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Dec 28, 2022

Demystifying Concussion Rehab with Dr. Christie Chiesa

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Dr. Yoni Rosenblatt: Welcome to the True Sports Physical Therapy Podcast. We got Dr. Christie Chiesa with us. She's gonna tell us about all things concussion. Before she tells us about all things concussion, she's gonna tell us about herself and this time we're all gonna be listening because now I hit record on the podcast.


Dr. Christie Chiesa: Perfect. Perfect. [laughter]

Dr. Yoni Rosenblatt: So this is as true a sports physical therapy podcast as you can get because we're not even gonna edit that out.

Dr. Christie Chiesa: Perfect. Perfect.

Dr. Yoni Rosenblatt: Rarely do we do things perfectly here. So before you tell us about concussion tell us about you. Tell all the sports PTs listening how you got to where you are today.

Dr. Christie Chiesa: Gotcha, so I am Christie Chiesa from Pittsburgh, grew up playing sports, went to Central Michigan University where I played soccer. Unfortunately, growing up, also had a lot of injuries so that's what made me want to be a PT very early in life. From Central Michigan after completing my undergraduate work there I came back to the University of Pittsburgh and did my doctor of physical therapy program and following that was fortunate enough to be able to do a sports residency, where I did that with Massachusetts General Hospital and Northeastern University, who had an association together.

Dr. Yoni Rosenblatt: Now not to be confused with Harvard.

Dr. Christie Chiesa: No, no.

Dr. Yoni Rosenblatt: Totally different.

Dr. Christie Chiesa: Different. Different.

Dr. Yoni Rosenblatt: Is there a Harvard PT school? 

Dr. Christie Chiesa: No. I do not believe so.

Yoni Rosenblatt: Let's just say you went to Harvard. Okay.

Dr. Christie Chiesa: I do have a Harvard Review though.

Dr. Yoni Rosenblatt: There we go.

Dr. Christie Chiesa: But so while I was there I got to work with a good amount of professional athletes as well as just D1 college athletes, in addition to a lot of people at the sports medicine program. So following there, I knew that I didn't necessarily want to be with a particular sports team but I still... I definitely didn't want to work with just a general ortho population. So once I had a mentor reach out to me and I learned more about this area despite the fact that it's in Baltimore and I'm from Pittsburgh, it seems like a great opportunity for me to work with some of the high-level athletes, still professional but also like the youth level and weekend warriors, and also having that interdisciplinary approach since we have a lot of strength and conditioning coaches. But throughout my time during my grad work and in the sports residency is when I also got introduced to concussion PT. So since then I've really tried to make sure that I've been developing that as well as my knowledge on the orthopedic sports injuries.

Dr. Yoni Rosenblatt: Yeah, it's been really awesome to watch you develop that expertise and to learn from you as it pertains to concussion. Small sidebar, you know when I look to add outstanding sports PTs to our team, the first thing I do is turn to my network and that's something we talk a lot about on the podcast is developing your network. Developing those strong relationships. I've reached out to PTs who have been through True Sports and moved on to some awesome opportunities as well as the current PTs. And one of them is Dr. Tim Machan who's been on the pod a number of times, ran a residency himself and now he's really head of sports science essentially at Rutgers football. And I said, "Who do you got? I need a great PT." And he reaches out to his network and I get your resume. And so as soon as I jumped on the phone with you, we had a great conversation and it was really immediately a collegial conversation. I really appreciated that because you were really quick to just drop how terrible Baltimore is at football. And still...


Dr. Christie Chiesa: Being from Pittsburgh I just... I had to. When I heard Baltimore I was like, "Oh no, oh no."

Dr. Yoni Rosenblatt: It's crazy that you say you had to because it was a job interview.

Dr. Christie Chiesa: It's true. It's true. I had to be honest.

Dr. Yoni Rosenblatt: Yes, you were very honest until I mispronounced your name like a million times in the phone call. But despite all those things I think that's just worthwhile highlighting is that the reason you kind of joined our team or that I was super interested in bringing you on was really your ability to connect quickly and speak so passionately about things like concussion. So really excited to have you with us. Let's dive right in. Walk me through your evaluation when a concussion patient walks in the door.

Dr. Christie Chiesa: So very extensive process when you have a concussion first presenting. A huge part, I mean it could end up being the entire evaluation, is the past medical history and the subjective. I often tell people especially those who start to treat, I feel like they bring that up in referral to orthopedic injuries. I know I've had some professors say you know with some people all you have to do is ask them questions and that'll tell you what it is. Maybe that's true for some but it's particularly true with concussions. All someone has to do is come in, tell me of mechanism of injury, some of the immediate and prolonged symptoms, talk to me about things that bother them. Very important to learn about if they got imaging, if they got certain things clear but just listening to their story and there's so many components including the psychological and the emotional component. You know there's different subgroups of concussion and I'm constantly trying to put that person in different groups.

Dr. Christie Chiesa: One is rarely in just one group and the psychological and the behavioral piece is huge. So that ends up being a big part of me just getting intake from them. A lot of times after that subjective, assuming that the red flags and all of that have been cleared, I can immediately give that person exercises without even doing a more formal exam. But if I'm able to get through everything normally, it's the past medical history, just generally observing them, having like a flattened affect or monotone pupil dilation, just different head tilts and asymmetries. Then going into, again, the current symptoms that they're experiencing, things like again if I want to clear out the cranial nerves and the bigger details neuro wise.

Dr. Christie Chiesa: Then going into making sure the cervical spine is clear, thinking about the C-Spine Rules. I often tell people a big mistake that people make is assuming that because that person went to the ER, because they saw a doctor that that automatically means that they're clear of things like cervical instability. But if anyone remembers in school that C1, C2 instability that can only be seen with an open mouth x-ray, right? So they could get imaging but a lot of times it's not that open mouth x-ray. So asking those questions especially with people who come in after a car accident or after getting head butted going up for a header in soccer, making sure that all those bases are clear and asking about questions such as head heaviness and debilitating headaches.

Dr. Christie Chiesa: I had a person at one point who got hit almost head-on, went to the ER, had a bunch of different testing, came to me. Then I'm talking to her and as we're talking my spidey senses were kind of tingling, especially when she talks about this feeling of head heaviness. Like her head is gonna fall off her body. So immediately I do a Sharp Purser and I didn't feel a clunk but she literally looked at me and said, "I feel like my head is where it's supposed to be." So needless to say I collared her up and sent her to the ER with her mom. She ended up not having that cervical instability and all the ligaments were okay, she did have a lot of laxity though but things like that you hear about those horror stories, it's important to make sure that you're clearing the cervical spine before you do anything else when it comes to having them do head shakes or full body rotations.

Dr. Yoni Rosenblatt: Okay so they walk in... Let's break it down a little bit. They walk in, maybe they say, "My neck is bothering me." Maybe they say, "I had a concussion." Maybe they say, "My doctor just told me to come, I don't know why I'm here." What are the questions you have to hit? Subjective history, what are the questions you immediately go to in that instance? 

Dr. Christie Chiesa: So asking about the mechanism of his, of injury, asking about things like did they lose consciousness.

Dr. Yoni Rosenblatt: Why does that matter? 

Dr. Christie Chiesa: I mean... Well, a lot of times there's different things that can indicate prolonged duration of symptoms or recovery. Loss of consciousness certainly is one of them and it's just important to know that that time frame between, and were they in a safe environment during that time, who was around them, but also an important one is knowing about immediate symptoms such as dizziness. Dizziness, not that loss of consciousness is a good thing or not that seizures on the field or something more dramatic is a good thing but immediate dizziness is actually the biggest indicator of a prolonged recovery. So asking about things like that, history of eye issues such as just wearing contacts, glasses, having a lazy eye...

Dr. Yoni Rosenblatt: And you're asking that because it gives you somewhat of a baseline?

Dr. Christie Chiesa: Yes, yes. And you have an idea you know if someone had a history of strabismus or lazy eye, needing their eye patched as a child, odds are that they could be a little more affected in terms of their ocular system after a concussion. Asking things such as a history of anxiety, ADHD, again, that puts them at a greater likelihood of all of those things being heightened after a concussion because that's essentially what a concussion does. Asking things like history of motion sickness, not just them, with their family. Some of these questions are also relevant such as migraines. History of migraines. Not just them but also of their family members.

Dr. Yoni Rosenblatt: Because it just gives you a better color and background as to what it is they might be dealing with. That's really important to highlight to kind of figure out like where you go. And I relate this back to something I see way more of. Knee pathology and questions just give you a baseline of a knee pathology. Have you had this before? What are things that have helped? What are things that bother it or symptomatic... It sounds like you go through the same thing, you're just... You know with the brain.

Dr. Christie Chiesa: Yeah and similarly... Similar to a knee pathology it's important to know do you have a history of this before. So a history of concussion is... Could also be a big indicator particularly asking about were they rehabbed appropriately, did they need rehab and then if they did need rehab, did they actually get back to their baseline. Because a lot of times you know I saw a jujutsu... She had been a world champion and obviously you're getting hit in the head a good amount with the jujutsu and the MMA and she had a history of like three different concussions arguably in the last six months to a year. And when she was done with me she had told me that she kind of felt back to normal, so she thought so but it was not until after seeing me that she realized, "I was not myself the past year and I didn't even notice it." So it's important to definitely ask those questions when it comes to history of concussion and how long that they took to recover because that could very much affect the... Again the current treatment.

Dr. Yoni Rosenblatt: Red flags that you're screening for when they walk in, in the subjective include what?

Dr. Christie Chiesa: Definitely talking about just the Canadian Cervical Spine Rules, so midline tenderness.

Dr. Yoni Rosenblatt: Can you just... Talk to me like I'm a moron, what does that mean?

Dr. Christie Chiesa: See you talk about like midline tenderness, inability to rotate their head more than 45 degrees in each direction. I talk about the feelings of head heaviness that would sort of off to the side but talking about that cervical instability of that C1, C2, that ligament. Also talking about the mechanism of injury, was it a traumatic, was it a fall of a certain height, different things like that. Was it more of a fall just standing up or was it falling off a ladder because all of that puts them at a greater likelihood of needing imaging.

Dr. Yoni Rosenblatt: Okay, and that's one of the things you're screening for?

Dr. Christie Chiesa: Yes.

Dr. Yoni Rosenblatt: Do I need to get this athlete some imaging?

Dr. Christie Chiesa: Definitely.

Dr. Yoni Rosenblatt: Okay, any other red flags when they come in you're saying let's go to an ER? 

Dr. Christie Chiesa: Definitely looking at... And I guess some of this may be in the exam, looking at their pupil symmetry. If I'm going a little more in the cranial nerves and they talk about different senses when it comes to eyesight, having like a really debilitating headache that doesn't change with anything, different things like that. Bilateral numbness and tingling, I mean you'd be surprised what some of these people can come in with and again, like the spidey senses are tingling. It's like when in doubt you need to make sure, especially with that numbness, especially with the bilateral symptoms, feelings of head heaviness.

Dr. Yoni Rosenblatt: You're referring that right away?

Dr. Christie Chiesa: Yeah.

Dr. Yoni Rosenblatt: Okay.

Dr. Christie Chiesa: Probably.

Dr. Yoni Rosenblatt: You're driving into the ER, you're calling your buddy who's a doctor.

Dr. Christie Chiesa: I'm collaring them up and if they have they have someone with them depending on the situation, I may have that person, if there's a closed hospital, drive them but fortunately I haven't had to do this but technically the protocol is collar them up and call the emergency people to get there and pick them up.

Dr. Yoni Rosenblatt: Okay, outstanding. I love kind of just crossing that off. There's so many different types of physical therapists that are listening to this pod, so just keeping a baseline of like when do you push the panic button. What I found is that you're never doing wrong by pushing that panic button and that's why it's so important when I say panic button to have an awesome network of providers and we'll get into that like how important that is to develop that so you can lean on some of these other health professionals. You get through that subjective, anything else you want to cover in your subjective as you're talking to this athlete?

Dr. Christie Chiesa: Big things are going to the behavioral on the psychological like asking about things... How are you feeling, have you felt... Don't think that you are making that person worse or more depressed by asking them if they feel depressed or sad or anxious. A lot of times they want to talk about it and haven't. Asking about their support at home, asking about things like are they avoiding busy environments, are they avoiding quick head movements, are they driving, are they doing things that allow them to be with people or are they doing things that are isolating themselves and probably making them more anxious and a little more depressed. So it's important like those behavioral components, like I said, even if I didn't give them a VOR exercise, even if I didn't give them something to address convergence, if they had issues, I could just end up giving that person behavioral references. I could give them behavioral things to work on to just allow them to slowly reincorporate themselves into daily life.

Dr. Yoni Rosenblatt: Because you got to treat the entire athlete?

Dr. Christie Chiesa: Yes.

Dr. Yoni Rosenblatt: I think that's a great point. A recent concussion case that you and I collaborated on was... A heavy part was that behavioral psycho-emotional piece which I already started seeing clues of before I met the athlete and so the mom called me about 17 times saying like, "Hey this athlete hit her head," however long, "They're still having symptoms. When do you think she can play?" And just immediately down that road, so when I got into talking to the athlete I already had an idea of what I would see. It did happen to be a big piece of what we're dealing with. I think once I referred that patient over to you, you did an unbelievable job of diving into that. And you're right, in that case that athlete really did want to talk about that stuff once it was addressed. I think the way I opened that conversation with them... Or you'll tell me if it was right or wrong was like, "I am knocking out the filter during this conversation, we need to address some of the things that are not physical in this pathology, in this presentation." And at first that athlete was taken aback, but it really actually ingratiated myself to her, and just had her buy into what we can do for her. So that that's a big piece. So it's awesome that you put that as a part of your evaluation. Now once you get towards objective testing...

Dr. Christie Chiesa: So again, looking at the cervical spine first like we talked about...

Dr. Yoni Rosenblatt: How do you do it?

Dr. Christie Chiesa: Again, just... In general, making sure that you have things like the ligamentous testing, clearing things like a Sharp Purser.

Dr. Yoni Rosenblatt: Sharp Purser. Yep. What else? 

Dr. Christie Chiesa: Again, the transverse ligaments.

Dr. Yoni Rosenblatt: Love it.

Dr. Christie Chiesa: Having them do just active range of motion. I make sure that I have them do active before I go and do passive and try to move their neck for them. Otherwise just palpation. Seeing what are the tight muscles. Are they holding their head in a certain way? Do you see increased tone? All of that's very important. And again, I try to do it to where I don't have them constantly going standing to lying down to sitting. So some of the cervical exam may be later too, when I'm just doing general mobility stuff. So I try to keep them positionally, even though that's in the... Technically the first thing I would do with them upright and sitting.

Dr. Yoni Rosenblatt: You make a good point though. The way to do that properly is to prepare. And so get organized. You know you're gonna have a concussion walking in. Maybe you know that or maybe you just know that you have a new evaluation, you're not sure what it is. You should have your concussion protocol, at least in your head. Maybe somewhere in your notebook, I gotta get through these tests, here's when I should do them. Especially when it's immediately post-concussion or post-trauma. You wanna be as organized and tight as possible so you can get through stuff. So, that's a great point. How soon do you wanna see them after concussion?

Dr. Christie Chiesa: Honestly, as quickly as possible. As quickly as they deem appropriate. Since I see a lot of post-concussion, normally it ends up being a couple weeks that someone's been out when they come in to see me. A lot of times if someone's acute, you almost wanna see, since a lot of concussions end up resolving within seven to 10 days, some symptoms. And that's not to say someone immediately goes back into that sport, but that's when they can start getting to that higher level activity. So sometimes I end up sending, seeing people, like I said, more like two weeks out or even... To be fair, some people I've seen years out who have had lingering symptoms.

Dr. Yoni Rosenblatt: You want to see them right away?

Dr. Christie Chiesa: Yes.

Dr. Yoni Rosenblatt: You do wanna see them right away, the next step.

Dr. Christie Chiesa: Honestly. Probably. Yeah.

Dr. Yoni Rosenblatt: Great. I was amazed to see 30% of concussion symptoms, 30% of all concussions, their symptoms last longer than a month. So I'm not surprised that you're seeing them so much later. And so once, if they're coming in that early, you get through your subjective, rule out your red flags, you've looked at the cervical spine because that's where you kind of want to start. Now where do we go?

Dr. Christie Chiesa: Then looking at the ocular component of it. So, resting alignment. And again, this all goes hand in hand with me asking before, "Do you have contacts and glasses? Do you have them with you?" You would be surprised. I just had a patient, actually have her right now, who... Her contacts have made some of her headaches worse, so she wasn't even wearing them in the eval. So some of it is gonna affect my exam later on, and it may affect too, some of her head tilts, resting alignments and how she's tracking and looking around at the environment. So it's important to know. Also things like special tests. You talk about head thrusts, looking to see if there is a vestibular hypofunction, if they have that eye catch up when you're rotating their head quickly to center.

Dr. Yoni Rosenblatt: Are we there already? 

Dr. Christie Chiesa: Huh?

Dr. Yoni Rosenblatt: Are we already in that part of the exam? 

Dr. Christie Chiesa: Yeah.

Dr. Yoni Rosenblatt: Okay.

Dr. Christie Chiesa: Yeah, we...

Dr. Yoni Rosenblatt: So resting alignment. Well, walk me through how you do it. Cause you're the freaking expert. So, resting alignment, you're looking at how they're kind of sitting, how they're holding a posture. Then what are you doing? 

Dr. Christie Chiesa: Then a part of the... A part of it can be tracking. There's the VOMS, the vestibular/ocular motor screening. A lot of people don't know about it. Some do. But basically there's saccades, so quick eye movements back and forth. There's smooth pursuits tracking. Then there's other pieces of it like convergence, how do the eyes work together? So some of that I also do...

Dr. Yoni Rosenblatt: So you do the ocular motor...

Dr. Christie Chiesa: Pretty much right on, right on around that time. But like I said, there's also things like the head thrust. There's the dynamic visual acuity. Well, I'll have some of those eye charts that they have at different ophthalmology or optometrists, and I'll have them do head shakes as they try to read to the lowest line possible. And if that ends up being a different line than what they can read at resting, if there's greater than a two line increase, then that means that they can also have some ocular deficit. So again, some of it is according to positionally not having them go too much up-and-down, side-to-side with the positions. But definitely alignments, looking at smooth pursuits, quick eye movements, slow eye movements. Adding in the eye chart if I think it's important with the head shakes. But some of it, if someone's really hyped up and the quick head movements are causing a lot of symptoms, I'm probably not gonna have them to do it. So some of it depends on those current symptoms.

Dr. Yoni Rosenblatt: And I think that's where rookie... That's the difference between rookie and being a seasoned expert. Understand, "Oh, why am I doing these tests?" I think early on coming out of school, and this is true for any pathology that I would treat, I just had this massive list.

Dr. Christie Chiesa: Yeah.

Dr. Yoni Rosenblatt: I gotta get through this. I gotta do Hawkins-Kennedy, I gotta do a knee, or I gotta do all this stuff for the shoulder. You're looking at me like "Now, why would I do it for concussion?" I'm talking about shoulder.

Dr. Christie Chiesa: No. I...

Dr. Yoni Rosenblatt: When you look at it for the shoulder, that's not the case. It's all about being a sniper with your testing. Don't be a carpet bomber. Be a sniper. Get to the point so that you can diagnose it, create a baseline and then you come back and retest. It sounds like it's the exact same with concussion. Another thing that you're saying that resonates with me is, that evaluation starts the second you hear from that patient, right? The second you see them in the waiting room and you walk them back, you're already starting to gather data. So that definitely resonates with me. Ocular motor.

Dr. Christie Chiesa: Then going into balance. Balance, there's the BESTest, there's the Modified CTSIB.

Dr. Yoni Rosenblatt: In the X-ray?

Dr. Christie Chiesa: The BESTest. I like the Modified CTSIB because normally that's... BESTest is best for less than 72 hours after injury, it's more acute injuries. The Modified CTSIB is more for prolonged recovery and further out, a little more accurate when it comes to that. But you can also do things like the DGI, the FGA, more dynamic stability. A lot of times I end up doing the static stuff first, since I'm going to be looking at some other things as well. And normally when I see people, they're pretty hyped up. So, again I'm looking at a bunch of different things. I'm not necessarily trying to have them walk with head movements, and negotiating obstacles right away.

Dr. Yoni Rosenblatt: And so if they can't do the static, they're gonna struggle with the dynamic. Is that correct?

Dr. Christie Chiesa: Yes, it's like a walk-before-you-run thing.

Dr. Yoni Rosenblatt: So you gotta start with your static testing. That makes a lot of sense to me. They look really good there. Okay. Now, you move towards more dynamic testing.

Dr. Christie Chiesa: Yeah.

Dr. Yoni Rosenblatt: Okay. Outstanding. Then... And that's all... That's balance.

Dr. Christie Chiesa: Mm-hmm.

Dr. Yoni Rosenblatt: Okay, and it's seemingly, it's convergence with both ocular motor. Anything... Any other tests you're moving through?

Dr. Christie Chiesa: So then going into the vestibular phase. So again, the VOMS testing, there's the smooth pursuit, the saccades, the convergence. Then you're also going into VOR times one horizontal and vertical. So that's the vestibular ocular reflex. It's basically showing one's ability to maintain clarity of one object as they're moving their head side-to-side. So that's important to look at, because almost all the time those are one of the biggest issues that I see with people who come in with post-concussion syndrome. So, you run them through that. Then visual motion sensitivity which is also vestibular ocular reflex cancellation. So the ability to keep something clear as you rotate everything at once. Also looking at that. And those two are the big vestibular ones that you're continuing with.

Dr. Yoni Rosenblatt: And it sounds like those are gonna guide some of your interventions, right? Tell me how.

Dr. Christie Chiesa: Yeah some of those can literally be the first interventions. You don't need a lot a lot of times to do some basic vestibular exercises. I straight up go to Michaels, I get some things and do arts and crafts basically where I have popsicle sticks, I use 14-point font which is what you're supposed to use according to research for convergence and for any vestibular ocular reflex. I tape it on a popsicle stick, and then I give them one and have them do things like quick head movements, like convergence. I always tell them...

Dr. Yoni Rosenblatt: Focus in on a point, quick head movement.

Dr. Christie Chiesa: Yes, and then convergences. Obviously they're bringing it in and out, trying to make sure that they're keeping not just clarity but that object as one object. I tell patients a lot of times that my job is the easiest in the beginning because I give them things that they're bad at. It's just a matter of finding a threshold of symptoms that we use to challenge them but not kill them and not make them have headaches for the rest of the day or make them so dizzy that they throw up. Nothing dramatic like that. But having them do things that bother them, create some of those symptoms. But then having the knowledge and the idea that if it gets beyond a certain threshold, say, like a six out of ten severity of symptoms, having them ease back and then assuming that everything calms down, they go back to baseline, having them go right back into it.

Dr. Yoni Rosenblatt: I'm smiling because it sounds like you're summing up where our field has gone as a whole. And I think that's changed since I've been out from PT school both with patellar tendonitis as well as concussion care. Like dip your foot, dip your toe into the pool of symptoms, and then take yourself back out. And you're gonna get accustomed to it. Does that make sense? 

Dr. Christie Chiesa: Yeah absolutely, absolutely. It's desensitization essentially. The expose-recover method is now more research-based, and I think we're getting out of the old paradigm of thinking where symptoms are bad and things are getting worse and that's not the case. It's like to get back to things that you want to be good at and normal things, you have to start doing the things to practice them and things that make you go back to normal. So you can't just keep adjusting the environment to you and expect to get better. You can't just continue dimming lights and turning down brightness on your phone and expect to suddenly wake up one day and be able to tolerate those things.

Dr. Yoni Rosenblatt: Yeah.

Dr. Christie Chiesa: That's a big education piece that I give people once I start to give them these interventions because some of them, I give them the tests for the VOR, I'm looking at them and they're like, "Oh, my gosh, it's terrible," and then essentially I'm telling them, "All right, we're gonna do it." And they look at me like, "Are you serious? Are you trying to kill me?" And that's where I... You have to give the educational piece about the importance of desensitizing their system, the expose-recovery piece, making sure that they have an understanding of that threshold. And I just tell them, "You will get better". If you do this stuff in combination, if I think you need other disciplines to help, that's also... I stay in my lane. I know what I know, and I know what I don't know. But if people do that, and truly have those hypersensitivities, they get better if they do it. Guaranteed. So that's... It's good like you said to have that patient buy in, whether it's psychologically like when you talk to your patient that we shared, but also talking about their physical symptoms that they're experiencing.

Dr. Yoni Rosenblatt: So, coming out... Those are all great points. Coming out of that portion of your evaluation, is there anything else you need to hit on day one? You like to hit?

Dr. Christie Chiesa: Those are the... I feel like those are the big ones when it comes to more objective measures. But a big thing is the behavioral changes. So some of that we touch upon when I listen to their subjective, but especially at the end when I ask about things like avoidance behaviors, when I ask if how someone feels going into a Costco or a Target. Some of them either tell me that they go in and they feel good for five minutes and then they leave because they get symptoms, or some people tell me, "I hate it. I don't go." So some of the things are behavioral. I tell them, "Go to Target. Take someone with you. Buy a nice shirt. See it. See how long you can tolerate that environment. Once your symptoms get up to that six out of ten, that same threshold, go to the bathroom. Go outside of the store. But once it goes down, go right back into it." Making sure that they are walking at least 20 minutes a day. Maybe having them start in a more quieter environment and then having them go to something like a busier park. Understanding those behavioral components, maybe even some mindfulness. There are different apps that you can use that I heard about when I was with Lenore Herget at MGH. She had some good apps that she gave people that were essentially like phone games that you can do that help with ocular movements and tracking mindfulness. There are different, like I said, behavioral strategies to use, and sometimes those in and of themselves make a huge difference.

Dr. Yoni Rosenblatt: So you're addressing it sounds like the emotional component. The best of our training ability. You're addressing behavioral. You're addressing the physical with some of that ocular motor stuff. Anything else... And as well as with tolerance, right? You call it activity tolerance training? So touch on that. Because I think that's a piece that we haven't necessarily hit. Are you diving into heart rate measuring? Or how do you coach them on their exercise and physical tolerance?

Dr. Christie Chiesa: Normally when it comes to formal exertion testing, I normally don't do that the first appointment unless that's something that's specified, and someone has had other components looked at that. Because of the type of testing that I go through, it normally ends up taking up a whole session. So I wait a little and just have them focus on the smaller but important details. But when it comes to activity intolerance I keep it all like, that's six out of ten, that seven out of ten, whether it's effort, whether it's symptom level, that's kind of money. And I may adjust that based on the individual because you have some people who maybe aren't willing to accept their symptoms as well, and try to push through and for them I may say a lower threshold. For people who are a little more fragile with their symptoms, I may say like seven-out-of-ten is okay but the walking, biking, things like that, all of the exertion components, maybe things like running probably aren't good right away because you have that head up-and-down movement. But I mean them getting their heart rate up, that physical activity is a huge, huge contributor to concussion recovery.

Dr. Yoni Rosenblatt: Yeah, I mean it's it sounds like you're really trying to meet that patient wherever they are, and get a feel for the way they translate pain levels of symptoms, things like that. A wise orthopedist once said to me, he'll look at a knee come back in to see him, and he'll see the way that that patient is walking. If they are super ginger coming out of a surgery and too protective, he throws him up on tables, slaps the brace off, and and really is aggressive with it to show that patient, "Hey, you can move." Versus he has someone come in, there's no brace, they're supposed to be non-weight-bearing, they kind of just sauntering in, he'll treat that thing like it's made out of glass. It sounds like you're doing something very similar just to relate to that patient and have feel for the way they are.

Dr. Christie Chiesa: Yeah and thinking about the opposite end of the spectrum as well. I know I didn't touch upon this sleep hygiene and health there. Making sure that they're being active, making sure they understand things like we don't want excessive napping. We don't want you... We don't want to say sleep deprivation to an extent, but a lot of times people with concussion, they have issues falling asleep, staying asleep. And it doesn't help with any of their other symptoms, doesn't help with them having the energy to do things like exertion activities. So having them understand how to return to their normal sleep hygiene, I just keep telling people, if you want to get back to your normal self you have to start doing things that your normal self did.

Dr. Yoni Rosenblatt: Get back on schedule.

Dr. Christie Chiesa: Yeah. And things like, even if it does feel like sleep deprivation at the time, even if they really want a nap and they're exhausted the rest of the day because they don't make themselves, they don't allow themselves to have one, odds are it's gonna be easy falling asleep that night. And that'll help to reset their system a little more. So it's important to know things like when to push themselves, but it's also important to educate them on how to rest. And to not just rest whenever they want, and to not always just listen to their symptoms and nap throughout the day, but to understand the importance of sleep hygiene and returning to their normal sleeping pattern.

Dr. Yoni Rosenblatt: There's so much that goes into this injury, right? So boil it down, coming out of that evaluation, what are the three most important things you're trying to get across to this patient?

Dr. Christie Chiesa: Basically that the education that concussions, there's no structural damage. Nothing is showing up on imaging. There's nothing wrong going on in your brain. Your brain is just... I just say freaking out. There's just a lot of things. A poke becomes a punch. It's working harder and not as much is being done. So they need to understand first and foremost that symptoms are not a bad thing. Nothing bad is happening. But it has to be kept within a threshold.

Dr. Yoni Rosenblatt: That's great. I don't think that's stressed enough. Okay, so that's one thing you're relating in terms of your education. In terms of home exercises, how many are you giving them would be I think the second piece that I want to hear from you as you wrap that session up.

Dr. Christie Chiesa: Yeah. So some of it depends on the deficits that I see so if I'm having them do tracking and I'm having them do convergence and how they look and be subjective and the numbers are normal, I'm not going to give them ocular things but a lot of times people can come in and they have convergence deficits where normally someone should be able to bring it in within five centimeters and then maybe it can double but anything six centimeters and beyond, if the object doubles before then, that's not considered within baseline. So if someone comes out of convergence and maybe they get a normal value but their headache is crazy and their dizziness is crazy, then convergence a lot of times I'll start with, like I said, the popsicle stick with the 14-point font on it...

Dr. Yoni Rosenblatt: From Michaels? 

Dr. Christie Chiesa: Yes, from Michaels, of course but...

Dr. Yoni Rosenblatt: Sponsor the show actually, Michaels.

Dr. Christie Chiesa: Yes, my beautiful arts and crafts. And then also compliments to Michaels, there's also something with, called a brock string, it's just I'll get some yarn and then put beads on it, between three and six beads, and that helps them to hold it up to their nose, attach it to a different object that's stationary, and try to focus in on each bead where if they're able to focus in on one bead and make it one, everything else splits. So again you're working on conversions just at different phases versus with a popsicle stick, it's that whole time coming in and out.

Dr. Yoni Rosenblatt: It's really smart. So okay so that's dealing with the oculomotor stuff, so you're giving them maybe an exercise for oculomotor, maybe a balance exercise... If there's a deficit you're trying to... Just how many exercises do you think you want to give them?

Dr. Christie Chiesa: Three.

Dr. Yoni Rosenblatt: Three? 

Dr. Christie Chiesa: Three.

Dr. Yoni Rosenblatt: And then if that is dealing with the education piece, if that is dealing with their deficits as they presented in session, is there one more piece that you want to hit at the end of the session to wrap up that evaluation or you good? 

Dr. Christie Chiesa: Like I said, I guess the education piece either like maybe two or three of whether it's the ocular vestibular balance and then at the end talking about making sure like the sleep hygiene, the walking again. Again behavioral things but making sure that those are clear. Normally it's things that I touch on are the normal sleep hygiene and the walking every day...

Dr. Yoni Rosenblatt: Sleeps important.

Dr. Christie Chiesa: Yes, and then if they have a lot of anxiety, different breathing techniques as well.

Dr. Yoni Rosenblatt: Okay. When you see them again, how do you wrap that up? 

Dr. Christie Chiesa: In the beginning I think a lot of people like being seen twice a week maybe in the first couple weeks because there can be a good amount of changes in those first weeks, especially if you're talking about cervical components and a lot of neck hypermobility that might be someone that I want to see more regularly because...

Dr. Yoni Rosenblatt: Because you want to work on them?

Dr. Christie Chiesa: Yes.

Dr. Yoni Rosenblatt: Okay. Do hands on stuff.

Dr. Christie Chiesa: Yeah and dry needling. Dry needling can be very helpful with certain headache patterns if they're coming from the neck. So that might be someone that I see for sure twice a week for a couple weeks moving forward. But a lot of times because it takes time to desensitize the body, I'll only recommend seeing them once a week unless they have... Unless they're opposed to it for most of our sessions because like I said assuming that they're doing things on their own, it takes time to desensitize the body. So if I see them you know on a Tuesday and then a Thursday, how much time are they really getting in between to work on their stuff enough to make sure that they're getting desensitized to it. So I want to give that person more time to work on things because it it takes time.

Dr. Yoni Rosenblatt: Yeah, and I'll tell you what you're great at is staying in contact with your patients, having them text you or working through our True Sports app, our home exercise app just to understand how, "Hey this is too easy, how would you progress it?" and vice versa, "This is killing me, how do you scale it?" That that's a really good education piece. And then as you take them all the way through and their symptoms start resolving, hopefully, what do those sessions start to look like further away from that evaluation, call it, four weeks of care?

Dr. Christie Chiesa: Okay, so well, let's say that someone has ocular and you know ocular issues like issues focusing on something and tracking something and then issues with quick head movements. So if those start to resolve then I start to do them together and then I start to do them with that person walking more and making things go more dynamic in movements. So having them do the quick head movements back and forth, they can do that statically, have them do forward-backward walking. If they can do with forward-backward walking, have them do it with, I call them boxer dodges, underneath a larger hurdle, boxing and doing the movement up and down as they're tracking something and zooming in on something and moving their head side to side, have them do planks while moving their head side to side and focusing on an object. You can combine those in a variety of ways, so a lot of times just adding the dynamic components and then adding exertion components and raising their heart rate whenever you're able to.

Dr. Yoni Rosenblatt: I love this because it's like you're being a strength coach for the brain. And so understanding what the brain has to go through activity-specific, beginning to get into that makes a lot of sense and is a really great pull on our education as PTs, so use that and be prepared to play with those factors. That makes a lot of sense, that hits home for me. Talking about neck strength and how important it is or not important it is, does it help prevent concussions and how important is it for rehabbing concussions.

Dr. Christie Chiesa: Very important. Not that, there's different ideas on why... So actually concussion's one of the few things where being younger is not a good thing. People who are young actually have a greater likelihood of having a longer recovery.

Dr. Yoni Rosenblatt: Why do you think that is?

Dr. Christie Chiesa: Some people say it's because of neck strength and different synapse formations, just general maturity of the brain but that's also people look at females and say, "Why do females get more concussions than men on average?" And a lot of times they say the neck strength. So it's hugely important. Sometimes in the beginning I'll do some of the classic chin tucks making sure that they have an understanding of how to activate those deep neck flexors and how to make sure they're maintaining appropriate cervical alignments because a lot of times you would be surprised at how some people move their necks after having something like a concussion.

Dr. Yoni Rosenblatt: I would not be surprised.

Dr. Christie Chiesa: Yeah, also looking at proprioception, I have a little like vestibular maze and it's kind of goofy but you have a headband and it has a laser on it and you have this person go through the maze with the laser. It is so hard and frustrating and you can tell the difference someone who has the cervicogenic dizziness or issues with cervical proprioception, they'll be all over the place or it'll take two hours to go through like half of the maze. So having them do things like that, making sure that they have an awareness of that, where their neck is in space and then also then going into a little more aggressive treatment. Banded neck resistance, side bending, making sure they're doing chin tucks with and without resistance and anti-gravity positions as well as standing positions. So it's hugely important.

Dr. Yoni Rosenblatt: Do we know that stronger necks decrease the incidence of concussions?

Dr. Christie Chiesa: It definitely... It definitely seems to be that way. I feel like some people keep saying, "Oh well, maybe females get it more than males because of XYZ," but a lot of times I feel like the more and more research is coming out, definitely neck strength has a big influence on decrease in likelihood of concussion.

Dr. Yoni Rosenblatt: I work with an NFL fullback who when talking about his workout routine, he said this as if it's totally normal. He has a leg day in the gym, an arm day in the gym and he has a neck day in the gym and I'm like, "What?" He's like, "Yeah, I gotta do all my neck stuff." So and the guy's never had a concussion, which you know, it's an N-of-1 but that is fascinating to kind of think about. You think we should be doing more neck strength as a... If you were talking to strength coaches? 

Dr. Christie Chiesa: Definitely. Definitely. I mean that's something that's...

Dr. Yoni Rosenblatt: How do you program that? When does that put in?

Dr. Christie Chiesa: So I again because it's kind of goofy to talk about especially... You know I had a 12-year-old soccer player, female soccer player the other day and she's looking at me like, "Neck strength?" like she doesn't even lift at that point. She's like, "I'm just gonna go and move my neck around a bunch?" but I just tell them a couple times a week, two-three times a week, giving them a handful of exercise whether it's banded, whether it's in combination with other exercises like planks, maybe some of the proprioceptive exercises as well, having a good idea of where their neck is in space. I mean it's huge because especially football player, a soccer player, going up for a header, you need so much stability but then again not just static stability, dynamic stability and force when you're doing things like heading a ball in midair having to be aware of where the rest of your body is in space as well. So it's hugely important. I definitely think that two to three times a week, not a ton of exercises, just some core ones would be hugely helpful. And I don't think they're emphasized or done enough unless it's at the professional or collegiate level.

Dr. Yoni Rosenblatt: I think even then, I think it gets glossed over and you're talking to a guy with a really long neck. So I totally get it and I'm really weak neck, so I definitely think it's totally worthwhile and definitely glossed over. You've done an awesome job of really trying to include as much information here. You've mentioned and touched on so many different topics that I think people listening to this need to go back, listen and just do deep dives on these like one-off tests that you may be mentioned like in passing or, "Hey, I got to go through a Sharp Purser." Well, what is a good Sharp Purser and how do you do it appropriately because I think as we get into the sports realm, unless you're specializing in concussion you forget about this stuff. So I think it's just important to like take a step back and dive into those specifics so you can be ready should that concussion walk in. What are some of the mistakes that you've seen, maybe you made them yourself, in rehabbing concussions. Ever made them yourself? Probably not.

Dr. Christie Chiesa: I think... No, never. I never make mistakes. Definitely not. Big things are rushing through the past medical history. Again I've said multiple times that I could not even put my hands on that individual, I could not do the VOMS at all and as long as red flags are cleared, all I could do is talk to them and right then and there I could give them behavioral things, I could know that... Issues with quick head movements and focusing on something, I don't need to look at it with the VOMS, I can just automatically give them that exercise. So again even if that means you spend literally the entire time talking to that person, it's so important. And in addition to the fact some of these people have memory issues...

Dr. Yoni Rosenblatt: Let me correct the one... I just want to correct one thing. Because I don't think it's talking to the person, I think it's listening.

Dr. Christie Chiesa: Listening, yeah.

Dr. Yoni Rosenblatt: To listen to that person. I know that's what you meant and that could be the best session of their lives, can be totally game-changing. So, okay. So that's one mistake is we don't listen enough. I think that's really true. Any other mistakes jump out to you?

Dr. Christie Chiesa: I've mentioned it, the not assuming that all red flags and all of the potential issues like cervical instability, not assuming that those have been cleared by other health professionals regardless of whether they've seen a neurologist or gone to the ER. It doesn't mean that everything is clear and that you don't need to cross the T's dot the I's. Also, making sure that you have that person understand that symptoms are not bad, they just need to be kept within a certain threshold, doesn't mean that anything is worsening or that any structural things are happening in the brain. They just need to be handled appropriately.

Dr. Christie Chiesa: And also recognizing especially in sports concussions that different athletes have different demands in their sport. When it comes to ocular tracking, quick head movements, a baseball catcher needs to have a lot of visual acuity, heightened visual acuity and those vision demands considering he's catching hundred-plus mile an hour baseballs, than a soccer player. And not that that soccer player shouldn't also have very good rehab but there are some crazy things that I've done with baseball players to make sure that they have that endurance with really really consistently fast pace things that they need to track. And you talk about soccer players, you need to make sure even more so than maybe a baseball player that you're looking at neck strength and understanding proper technique with things like heading the ball. So you need to make sure that you recognize the different demands that a different athlete has in their sport because that... There could be one movement that makes a big difference if that athlete has to do it repeatedly over their sport and if you don't find it then they're always gonna have a little bit of a deficit.

Dr. Christie Chiesa: And a lot of times that's what I saw with some of the people that end up coming to me is, there's such high-level athletes, they cleared all these standard objective tests, being able to do this at 180 beats per minute being able to do this at 50 beats per minute, there's all of these standard values but athletes need...

Dr. Yoni Rosenblatt: Pain standard.

Dr. Christie Chiesa: Yeah. Pain standard.

Dr. Yoni Rosenblatt: And that's what I think makes a great sports PT is understanding... It's funny when I was preparing for this conversation, I was thinking to myself, "How the hell did PTs... How did this become a specialty of ours?" Right? But as you talk, it makes total sense. Just understanding the demand that a patient needs to go through with a sports PT, it's just that on steroids. Understanding the insane demands that these elite level athletes or athletes in general need to go through and then pairing our intervention to match that. That makes a lot of sense. What do you think a PT clinic needs in-house to treat a concussion well? Toys, equipment? What do you think we need? 

Dr. Christie Chiesa: Like I said before, most of my, some of my baseline concussion exercises I can go to Michaels and do arts and crafts, popsicle sticks, print out some little squares of paper with 14-point fonts on them. There are things if you google it called heart charts, where you can... It's basically a sequence of different letters, multiple lines on it, and that can help them to work on tracking and focusing HIRT, heart charts. There are big ones and there are small ones, you can just print them off pretty easily. Put the near one on a popsicle stick and again, it could be a progression. Once they get good with one letter, have them do it while reading side to side and shaking their head back and forth.

Dr. Yoni Rosenblatt: This is one of the things that I love here and because putting on the business owner mindset, what do you have to buy? You don't have to buy that much, you don't have to invest so heavily outside of the education which is not free through the True Sports PT Podcast. And you can really develop a niche within this practice. So I think that goes both ways. Business owners that are listening to this, this makes a lot of sense to wrap your arms around. Sports PTs that are dying to create this specialty, turn to your business owners and say, "This is easy. It's not a huge investment." is there one massive investment? Treadmill you said you love.


Dr. Christie Chiesa: There are... So again I use things and I use these regularly because I see a good amount of them. The vestibular maze, like the giant maze on the wall, I mean that would be something you pay for the headlamp. I think that was like $25 off Amazon, yeah.

Dr. Christie Chiesa: No. No.

Dr. Yoni Rosenblatt: Is there anything over a $100? 

Dr. Christie Chiesa: Besides a trap belt, that would be ideal. No. Not that I'm aware of.

Dr. Yoni Rosenblatt: Okay, that's awesome to hear. I'll tell you what you did educate me tremendously on is aside from equipment, the network. So who do you need to meet that can help these patients?

Dr. Christie Chiesa: So big thing is, neuropsychologists are normally the first people that I would refer to if I think that this person needs just a little more look into the medical side of things. A lot of times they're the ones that look at impact testing, they have a little more knowledge of medications while also, again, the psychologist part, addressing the behavioral components. Neurologists are also very beneficial but a lot of times that's more imaging, purely medication standpoint. They don't look as much at the behavioral piece. So very important when you need them but a lot of times I go neuropsychologist first and then they help me to see if a neurologist is required. Also, and this is hugely important, a neuro-optometrist. A really good person who you can look to for assessing the eyes a little deeper. And some of this... I say this as if you can just go and google a neuro-optometrist. It's hard to find people who are good at what they do.

Dr. Yoni Rosenblatt: How do you find them or what are you looking for? 

Dr. Christie Chiesa: I'm fortunate enough to have different people that I trust who I've worked with in the past that I've... That have told me some of the names at least around here who...

Dr. Yoni Rosenblatt: It's all about the network, right?

Dr. Christie Chiesa: Yeah. It's all about the network. So some of it's who you know who do you trust who already has a little pre-existing network out here. But sometimes you have neuro-optometrists who overtreat, who maybe give that person a little more of a crutch than they need, some under treat or just don't... Some people just don't see concussions as much and that's where going to a general optometrist can also get you into trouble. It's not that these people are bad at their job but just like a PT, just like a doctor, some people just don't see concussions as much. So it takes some shopping around and I know that this neuro-optometrist that I have a relationship with, I went on site and visited him and he showed me some of the things that...

Dr. Yoni Rosenblatt: What's his name? 

Dr. Christie Chiesa: Keith Smithson.

Dr. Yoni Rosenblatt: Keith Smithson? 

Dr. Christie Chiesa: Keith Smithson.

Dr. Yoni Rosenblatt: Hell of a doctor, I agree.

Dr. Christie Chiesa: Yeah, okay, so...

Dr. Christie Chiesa: Northern Virginia Doctors of Optometry.

Dr. Yoni Rosenblatt: Okay and you found him just from your network and he sees a ton of concussion. Are there any other medical providers that you want to keep in your back pocket? 

Dr. Christie Chiesa: Names? 

Dr. Yoni Rosenblatt: No. No.

Dr. Christie Chiesa: Names of... Sorry. Psychologists and psychiatrists like that behavioral management part, huge. When it comes to again the emotional component, the anxiety, pre-existing depression, all of that hugely important. And then not... Making sure that you're understanding the network that that person already has whether it's an athletic trainer, strength and conditioning coach, even like a PCP or just like a general sports med doc, you all need to be on the same page. Especially, the athletic trainers. The strength and conditioning coaches in that return to sport phase. If it's a college athlete and they're constantly going back and forth between their time with the athletic trainer and their time with me, it's... Concussions are very easy to treat quite differently depending on that person's training.

Dr. Yoni Rosenblatt: Which is why communication is imperative and making that a part of your craft as a sports PT. How we communicate, how often we're communicating, how can we be as thorough as possible. We need to get out of these silos and really start to communicate with all of these specialists because it's the patient who wins there. Is there any surgical intervention here at any point and specifically I want to dive into occipital neuralgia and stuff you've seen around that.

Dr. Christie Chiesa: Yeah I've heard of some more recently coming here, occipital nerve ablations. To be honest, I had not seen anyone with that procedure done leading up to being here now in the last year. But otherwise when it comes to surgical interventions... I mean, to me, that would be if someone has more than a concussion. That would be stuff that's done a little earlier on in the process.

Dr. Yoni Rosenblatt: Yeah. I have seen some of that occipital neuralgia intervention. I've seen releases of the nerve as it exits the cranium. I've seen ablations like you spoke of. I've seen some of those and I've seen injections. Have you seen those? 

Dr. Christie Chiesa: Not...

Dr. Yoni Rosenblatt: Like Botox injections.

Dr. Christie Chiesa: Botox injections. I have. I was thinking more like surgeries. I don't know if you meant surgeries versus procedures.

Dr. Yoni Rosenblatt: Yeah. Both. That's a rookie podcaster question. I didn't do a good job of clarifying. So I've seen both of those interventions to differing levels of success. I've seen some of them go absolutely terribly and I think a piece of that was, it may not have been the right patient for that because I don't think that everything that you covered today was exhausted before that happened. So I think it's like with anything you want to check those things off your box or off the list and just make sure that we're covering all of our bases. What's the future of concussion care? What are you really excited about that you think is coming out or being researched currently?

Dr. Christie Chiesa: A lot of... So I worked with UPMC Concussion Clinic when I was in Pittsburgh so I got a lot of my teachings from there.

Dr. Yoni Rosenblatt: Do they have a football team up in Pittsburgh?

Dr. Christie Chiesa: Huh? 

Dr. Yoni Rosenblatt: They have a football team in Pittsburgh?

Dr. Christie Chiesa: They do. They do as a matter of fact.

Dr. Yoni Rosenblatt: I haven't heard of them this year. Go ahead.

Dr. Christie Chiesa: Oh man. Oh my gosh. So many thoughts.

Dr. Yoni Rosenblatt: Yes. Please don't share them. Yes, UPMC, you were saying.

Dr. Christie Chiesa: UPMC recently came out with EXiT testing. It's called EXiT testing. It's similar... There are different return to sport protocols that had been used. The Buffalo Bike Testing, Buffalo Treadmill testing, basically looking at that threshold of cardio output or exertion that that person has before they start to get any symptoms with if they have a concussion actively. So the EXiT testing is a little more sports specific. I had a head injury in the past that was actually treated through UPMC. And it's certainly more thorough than the exertion testing that I had done. And I'm excited to see more sports-specific rehab coming out. Because I think, like I mentioned earlier, with some of the high-level people that ended up coming to me because they got missed. Because they needed higher level care or needed to have higher level expectations and movements looked at that go well beyond just standard values. So they continue to have these lingering things that I think, otherwise, would have been caught if there was more thorough exertion return to sport testing.

Dr. Christie Chiesa: So I'm excited to see where that goes as things like the EXiT testing, the article on that comes out, other things are being developed that can help people for prevention strategies as well like neck strengthening. There's just a lot more education out there now and different resources and there's hundreds of pieces of literature being put out each year about concussion. It reminds me of ACL rehab in the muscular world but there's just so much information coming out and it's overwhelming to an extent to try to keep on top of. But I'm excited to see how that continues to improve the efficiency of getting athletes back to where they want to be and making sure... I mean, to me, I tell the person, "Me clearing you back to your sport is basically me saying that I feel comfortable with you getting hit in the head again."

Dr. Yoni Rosenblatt: How do you do that? How do you clear your athletes for sport? I think it's something we haven't covered.

Dr. Christie Chiesa: So aside from a lot of different sports-specific movements that I have them doing and modified things that I have them do if they're working in a college setting with their athletic trainer, I run through the EXiT testing that I had done with UPMC. So the EXiT testing was developed by them. It has, first and foremost, a cardio component. Some do continuous cardio, some do more HIIT style cardio. It also has a bunch of rotational squatting components, has components that involve quick step up downs, shuffling while also focusing on a cone, different directional reaction exercises, looking at line drills and sprints towards the end. So again that's an example of something that I can appreciate the Buffalo Treadmill or the Buffalo Bike Test but that's very uniplanar, just looking more at the cardio piece. It doesn't look at the rotation piece and some of that is where athletes can really get into trouble. And furthermore proprioception, there's a much greater risk of musculoskeletal injury, in particular lower extremity even after someone gets cleared from a concussion.

Dr. Yoni Rosenblatt: It gives you a score? It just gives you a score of readiness to return?

Dr. Christie Chiesa: You more so look at symptoms similar to when you're doing VOR exercises but the big symptoms are dizziness, fogginess, nausea and headache, are the four main guys you look at. So similar to the VOMS exam which that's also something you look at, those are some of the main guys that you're tracking throughout their time. Throughout the components that you are splitting up during that EXiT testing.

Dr. Yoni Rosenblatt: That's really great. I think that's... Add that to your list of things that a clinic has to have is an understanding of that, so you can release your athletes safely. You bring up the NFL and the way they deal with concussions. You talk about how far they've come and how they have this third body supposed to be clearing these athletes to return to sport that is independent from either team. It's crazy how far that's come. I'm of mind to think that it should be like that with every musculoskeletal injury. There should be an independent body to say this athlete is safe to return and they're not influenced by the Steelers and they're not influenced by the Bengals. They're just out there for the athlete. I think... I hope that eventually that's the future. I don't know that it could ever get there. That'll be something I would be really excited about. Not that you asked. But I think that's... Why are we not there? Why are we not there? Because aren't those medical professionals for the team saying, "You're good," because they're on that team? I think that would be something that'd be super interesting that maybe we could get to... We should do a whole pod on that.

Dr. Christie Chiesa: I think some of it too and I know I mentioned mostly the symptoms but the EXiT testing, I don't always do this. A lot of times I look at just perceived exertion but you can get data like blood pressure and heart rate and changes like that depending on the person that you're working with. So I think the opportunity to have that more objective data and those changes over time could also help when it comes to third-party involvement and more standardized values. So some of it may be that having more standard values and being able to trust other people doing... Running them through testing as well.

Dr. Yoni Rosenblatt: Yeah. I love that. And I bet you eventually it gets sports-specific. Like you said those demands are so unique. Lacrosse athlete, pitcher, catcher. They're so unique. So getting better values around that, I think, will be awesome. How do people find Dr. Chiesa so they can just learn more about concussion and what it's like to be an outstanding sports PT?

Dr. Christie Chiesa: So I work at the True Sports Columbia Clinic right by Howard High School, right down the street. That's mostly where I do all my treatment out of so I'd be happy to give out my email or...

Dr. Yoni Rosenblatt: Give us your email, give us your social media. How do they find you? 

Dr. Christie Chiesa: My email is and my Instagram handle is ChiesaDPT. So you can find me on either of those.

Dr. Yoni Rosenblatt: We will definitely list that. It's Chiesa, not Chieza.

Dr. Christie Chiesa: I was trying to be specific.

Dr. Yoni Rosenblatt: No. It's great. Thank you for pointing that out. A real wealth of knowledge, I think, you do an unbelievable job of being such a pro and being as objective as possible but also being subjective when necessary in evaluating and treating these athletes specifically with concussion. So it's something that I've learned a tremendous about by having you on the squad, by having you as a piece of the pod has really been awesome. We're always also looking to improve, so we're totally open to feedback. We want to know who we should have on this podcast. Reach us at You can always reach me directly Chiesa, you've been awesome. Thank you so much for joining The True Sports PT Podcast.

Dr. Christie Chiesa: Thank you for having me.

Dr. Yoni Rosenblatt: No problem.


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