Podcast | Episode 4: Concussion Program with Nata Salvatori and Sarah LaheyClinical Expertise
Nov 19, 2019
Tracy Davis: Welcome to the Brooks Rehabilitation Podcast. My name is Tracy Davis.
Michelle Orallo: My name is Michelle Orallo. And this week we spoke with Doctors Sarah Lahey and Nata Salvatori about the Brooks concussion program.
Tracy Davis: It was a very informative discussion. I learned a lot more about concussions in general and exactly how unique the Brooks concussion program is. Make sure you visit us online at brooksrehab.org and follow us on social media @BrooksRehab on Instagram, Facebook, LinkedIn, YouTube, pretty much any social media platform. Just search for @BrooksRehab and connect with us.
Michelle Orallo: We’d like to hear from you, just email us at [email protected].
Tracy Davis: So let’s just jump right into it.
Nata Salvatori: My name is Nata Salvatori. I’m a physical therapist here at Brooks and I’m also the outpatient orthopedic coordinator. And under that hat that I wear here is one of the things that I work on the concussion program kind of came alive a couple of years ago now.
Sarah Lahey: I’m Sarah Lahey and I am a clinical neuropsychologist that works both in the hospital and in the outpatient setting. And I see all of our outpatient concussion patients. I also am the neuropsychology consultant for the Jacksonville Jaguars.
Tracy Davis: So Nata, what brought you to Brooks? Why did you choose to come and work here?
Nata Salvatori: So I’ve been at Brooks now about nine years. I came from Virginia right after I finished my doctorate physical therapy. And at that time, I learned about residencies and fellowships. So I was looking all over the country to try to figure it out where I would do my post-professional training. And it was in between here and Kaiser in California. And once I heard a little bit more about the program and came on a visit, actually on site and saw everything that Brooks had to offer, I decided that that’s the place I want it to be because I wanted to get that additional training and Brooks has an amazing program with a lot of different disciplines. And I’m really happy that I did it.
Tracy Davis: Where did you go to school?
Nata Salvatori: In Virginia Commonwealth University, Richmond, Virginia.
Tracy Davis: That’s great. And what brought you to Brooks, Sarah?
Sarah Lahey: Let’s see. After a long road of long distance with my husband, who is a Jacksonville native, believe it or not, there are few and far between here. Oh, nice, nice.
Tracy Davis: Yeah, that is very rare.
Sarah Lahey: Oh my goodness.
Tracy Davis: Doug is too, actually.
Sarah Lahey: Whoa. Thanks for proving me completely wrong.
Tracy Davis: No, no. That’s just the people that we know, but it is very rare, you’re right.
Sarah Lahey: I swear I’m credible. So after doing long distance with completing my residency up at Johns Hopkins in Baltimore, and then my fellowship at Emory in Atlanta, finally lived under one roof with my husband. And I’ve been here at Brooks for about six years and I love rehab. I love the rehab setting, I love seeing people get better and stronger and get back to their activities. And I love working with other disciplines and learning from them and the different perspectives that we have on patient care and conceptualization. It’s really been eye opening and a wonderful symbiotic relationship with all the other disciplines here. And Brooks is a great organization, as far as community involvement, as well, and I like to be active in the community.
Tracy Davis: What was your experience before Brooks? Was it a completely different setting? It wasn’t rehab?
Sarah Lahey: It was rehab, but it was primarily an academic medical institution. So it’s different. There’s different hoops to jump through and different, in any setting, there’s politics and certainly in the academic setting, it’s different pressures and different poles as far as your workload goes. It’s really different than working for a nonprofit. And I think working for a nonprofit is really in line with my values and my mission as a human being on this earth. And so it seems like a good fit.
Nata Salvatori: I agree. It makes a huge difference to be able to just focus on your patient care and not having to worry about other things that come with working for different places out there.
Tracy Davis: Right, right. You went to school to treat patients, that’s what you want to do.
Nata Salvatori: Right. Right.
Tracy Davis: Right.
Michelle Orallo: So how did the concussion program come about?
Nata Salvatori: So I’ll say around 2015 or so, in the clinic, I started seeing some of these patients come through with this diagnosis. And at that time, I had not seen anybody before. And I thought it was a little odd. I was like, “Well, that’s different.” Every once in a while, you see one of those one-off diagnosis kind of patients and you’re looking up what you need and treat them. And then you probably won’t see one again in 10 years. So I thought maybe that’s what was happening, but then they just kept coming and coming and coming. And I was like, “Okay, we need to do some good research and learn as much as I can to really take good care of these patients.” And I learned from my patients that they were really having to go all over the place to piece together their care.
And because this is a multi-disciplinary or interdisciplinary situation, when it comes to the diagnosis, they were having to take time off and travel out of state or coordinate different appointments. And it was really difficult on the family and the patients to be able to coordinate all of that. So I started reaching out to people inside of Brooks that have treated these patients in the past. And I found out that we actually had all these amazing clinicians within our system that have had the experience and were ready to get together and help. So we put together a group of people. We sat down in a room, several times in a row, and start working on what the structure of the program will look like, who are the patients that we’re going to be treating, what the name of the program was going to be, and all kind of logistics to make sure that we could put this together. And then here we are, two and a half years later, three years later.
Sarah Lahey: There’s a lot of history and culture tied in with that. And when you start to challenge it, you can get some pushback, but it’s a starting place. And I’m really looking forward to seeing the outcomes of some pretty fantastic studies that are underway with several different institutions and several that the NFL is supporting too as well.
Tracy Davis: So can you explain a little more about that, the multi-disciplines that’s involved in the concussion program? Because I got to know more of it whenever I started working on the video with you guys. I had no idea. I really I thought they just come in to a physical therapist. Really, that’s how ignorant I was to it. So it’d be great to hear more about it. Go ahead.
Sarah Lahey: Because concussions often have symptom presentations that fall into many different categories, so often you’ll see some changes with thinking such as paying attention or remembering emotional changes, so mood lability where your mood is going up and down, or just really not experiencing any emotions at all. Some physical changes with maybe balance and coordination, headaches, neck pain, sleep changes. And all of these factors play a role in how the individual is functioning and their day-to-day life. So because concussion symptoms fall into all these different categories, it makes sense that best practices recommend that there are multiple different disciplines involved in, not only just the diagnostics, but most importantly, the care and the management of these patients. And so Brooks, like in many other areas, follows best practices and really strives to be an excellent care provider in this way. And so we have many disciplines involved in our concussion program so that we’re not only individually treating these different symptoms, but also working as a team and approaching the patient as a whole person.
So as to come up with a coordinated care plan that not only targets these individual symptoms, but also the patient as a whole, and then how that patient as a whole is operating within the different domains of their life, whether it’s work school, social life, significant others, et cetera. So with the program, as it stands, we have neuropsychology involved, we have a physiatrist involved, we have different physical therapists that specialize in different areas, whether it’s vestibular or more kind of exertional or manual therapy. We have occupational therapists, speech and language pathologists, a school re-entry coordinator that works with our students that come to the program where they help advocate and coordinate on the academic learning piece. And then we have a driving specialist that can do driving evaluations to make sure that they’re safe to get back out on the road. And we also have optometry and vision services that work with the patients, because often there’s some visual disturbances. So we all work together as a team to treat these patients.
Tracy Davis: Yeah. Yeah. That’s a lot of parts. And then, like you were saying, about how Brooks can offer one-stop shop for all of these things and these patients aren’t having to jump around to different organizations.
Nata Salvatori: To be honest, so I attend conferences related to concussion and we are very aware of all the programs out there in the country. And I don’t think there’s anybody that has such a comprehensive list of services to offer such as the one we have.
Tracy Davis: Like even down to the school re-entry, people don’t realize how vital that is for someone trying to get back into school and reintegrate back into that. It’s not necessarily an easy thing.
Nata Salvatori: Absolutely.
Tracy Davis: You’re not just out sick one day and then you get better and you come back.
Sarah Lahey: Right. Right.
Michelle Orallo: So what is a concussion?
Tracy Davis: It doesn’t have to be the full clinical definition, because it’s come into everyone’s mind, like in the past few years with the Will Smith movie and then the whole thing with the NFL and all that. That’s when it started coming back to me of like realizing not just how the sports world, but how big concussions is, it’s a bigger deal than people think. It’s not like I got hit in the head, “Oh, I had a concussion” and you kind of play it off. But there’s so much more to it.
Sarah Lahey: Yeah. So the actual diagnosis of concussion, depending on the resource that you’re referring to, to review the diagnostic criteria, but in general, the general consensus is that a concussion is this on the spectrum of a traumatic brain injury.
Tracy Davis: Okay.
Sarah Lahey: So when we take a step back and think about traumatic brain injuries, they’re classified as mild, moderate, and then severe. Concussion falls in the category of a mild traumatic brain injury in that there’s often not a loss of consciousness. And in fact, a lot of people think that there needs to be a loss of consciousness in order for there to be a diagnosis of concussion, and that in fact is not true. I think only about 10 to 14% of actual diagnosed concussions result in a loss of consciousness. And then taking a step back, there needs to be some sort of altered mental status.
So there needs to be some change in functioning to indicate that your brain received some sort of trauma. So that trauma is in the form of exertional force applied from outside of the body to either the head or the body. And that’s another misconception, is that often we think that you have to be hit in the head to have a concussion. And that’s not true because our head is connected to our body. And if you go back to your physics courses and think, it all flows throughout the body.
Tracy Davis: Right.
Sarah Lahey: So there’s enough force that’s applied directly to the head or to the body that results in some alteration of mental status. So what that is, is confusion or feeling disoriented. Sometimes people say seeing stars is often a classic term that people use. Then from that point, there’s often a cascade of neurochemical changes that occur in the brain that result in the symptoms that present. So the tricky thing about concussions is that there’s not one specific set of symptoms that occur. Every person, and I think Nata could agree with this, every person that we’ve seen that’s been diagnosed with a concussion presents in a different way. So typically, we’ll see headache, maybe some dizziness, maybe some vision changes. But that’s not a requirement. Like we talked about before, these symptoms present in many different domains of functioning. And so just as many different combinations as you could see, you’ll see it.
Nata Salvatori: We often say, if you’ve seen one concussion, you have seen one concussion, because one case is not like the other at all.
Tracy Davis: Right.
Nata Salvatori: They’re unique.
Tracy Davis: So not every patient is going to have to go through all of the other programs that you mentioned before and they all don’t need all those things, it’s just some might just need physical therapy.
Nata Salvatori: Correct. Yeah.
Tracy Davis: Don’t need all of them.
Nata Salvatori: Treatment is very tailored to the symptoms that you’re having. So the good thing is we have all these great clinicians that can treat you if you need, but if you don’t, then you don’t. It can be very specific to the symptoms that you’re presenting with, but there is a huge net of support in case you’re having a lot of these symptoms. And because there’s such a variety of symptoms, you can need a couple of people for this one and then the next patient can need a totally different group of clinicians to really take care of them.
Tracy Davis: Have you guys seen, since like I said before, with the Will Smith movie and stuff like that, has that changed people’s mindset of what it is? Has it been beneficial or negative, to inform people that they’re more aware of it or has it been?
Nata Salvatori: I think it had some pros and cons, and I’ll let Dr. Lahey talk a little bit too, because she did do a little panel in relation to the movie. But I think on the good side, it brought attention to what a concussion is and how you should report when you do feel like you have suffered a concussion and that you do need to step back and say, “Okay, let me have somebody look at me and make sure that everything is okay before I go back to play sports.” On the negative side of things, it created this hype on CTE, right? So the chronic traumatic encephalopathy. And so we had a lot of people now think that just because they’ve had a concussion that they’re going to have CTE.
Tracy Davis: Right.
Nata Salvatori: And that’s absolutely not the case. And there’s a lot of education that needs to come with that too. So the movie was good to bring attention to the issue, but there’s so much education that needs to come with that, that obviously you cannot put all that in the movie.
Tracy Davis: Right.
Nata Salvatori: That’s not the goal of the movie, right?
Tracy Davis: Was the movie specifically about football?
Nata Salvatori: It was. Yeah, it happened within the NFL.
Tracy Davis: Okay.
Nata Salvatori: So it’s very specific to football, was very controversial with how things were handled and all that. But we have parents that will call us and ask us to diagnose their kids with CTE or not. That’s not something you can do when you’re alive because you have to look at the brain to have a diagnosis.
Tracy Davis: Okay.
Nata Salvatori: So we usually don’t do that. We keep our patients alive. We like our patients alive.
Sarah Lahey: Put it on the table. I say, I can diagnose it if you want, but we’re going to have to cut off your head.
Nata Salvatori: So there’s a lot of just education that obviously didn’t come with the movie that needs to also be out there. So that’s one of our jobs is to make sure that we are disseminating information and helping everybody understand what is a concussion and how to take care of it, but also what the prognosis is and that most likely you’re going to be just fine, and there’s a team here that will help you do that.
Sarah Lahey: Yeah, absolutely. One of my biggest beefs with the movie is that it should be called CTE and not concussion because the fact of the matter is absolutely, it’s impossible to deny that repeatedly banging your head or getting struck hard enough in your head where you’re having altered neurological functioning probably is not a good thing. There’s plenty of people out there, and we don’t know just because of how scientific studies are designed, but we don’t know of all of those players that have been hit in the head repeated times, why some present this way and others don’t. And others are perfectly healthy and live full productive lives and die of old age, very healthy. There’s a lot of work to be done, but it’s a starting point and I think the culture that surrounds professional football or really sports in general, but especially professional football, is pretty tricky because there’s a lot of money in it and there’s a lot of just history and culture tied in with that.
Tracy Davis: I think it’s funny how sports, each sport is so different because you have the velocity of the NFL, of those guys weighing what they weigh and running into each other, and then you have soccer, they don’t get kicked in the head as much as the ball hits him in the head. Right? And then you have UFC where they’re getting punched in the head constantly.
Nata Salvatori: Yeah.
Tracy Davis: And I’ve heard a lot of stories, like I hear Joe Rogan talking about on his podcast, about how he talks a lot of these UFC guys and they’re not well later in life, the ones that have retired and they wear no protection on their head. And boxing, and then the best ones, I think like Floyd Mayweather’s best, because he’s the best defender. He doesn’t get hit very much.
Nata Salvatori: Yeah.
Tracy Davis: And there’s a lot of people that say, I don’t know if they say that like Muhammad Ali, because he got hit in the head and stuff like that. But I don’t know if there’s proof of that, but it makes you wonder why do some guys get hit in the jaw just the right way and they go right down and then other guys just get repeatedly hit throughout 10 rounds in a match. So it can’t be good to be getting hit in the head.
Sarah Lahey: No. Especially with the UFC. And the sole goal is to cause concussion in that, right?
Tracy Davis: Right, yeah.
Sarah Lahey: That’s how you win the game.
Tracy Davis: You need to fall down and not get up. Yeah.
Sarah Lahey: Right. Absolutely. Yeah, it’s interesting. And like I said, I’m excited to see what comes of it and also with some new developments with biotech and functional neuroimaging and just better ability to correlate some of those, what have historically been used for research, with some clinical coordinates is going to be pretty cool.
Tracy Davis: Yeah, because, like you said, there’s so much money tied into these. They’re not just going to be like, “Guys, this isn’t good for humanity. We’re going to stop the UFC now.”
Sarah Lahey: No.
Nata Salvatori: A lot of people won’t be happy.
Tracy Davis: Yeah.
Nata Salvatori: We’re also working towards being able to participate and being some of the people that answer some of these questions. So we’re really building our program to position ourselves in a way that we can start answering some research questions and contribute to the body of knowledge in relationship to concussion. So those good structure that we have will help us achieve that goal.
Tracy Davis: Yeah. And then you guys said before, about it’s not just head hits, it’s body hits and everything too.
Sarah Lahey: Yeah. And to that end, the NFL, every year, puts forth new rules, if you will, and regulations to try to limit the actual outcome of a concussion. So there are certain drills, certain types of hit like lowering the head was recently banned. So every year, there’s new regulations coming out with this sole goal of decreasing the rates of concussion on the front end. But then also as far as the amount of spotters or reviewers that are at every single practice and game that are independent, not necessarily tied with the team or the NFL, but completely third-party reviewers, of signs or symptoms that might look like a concussion and removing that player from play.
Tracy Davis: Right.
Sarah Lahey: We’re getting there.
Nata Salvatori: And that’s a place that has a lot of structure and support, but if you think about your day to day people, people have concussions from car accidents, from falling, from somebody kicking them in the head, in the pool, from falling from a horse. We see all kinds of stories.
Tracy Davis: That’s the stuff that scares me in life.
Nata Salvatori: There’re no spotters for that, there’s no rules for that.
Tracy Davis: Someone tears their Achilles because they rolled their ankle falling off of a curb or those kind of things.
Nata Salvatori: So that’s where education comes in and really making sure that the general population understands that at least recognize there’s something wrong and where to go to get help.
Tracy Davis: And not to pick on football too much, but I’m guessing obviously the helmet does help. It helps more than not having a helmet on, I would imagine.
Nata Salvatori: It helps you when it comes to a cranial fracture.
Tracy Davis: Okay, but not the impact because the brain’s shaking in the head.
Nata Salvatori: But it doesn’t prevent concussion at all. Yeah. The brain is loose inside of your skull, right?
Tracy Davis: That’s true.
Nata Salvatori: So having that, as much as the helmet manufacturers would like to claim that there’s something in there for it. And every year they try. They try to make something that would maybe decrease the risk or they try really hard, but it’s not something that right now we don’t have any equipment that does that. It will keep you from fracturing your skull but it won’t necessarily keep you from having a concussion.
Tracy Davis: Right. That makes sense. I didn’t think about it that way because the concussion is the brain and then moving the head and hitting your skull.
Nata Salvatori: Exactly.
Sarah Lahey: Yeah, think about an egg and an egg carton. Right? So the carton helps keep your egg from breaking when you drop your grocery bag. But that egg yolk is still sloshing around inside the egg shell.
Tracy Davis: Yeah.
Sarah Lahey: And so the egg yolk is our brain.
Nata Salvatori: So does your brain.
Tracy Davis: Yeah. That makes perfect sense. Yeah. That’s right. And then there’s still sports, even like rugby, that don’t wear anything.
Nata Salvatori: I know. I actually think that, don’t hold me to this, but I think that if we actually made the helmets less of a factor, we might have a reduction.
Tracy Davis: Because they don’t feel like they have a suit of armor on that they can just bash into anything with.
Sarah Lahey: Yeah.
Tracy Davis: That makes sense.
Sarah Lahey: Yeah. Probably will never happen. It’d be a rather boring, I’m using air quotes, boring game.
Tracy Davis: Yeah. Maybe you just have more like broken collarbones and things like that.
Sarah Lahey: Yeah. Orthopedic injuries.
Tracy Davis: Yeah.
Michelle Orallo: What does a typical recovery look like for someone that has a concussion?
Sarah Lahey: A typical recovery from a concussion is it’s time-limited, and people have a full recovery back to their baseline level of functioning. So we think about usually within the first few weeks, say three weeks, full symptom resolution. So all of the symptoms that presented after the injury have resolved and the person is along their merry way. In a handful of individuals, usually less than, studies show anywhere from 10 to 15%, have what we call protracted recovery, meaning they have symptoms that persist outside of that general one month window and can persist to three months, six months, even longer.
Nata Salvatori: Or longer.
Sarah Lahey: Yeah, even longer. So when we think about the actual mechanism of injury and what happens, it doesn’t matter if it’s a sports related injury, you’re walking down the street and you fall, you fall off a horse, you name it, doesn’t matter that specific mechanism of injury. But what matters is the neurochemical and the neurobiological changes that occur as a result of that mechanism of injury are time limited and they typically last, at least, what we’re able to demonstrate, about at the longest a week, per se.
After that time, the symptoms can still persist though. When the symptoms persist outside of the typical recovery time window, so that one to three months, there’s often other factors at play. So we think about possibly some pre-existing factors related to that individual. So do they have a history of depression or anxiety? Are they what we call catastrophizers? I think we all know people like that, that one negative thing can mean the end of the world and it’s never going to get better and we’re all doomed. Or if they have a history of learning difficulty or a learning disability. Also, age is a factor and sometimes even gender can be a factor for those adolescents as well.
The one part that’s difficult is that some studies demonstrate certain areas to be risk factors while other studies don’t. And a lot of that just speaks to some of the methodological issues with concussion research right now. But just like with what we’re talking about with the NFL, it’s getting better. And I think there’s more standards of care and research in place so that we can compare apples to apples and oranges to oranges, with regard to that.
Nata Salvatori: Yeah. You got to remember that there’s not a structural damage to the brain when you have a concussion. That’s why you don’t see a positive test on the MRIs and CT scans and things like that. So all that chemical imbalance, your body works really hard to reestablished that homeostasis, that neutral point of what is normal to your body. So that’s why after a few weeks, vast majority of people are back to normal. So there’s something else besides what that initial cascade of events is that would make somebody have those prolonged symptoms. And that’s still what everybody’s still studying that, we can’t exactly pinpoint that. And when you deal with people, that’s what happens a lot of times, we’re so different from each other and concussions present so differently that it makes a little bit harder to pinpoint. But there are some known factors of, the things that Dr. Lahey was talking about, that we know would potentially cause you to have that prolonged recovery. But again, vast majority of people, even if you have had symptoms for a long time, there’s still a big chance that you can recover.
Tracy Davis: Sure. Well, thank you guys so much for taking the time to do this. If anybody inside of Brooks or outside of Brooks is interested in getting in contact with you guys to get more information or to become a patient, where should they go?
Nata Salvatori: They can go to our website, brooksrehab.org. And we do have a space in there for our concussion program where you can look at some information and email us as well, is [email protected].
Tracy Davis: Great. Thank you guys.
Michelle Orallo: Thank you.
Sarah Lahey: Thank you.