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Using Telehealth & VR to Diagnose and Treat Concussion | Jennifer Reneker | TEDxJackson

Using Telehealth & VR to Diagnose and Treat Concussion | Jennifer Reneker | TEDxJackson



my husband came home from work one night and standing in our kitchen in Canton Ohio he told me that he had found a job and that he thought we needed to move to Mississippi and to that I responded absolutely not we are not moving to Mississippi so over the next several days and weeks he was very patient and he said why not Mississippi now I was in epidemiology I am an epidemiologist and I knew that Mississippi is not exactly the mecca of good health but to be honest with you I had nothing to do with my rationale of why I didn't want to move Mississippi could have been anywhere I just didn't want to move I had my family I had my friends I had my routine and I had my work and I was pursuing a line of inquiry and a line of inquiry as a researcher simply means that you are sequentially asking and answering questions to generate new knowledge such that one answer helps formulate the next question and so you're building and then whenever you're building you have a greater understanding about a specific topic and it's kind of like bricks buying by itself a single brick really isn't that useful for much of anything but when you have many bricks you can build something beautiful like a house in coincidentally these are left over from building a house because when we moved to Mississippi I said I want to build a house and my husband said under no circumstances will we be building a house and there you go so my line of inquiry began in around 2010 to 2011 when I started working with the medical director of a Sports Medicine Center that ran a concussion clinic and at the time I started working with him he told me that his burning question when should I send a kid with a concussion to physical therapy for treatment and I honestly thought this guy just does not know how to find medical literature so I went back to my office and I went to PubMed to search for it myself and to my absolute amazement there was nothing to answer that question in fact the international consensus by the experts was that rest was the cornerstone of management for concussion physical and cognitive rest until symptoms go away or they become chronic at which time you might seek some type of treatment and that just did not sit well with me because basically over the last twenty to thirty years we have found through research that almost every other physical injury responds better when we start doing some movement prolonged rest is not the best treatment this is true for low back pain it's true after you've had a cardiac event to get into cardiac rehab it's true if you've had a traumatic brain injury or a stroke we get you into rehab so why was concussion the one thing where prolonged rest was the treatment of choice so he had me hooked now I wanted to know some more so the first thing I needed to know was actually from him which was why are you sending these kids to physical therapy anyways what is the problem and the answer was dizziness so dizziness is an interesting thing to feel and the reason is because it is a subjective experience that if any of you have felt dizzy you may have used different words to describe it and it also does not spawn point specifically to one particular problem so for example your eyes you have two of them this guy only has one but your two eyes have to move smoothly together they have to also perceive the environment correctly and if they aren't working quite right and they aren't stable or they're not they're not they don't have control then you might report a sense of what might be called busyness the next one would be inside of your ears you have two organs that make up your stealer system and when one of them is firing faster than the other it actually causes a problem with your gaze stability the ability of your eyes to hold on to an object whenever your head is moving and that also can be described as dizziness the next one might surprise you and actually in your neck your joints and your muscles convey information about where your head is in space and if they aren't correct you could have something called dizziness in fact that's called cervical genic dizziness but finally when we take our information from our eyes our ears and our neck our brain has to simultaneously process all of that information and then use it to direct movement well if the eyes and the ears are saying your head moved 10 degrees but your neck says it only moved 8 then your brain likes to do something that a scientifically called freak out and that can also cause a report of dizziness so now that I had this understanding I had my first research question that I wanted to ask and so the question was after a concussion do athletes report or describe their dizziness differently and is that description helpful to determine where the dizziness is coming from and the answer to the question is yes they do describe their dizziness very differently but no it is in no way helpful to figure out what is going on so since that didn't work we needed another approach and that would be our first brick so we needed another approach and then the next thought I had was are there objective tests or clinical examination tests that we could do with an athlete to determine where the dizziness is coming from and the answer to that question is yes there are physical examination tests and they are useful but in the presence of concussion generally speaking it's not just one area that's injured it's several which makes sense because it's induced by traumatic forces and all of these areas are liable to be injured so now we were finally at the point we could get to his question and his question had to do with when do I send him for treatment for dizziness and so we set up a randomized trial clinical trial and we sought out to answer the question of can we start physical therapy during the acute phase of recovery is it feasible is it safe and does it help speed recovery and the answer to all of those questions is yes we can start physical therapy in the acute phase after a concussion it is feasible it is safe and it can help speed recovery and since that time there have been several studies that have shown the same thing whether it's starting in the acute phase or in the chronic phase physical therapy's effective so I was able to do all of that while I was in Ohio because I had my patients I had a concussion clinic where I had access to patients I had my my peers and I had my tools and then we moved so in April of 2016 when I got to Mississippi the thing I wanted to find most of all was a medical director who ran a concussion clinic within a Sports Medicine Center so I could continue answering questions and building upon this and I could not find a concussion clinic anywhere one thing I did find out was that Mississippi was the last state of 50 to pass a youth sport concussion law so I actually began to realize that this might be a little more difficult than I had originally thought but I also found some other things as I started to talk to people talk to everyone who would talk to me about concussion I found that there are fantastic communities and people in Mississippi who have a lot of pride for their sports teams and I also got a taste of southern hospitality when I went to my first tailgating which I had never been to before but people have tents and food and they just welcome you to eat their food and drink their drinks and it's fantastic I mean there's nothing like it where I'm from I also learned something new about the concept of a rivalry I come from a place where I grew up rooting for the Buckeyes and we have a rivalry with Michigan but you guys put us to shame whenever it comes to that because we don't have we don't have nearly the rivalry you guys do nearly the passion the other things I found were I found youth as teams municipal teams volunteer coaches who start working with little kids five-year-olds teaching little girls little boys how to play soccer how to play football how to work together as a team how to be coordinated and they volunteer their time and they volunteer their money and they do it and they say they do it just for the kids and I believe them I also met parents who have had kids who had a concussion in high school maybe more than one concussion and when they didn't get better they just pulled them out of sports and that was it for them or when they didn't get better they went to other states to seek treatment I also met many health care providers who recognize that there is a need for specialists to be in one location so that we have an organized concussion management system because unless you seek training outside of your entry-level education no matter what health profession you're in you probably don't know how to deal with this particular diagnosis concussion in sport is regarded as one of the most difficult diagnosis to manage in a sports setting that's just the way it goes so as I saw the need and I saw the passion of the people and the love for sport I just could not figure out how all these other states had concussion clinics and I was like why not Mississippi but one of the things that made me somewhat hopeful in fact very hopeful is the system and the resource that is telehealth in Mississippi this is a phenomenal resource and Mississippi is regarded as one of the top two states in the nation as evidenced by the fact that we are now a center of excellence for telehealth and I really do believe that when we do finally have a concussion clinic that use strategically we can reach all of Mississippi and provide equitable at least decrease the disparity by having that specialist interaction no matter where you are and this would change not only care in Mississippi but in all the Mississippi's across the u.s. where you have rural or you have poor areas so in the meantime over this past 12 months I've not been doing any research and so I want to do research so I started down a side road with a new question and the new question was are athletes who have had a previous concussion at greater risk for an injury than athletes who have not and the way they said about to answer this question is to do what's called a systematic review and doing that what you do is you find every piece of evidence that has sought to answer that question so you're searching for bricks and you bring them all together and then you do a special type of statistical analysis to come up with one summary estimate so we were able to find 28 bricks that endeavor to answer that question we put them all together we have a big old answer that answer is athletes who have had a concussion are over four times as likely to sustained a concussion than an athlete who has not and they're also almost twice as likely to sustain a subsequent leg injury now nobody really knows why this is we're just learning that it is but I really believe it has a lot to do with residual deficits over here since we know most of these kids aren't getting physical therapy potentially there's the potential that there exists residual deficits that are just small and even though they were good enough to go back into sport their reaction time is just a little slower their balance is just a little off their agility just isn't quite there which would certainly in a sporting environment lead to an increased risk of injury so with that thought in mind I started to develop a new clinical trial and this time what I wanted to do was design a population health type of intervention and what that essentially means is that it would be an intervention that could be applied to a large number of people to see if we can prevent something from happening so as I'm starting to design this intervention in May of 2018 I had my first experience with this now this is headset virtual reality and this provides an immersive sensory experience where you can play games I mean that's what it was designed for and when you're in here truly you're in another universe in fact you're in a place called the Metaverse well when I put this on here since I'm not a gamer all I could think about was how could this be used in concussion there's got to be a way so I very quickly got hooked up with a meta vers curator which is a fancy way to say a software developer for experiences in games and virtual reality right here in Jackson Mississippi and I told him the types of training the types of physical therapy interventions I wanted to be able to do inside of here and then he and his creative team helped me develop those games and we added that to the intervention I was already doing so in the fall of 2018 I enrolled 75 men's and women's soccer players from a local university who completed eight sessions of training so using typical physical therapy trainings like what we did in this study and virtual reality and that the purpose of the study was to answer the question can we implement this training intervention and will improve sensory motor control and decrease risk of injury and the answer to the question is yes so taking healthy athletes we can improve their sensory motor control whether they've been injured in the past or whether they've never been injured in the past our statistics are showing significant improvements in many of the measures of sensory motor control after the training in addition when comparing the 2018 soccer season to the 2017 soccer season where they did not have this intervention we saw a 27% reduction in the number of injuries while that is not the last study that needs to be done on this topic it certainly is promising and very exciting and we're definitely going to go further so for me the next question is can we take all of the physical therapy interventions we use to Train sensory motor control to rehabilitate kids after a concussion can we take all of those sensory motor training and put them inside a VR and can we use that to rehabilitate people after a concussion and can we use it to continue training them preseason conditioning so that they have less risk of injury and the next question I have is can we take headset virtual reality and develop diagnostic tests that are at least as good as these tests if not better and the next question I have is can we merge telehealth with headset VR to be able to deliver the same level of clinical care if you're in the room with me or if you're a hundred miles away I don't know if the answer to any of those questions is yes but what I do know is two things number one we have everything we need to answer those questions right here in Mississippi and the next thing I have to say is if any one of those questions can be answered yes it will radically change concussion management not only in Mississippi but in everywhere across the u.s. so in my story Mississippi is a real place I mean it's here but Mississippi can also be seen figuratively so where is your Mississippi it's the place where you don't want to go to and where it is unlikely that you will succeed it's also of a place where once you get there you can build a house you can meet some new friends and you can learn about something that you thought you already knew it's also the place where you can take things and put them together in a new way for ideas that are worth spreading and so my last question for you is why not Mississippi [Applause]

Author Since: Mar 11, 2019

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