are believed. So they're very defensive by the time they get to you. And so you just got to try to take the time and I love a, a board to draw out the map. So I draw out the graph and just, you know, this is the acute and then it, you know, goes down like that angle down and sometimes people don't go right back to that, that y axis. They, they kind of stay, yeah, they kind of stay, they plateau. So and then it's just like we just got to bridge the gap to get you back. So yeah, so sometimes they'll be more helpful if people aren't as familiar with, with concussion. And people, the sequela of it just treat it like it's individual components, use the tools that you would normally have in your toolbox for treating migraine, treating sleep, treating mood disorders. And it just so happens that they're all coincident with each other as a cycle of the concussion itself. But there's nothing necessarily exotic or unusual about how you would manage them uh as a whole. Yeah. No, it's not. Nothing too crazy. Sorry, I think I misspoke from it goes from the peak of the Y axis and then it just kind of goes to the end of the X and sometimes people don't hit that, that line, they kind of stay up in the plateau in this horrible phase of symptoms and you just got to bridge the gap for them. But, you know, I can understand the fear and things that go on with that. But you know, if you break it down into like a symptom instead of seeing it like, oh, they had a concussion and I have to treat this huge crazy thing when you know that it's months later and it's an acute thing. You, you treat their symptoms and patient's feel really well when their symptoms are treated. Um, it's also, you know, difficult because they've been dealing with this for so long. So some patient's don't believe they'll get better. And so you have that hurdle to kind of get over to, like, just trust me and, and that can be difficult. Sure. Yeah, especially like you said, that they've been disbelieved by, uh, different people in the medical community for months on end while they, while they feel terrible. Yes. I mean, we all trust our neuro exam and we see the exam were like, exam's fine. Yeah. But, you know, my Graner's have normal exam too, you know. Yeah. I mean, people with epilepsy often have normal exams. Right. It's not, doesn't mean it's not serious. Right. That's exactly. But, yeah, any, any final thoughts that you would say that people with like in primary care or neurology trainees or trainees in general should, should know when they're encountering, uh, people who have suffered concussions either in the acute or the, uh, post phase. Uh, you know, just to, you know, you've had the training, it's patient's are fearful of concussions and the state that we have right now with everything everyone's kind of fearful of it. Um, but if you just take a kind of a step back and listen to the symptoms and the severity and you just go from there, like, is it within that first week period, have their symptoms? You know, the natural course is they start to feel better and if they're not, you know, their symptoms weren't well managed, you manage your symptoms, you know, if not every concussion needs an MRI, but if it's going to make you feel better as in, you know, a provider to say that it is normal for them, you could do it, it'll help them and help you a sideline to that. You know, I know we sometimes get imaging to treat ourselves rather than our patient's. But do you ever find that like when you're trying to build that rapport with the patient, like we're going to get these symptoms under control by doing XY and Z, if there's someone who is, let's say more skeptical, oh, for your plan, will you say like, well, we'll get an MRI, we'll make sure everything looks okay. And is that, is that a helpful strategy at times? Yes, I have done that before. Um It can be helpful and I tell patient, you know, some concussions or, you know, they do say M TBI mild traumatic brain injuries, you can have like a slight contusion instead of, you know, in certain areas. But I do go over that, you know, that's likely normal. It'll be normal. But if they need it, I'll get it and it's kind of a mixed bag. So some patient's see the normal exam or see the normal MRI. And they are mad because they're like, it's all in my head and you, you know, and they are mad at themselves, they're mad at you. And then I tell them it's not all you have headaches. Like I told you have headaches, we can treat it or, you know, some patient's see it as well. There's something else going on and you just haven't found it. And so it's, if you can kind of lay the foundation as best you can, like, you know, the MRI is not going to necessarily change my management. I'm going to still want to do these things. But if it's going to help you for, for me to go over it, um, you know, once you get it and I do, I go over all the sequences, the flare, uh, you know, a DC wi to like explain which ones we use for the bleed, the t to looking at the vessels. It and it, it helps, um, for them because they, a lot of patient's feel that they're broken because they've had this and, you know, with, you know, physicians and providers to just reassure them that this is something you can recover from, you can, you know, do great things still. There's a lot of fear out there with it and there shouldn't be. I love to use one of my friends as an example. He's had, like, four and he's a new radiologist. He's one of the hardest people I know. So, with rugby. So I'm like, yeah, no, there's a lot of fear and just, you, you know, you get more comfortable with it and go from there. But, yeah, or call, you know, you can always, like, curbside people to get their opinion too. Yeah, it never hurts to get another opinion. No, it doesn't. No. Well, thank you so much for talking about concussion with me today. For anyone who wants to reach Dr Misty Woodburn. Uh Please reach out to me either on Twitter at Doctor Ken Trist Drkentris or by email. Yeah, that's a good way. Doctor would burn. Thank you again so much. I appreciate your time today. Oh, I enjoyed it. Thank you everyone for listening. If you enjoy this podcast, please rate review and share it on Apple Spotify or wherever you get your podcasts and please subscribe for future episodes. You can reach me on Twitter at Doctor Ken Trees. That's Drkentris or by email at the Neuro transmitters podcast at gmail dot com. With any questions or show suggestions. We'll see you all next time.