Heading in the right direction?

Welcome to Osteotalk, Osteopathy Australia's podcast dedicated to delivering clinically relevant education for osteopaths to learn, connect and collaborate. Join us as we explore real clinical issues with Australian and global practitioners and experts in other disciplines. The views and opinions expressed in this podcast are those of the speakers and do not necessarily reflect the views or positions of Osteopathy Australia. For more information visit us at osteopathy.org.au. Welcome and enjoy. All right, my name's Flip Butler and I'm wrapped to be joined by Neil Holmes from New Zealand. We're both here on Osteotalk, which is the Osteotalk Australia podcast. So I am the director of Weems and Health and Lifestyle and my passion though is we also have a project called the Melbourne Headache and Concussion Group. So we work with local teams basically with return to play and education around concussion and Neil, it's such a pleasure to have you here mate. If you want to introduce yourself and let us know a bit about what you do. Also, thank you very much, my name is Neil, I'm owner and director of the Holmes Clinic and Faggley in Northland, so it's two hours north of Auckland. Experience wise, I've been working with the sports for a coming on to 10, 11 years now. Working both pitch side and within the clinic, we see concussions day in, day out whether and in clinic or in pitch side settings, yeah, pretty much sums up me, really. Yeah, well, and it's awesome to be having this conversation, I mean, it's not awesome, it's under a cloud of a horrible event that's occurred obviously with the, the Ellie Katoa event, I think it was a week or so ago. And it's really thrust concussion back into the spotlight with a lot of public debate, a lot of outcry. And I guess those clinicians that work closely with athletes and clubs, these moments remind us how critical those first few minutes are and also just how critical having procedures in place that we follow are under stressful situations so that we can actually make sure that we're putting the players immediate safety first. There's an extensive training in immediate care in rugby and pre-hospital emergency care. And you just, as you just said, you're working pitch side with rugby teams day in, day out. So I'd love to start there and see if you can take us inside your world of what happens when an incident happens, what do you do, what are your first thoughts, what procedures do you have in place and what's your process for removing a player from the field of play? Yeah, so we work on a structure and a framework that's clear within obviously New Zealand. We've got ACC, which is our government insurer. They've come out with guidelines on return to play, return to train elements, but also in addition to just clarifying symptoms, which we need to look out for whilst we're pitch side through the world rugby, immediate care qualification course. It takes for a nice process of how we can identify concussion in multiple ways with what I tend to look for is based in and around how they train when they're looking towards the video aspect of concussion, but it's something that we can also use when we're pitch side and the first response is the immediate response to events. So this happens between 0 to 2 seconds post injury and the thing that we need the item to look for here is the posture of the athlete. What is the athlete doing on impact? Is it, I'll be looking at head on head impact, I'll be looking at shoulder on impact, I'll be looking at actually move a whip lash motion because we can't forget that concussion doesn't necessarily have to have a direct impact to the head, it can be a whip lash motion. And they are a little rarer, but it can happen. So look at the impact, what happens in the first 0 to 2 seconds, whether the athlete goes stiff straight away, they lose control of what they have. So if we're looking at rugby or rugby league, do they still have the ball? Are there arms straight? Are they in a tonic position? If we're looking at football, so round ball football soccer, are they protecting themselves as they fall? Are they trying to strike the ball? Are they off balance so we're looking at first 0 to 2 seconds and the immediate response to injury. So from that, then we moved on to the delayed response. So that's based on about 3 to 7 seconds post injury. So what we tend to do here is we observe function. Is there a delayed or inappropriate response? Are they in that classic sort of tonic position with their arms still straight, their legs still straight and they're just kind of fall quite hard down to the ground? Do they try and protect themselves as they fall? That's quite key. If they're not protecting themselves as they fall, there's a massive issue there. What we're on there, the next stage there is about 7 seconds after injury and it's how they get up, how they return to their seat, like not one can they get up on their seat. Is there a delay? Are they in all fours, are they clutching their head? As they stand up, especially in rugby, are they actually running to the correct side of the field? Are they going to bear a defensive line, are they going to the other defensive line? Is there a spot quite immediate? Is it an up and run? Are there a bit dazed? And that's kind of the process I tend to look for in the immediate response. Bearing in mind, so when we are pitch side, can we get to patients or can we get to athletes very quickly? Sometimes it's very difficult to do so. Obviously if they're unconscious, then we obviously need to make sure that there's no other distract in injuries. Obviously head injuries had stacked in injury towards a potential neck injury. So before obviously we remove anybody, we need to make sure that there's no possibility of a spinal injury. And then we go through our process there. And I think you would see that, I'm not a real NRL, a Fishy and Ardo, but I think there was the player that played for the Broncos who got hit against the storm in the final there. And that was a pretty clear indication of what concussion symptoms look like. Like he's popped up, he wants to keep playing, but he's unsteadied on his feet and then he, you know, in the end, players went to him and kind of grabbed him and he didn't take any further part in the game. So obviously there's a number of things we can talk about here. Like I think there's the neurofusiology of it in those immediate seconds around, you know, why players have these responses, you know, with the depolarisation of neurons and we can go into the kind of, the kind of neurology of it, which I think maybe some people would want to hear. And I don't know if you're all kind of across that heavily there and able to kind of spill on that. But I mean, without pointing fingers as well, there were symptoms in that guitar or incident like, I mean, the signs were there, right? Like, and I know we love doing HIA and it's, you know, we, again, I don't want to point fingers at that either. There's clearly it can be gamified. It can be, it can be learned. It can be, you know, players can get around it. So there's those issues with that, which obviously we put to the side. But clearly the HIA should not replace clinical reasoning and kind of working through those, those, like you just said, working through those observations. It seems like it's now the gold standard that, oh, they passed the HIA, you know, dramas, they're good to go. But clearly we're watching video. We're looking for those neurophysiological changes and issues that that you are talking about. Yeah, definitely. There's the latest challenge that's been out there in the media recently. Obviously, something's gone wrong with the process. Something's clearly gone wrong. Whether, whether staff haven't seen it or they've hidden it or, you know, they've looked at a key player and gone, actually, we can get them through. I think it's vital that we, in no matter what team situation we're in, whether it's a key player, whether it's not a key player. At the match scenario we're in as well, you know, the welfare of the player has to come first. Yeah. And that's quite key. And HIA is an indicator, it's just like a scat, scat or any other concussion tool that we can use, like Maddox questions, there's only an indicator of concussion. It's not definitive. This is a concussion, yes or no, it just gives us an idea of what could be going on. But I think the power of observations quite key, like we look at that massive hit that he took and that first one of the warm up and that was, that's good enough to be a category one in itself in terms of, you know, the way how he fell, he lost control of the board, the way how he fell, he was stiff, was he knocked out when he was fallen, yes or no. That's enough to pull him off. Yeah. And that's, it's quite a vivid. vivid example what actually goes on. And this one was just recorded. Like this, this probably happens. We can we count in rugby games, rugby league games and other sports. Um, it's just this time around that we've got some, unfortunately, some very good video of what's happened. And then obviously it's a horrible, horrible event that we just don't want to see occur. But do you feel that finally parents, players, coaches, again, I start taking concussion seriously. I mean, you know, second impacts in dreams, pretty rare. We've seen examples of it in the past. Um, and that's where, you know, a player basically is hit twice within quick succession in their brain swells and they, they invariably pass away, right? And we've seen that happen pitch side, you know, recently. Um, but then, you know, we step back from that. We've got guitar with a blame brain bleed. But then we step back from that again. And what do you, and I see this in clinic where, hmm, players don't want to tell their parents or their coach that they've received a blow or a weak lash or something like that. And then they don't report it and don't take it seriously. And they have the second one. And then we have these, you know, either catastrophic outcomes or we can have some real, real outcomes that for real everyday people. And what do you see, um, in your clinic with that where people maybe don't report initially, play on or whatever, um, what are you saying? Oh, I, I, I, I think the biggest concern for me around this is the previous word in and around concussions and what doctors say, you know, there's, there's different ways you can try and grade a concussion. And, and for me, it kind of downplays it like if you've got, we hear it all the time from, from doctors, when we refer patients or athletes off to either ED or, or, or emergency care, immediate care or to their, to GPs, they'll go, uh, it's only a mild concussion. This, there's two things like it's like the moment that are on my, at least, Neil, and it's anonymous Facebook posts on the discussion forum. And, uh, GPs using the word, like, you know, mild, moderate, severe, like as far as I'm concerned, as I know that, and you're going to agree with me, I'm sure you've got a concussion. That's it. Your symptoms weaken grade, you know what I mean? Like, I'm happy to say, oh, you've got mild symptoms as a result of your maltraumatic brain injury. But you still got a maltraumatic brain injury. Are you, do you feel the same way about that? Yeah, 100%, like there's, there's a lot of education that's needed in around, we, we need to ignore, we need to get rid of this, this, this, this, this, this thought process of mild or moderate. It's a concussion, yes or no. That's quite clear. Um, because it downplays everything. And then you, when you get athletes and parents to an extent who want to be able to be on that field as soon as possible, it's any mild concussion with fine. They don't, they don't downplay it significantly, which then obviously opens a Pandora's box of frustration on our behalf, because we're trying to do what's best for the player and their long term welfare. Um, but also, you know, then they start getting in the year with the club and the clubs like, well, what are we doing? And, and I think that's the beauty thing of hearing New Zealand is within rugby itself. If there's a concussion on the field, you know, discipline card, the card means you're an immediate 21-day stand-out period. It's easy to pull that through to I think it's the five or seven major sports within the country that that is meant to be the process. So if there's a concussion, it's really clear on the guidelines, there's no ifs, no buts, no babies. It's 21 minimum, 21-day stand-out period. Um, we can potentially dive into that a bit deeper and go actually, if you're under a certain age, then we should be looking at least a minimum 23-day period. I've seen this research, a little bit of research out there saying, or for youth athletes that it should be at least 28 days. And you see it, like, most of the, if you, if you give a target of, you've only got a mild concussion, we expect you to put back into 21 days and suddenly, they can start not achieving that. Then we go on to a different element of, you know, we've now got an athlete who is anxious to return, getting down because they can't return. So it opens up a whole broader Pandora's box of challenges, not only for us as practitioners, but for parents, coaches and the player themselves. And not to mention, then you've got the ADHD kids, the, you know, the migraine sufferers that just extend out that, you know, period and then even further, you know, and it's like, well, hang on, why is this kid that three weeks and still tired? I will, he's had migraines, he's got ADHD and that's proven in the research to take even longer again. So it's an arbitrary number and I, I'll hate when people count the days down. That's one of those things up there where it makes it really, really, really tough. Definitely. And I think, I think as well with the numbers, we've also got to remember you've touched on some groups there of quite key ones at the moment is female concussion and their response to the Ted Andrews and Kirk concussions and in and around their menstrual cycle and where they are on their menstrual cycle because that can, that can add days and weeks on to their recovery phase. Just due to, I think it's high progesterone and then when they get the heat, it depolarises and then they get that sudden drop and progesterone through their body. So that means their symptoms can potentially last a lot longer. So we then we've got to educate our female athletes on why they could be lasting longer with their symptoms. So there's many subgroups that we have to consider and and and be aware that this 21 day minimum can be extended quite easily, quite quickly. Yeah, that's, it's, yeah, and that's, it's, yeah, you've got to work with each individual. There's no template or blanket kind of approach to this with concussion. It, it seems to be each individual. I've seen guys knocked out, I've seen guys knocked out with their legs trembling and then they, they're up the next day and they're feeling fine. Or as I say, people get hit in the head with a ball and they, they're out of work for 12 months with, you know, persistent symptoms. So each individual is just going to be treated like that as an individual and taking that, taking all of their, those elements into account. So we've talked about the initial, I think we've got, well, I think we're about eight seconds into the, into the post concussion world with you on the pitch. And we're talking about, you know, at the initial hit and, again, jump in at any point, the initial hit, we're getting stretching of neurons, we're getting, you know, depolarization of those, of those neurons, we're getting firing. So like fireworks in your brain, basically, for the first kind of, they, you know, I think that can last for the minutes to, minutes to hours, but usually it's minutes. And so you're getting this kind of just rapid depolarization within the brain, creating these symptoms of, you know, disorientation, confusion or, or, you know, like you said, the skeletal ramifications, you can get the spasming, et cetera. And then our players either awake now and up and, up and going. But I think this is really where the osteopaths listening are going to perk up a bit. What happens from here now? So, you know, you've got them at a safe place. Where do you go from there? So there's, depending, depending on how well you know your players, it kind of, merges your full, or creates the pathway that you go. So the way how I try and deal with both my football players and my rugby players is that I try and get to know them quite well, get to know what makes them tick. And even to the point of actually knowing their sense is she might have more, we'll touch on that and a little bit. So my first thought of cause is Maddox questions, which is in and around orientation, time and space, pretty much. So it's a nice simple, I think it's five questions. What venue are we at? Which half of the game we're in? Who's called in the last game? Who did we play last week? And did you win last week? Yeah. So just a mental note on that one. You want to know the answers to those questions? Cause I want to know. Oh, yeah. Who did you play last week? I don't know. Yep. Great. Correct. Correct. Like the challenge part is, is the boys that I have dealt with in the past is if they know they've been hit, they'll start even before I get to them, they've got their buddy next to them to learn them the answers. All what I have seen is they've taken it on their wrist. So they have a quick glance at us. And then you like right? Okay. So they can answer all the questions. I'm back to that sense of humor and I'm just trying to understand their sense of humor. I'm a little bit known for a few witty. I call them witty jokes towards my players. So I try and engage their normal response. And if they're responses and quite as normal, I know there's something not quite right. Plus I'll go through some other additional questions, you know, headache and again, we can't forget that these are athletes at times want to start on the field. Whether it's football or whether it's rugby, whether it's hockey, whether it's whatever sport they're doing, they were patients like athletes like they want to carry on playing. So if you're sick, you've got a headache, any vision changes, balance problems and go through that, that whole kind of. mini screen and process there. And then the other thing that we've got to do and what osteopaths are, or what we're known for doing, it's just observe our patients, observe our athletes. Do they look normal? Do they look normal to what you know them as? If it's, if I think they're hiding something, sometimes it's actually quite useful to listen to the players around you. So when, when, when we were at Whitepool with our rugby team, when, when we had a very strong team, we had a lot of boys and around the high performance squads and, and we're north from contracts. These boys looked out for each other. So I would get to them, sometimes they can answer all the questions correct. And then I could have to play next them and go Neil. It was out cold. Yeah. To me, that's good enough to go. We're done. Yeah. Yeah. And that's, that's a, is that a red flag for you like in terms of like you're at cold? Maybe we're, we're, we're heading to the hospital and that one like it's, it, that's the, that's everything, isn't it? And so, so you've got through this process and, and just to summarise it, it's basically, you know, you've got, you're excluding your red flag. You're obviously doing your doctor A.V.C., when you get out there, first of all, I'm making sure to move them safe and you're making sure they're breathing and all those things. And then you're, you're ruling out your red flags. You know, so that's that, you know, you're looking for skull fractures, you're looking for signs of unconsciousness, you know, tingling in the fingers. What else is there? I'm, I'm trying to reel them off top of my head. But, yeah, so you're, you're going through those things that, that basically necessitate an ED visit due to possible skull fracture or brain bleed is what we're trying to ascertain there. And then obviously you're then looking at your player, looking for the signs, assessing and moving, looking at, and you want to watch some video of the incident, you're looking at how they're walking. And then you're engaging them with Maddox questions and you're looking for symptoms. Basically, so you've gone red flag sign symptoms. You've ruled the player out, right? So you've gone, sorry, and because he's made to do him in and told him he was knocked out. So you're gone, you're done. What happens in that first 48 to 72 hours? I know we've got a lot of, well, hope there's a lot of people listening. And a lot of our osteopaths get roved into being volunteer sports trainers at their local clubs. Heath Williams down there in, in the Western suburbs of Melbourne does a fantastic job at the Newport Juniors. And this is a real tough one because they've got to make the decision. So they've got to use that scat or they've got to use that CRT6. They've you know, got to rule the child out, unfortunately. And then what then happens there? You know, so that it's like, right, are you reported to the club this and that? But what do you tend to do in that first 48 to 72 hours? What should parents trainers do? Once they've done, you know, they've taken a kid off the ground. So we, well, we'll start off with what ACC you recommend. So it's a nice simple three, three balls. Recognize, remove, refer. Obviously, we need to recognize what happens in the potential signs and symptoms. We need to remove them from full of place and removing them from full of play, pretty much prevents them from any further injury. So do know further harm and refer is often the appropriate people, those GP, whether it's immediate care, whether it's the ED, depends where we go. What I say we do is at Nolson football club at WIP rugby, we have very, very clear policies. If we suspect a concussion, they go to the doctor that day. Normally, it's a weekend, that's usually immediate care or ED, depending on how serious it is, we try and hide which way they go. From there, I would then, because we can't determine whether somebody's got a brain bleed or not, we don't have scans in our, we're unfortunate that we don't have scanners. At side, however, ED does. It's outside our scope of practice of osteopaths to number one diagnosed concussion that is in New Zealand. I think it's probably the same and it wasn't. There's only doctors that can do that. Most of the symptoms that we deal with can actually be indicates of brain bleed. If we are in a position of trust with these players and athletes and parents and we go, "Nah, sweet, you're good off you go," worst case scenario happens. Play doesn't wake up the following day. That's obviously what we're trying to avoid. We refer straight off to ED, we refer to immediate care and then as up to them whether they fulfill the criteria to get a CT scan or not. We've been quite fortunate that the last few that we have sent up here at Northland Street at ED, they're on a roll at the moment. They're CT scan and most people that walks through the jaw with a head injury, with a decent head injury, which makes our life considerably a lot easier. That's what happens when we do them pitside. Obviously, we then get a medical cert scan that they can cast. They're not can cast. What we try and do is within our football realm, within Northland football. We've kind of copied what Northland rugby do and what I believe other unions here in New Zealand do is we will send out an email to the players, to the parents, and include in the coaching staff as well, go ahead and say hello. This is the concussion, this is the day of injury. This is the 21 day mark or this is the 23 day mark. This is when we are, that's the earliest you can return to play. These are our symptoms we need to still look out for. These are the return to education, return to work or return to play processes we need to follow. Right at the end, we have a bit where it allows the GP to then add any comments in, so we literally send everything to them. They will then attach a medical certificate to make sure that they're clear to play. That's our whole process. What we do within that first sort of 24 72 hours, we try and encourage the patient to make the appointment with the GP or the appropriate person to clear them quite early on because don't know what your health care system is like to try and see GP, but either here in New Zealand you're lucky to get in in about three weeks. So we can get that process in place with our patient and we've already got our whole process set up from from pretty much day one all the way to day 21 or even further if we have to. Yep. And I think in Australia, you know, again, I think depending on where where you are, we send patients to the ED, they sit there for four hours and come back and haven't had a CT scan. So I think we're in a bit of a different predicament over here, we're based on where you are, the framework you're working within. Yeah, we find it really hard to get people's hand. It's crazy. So, you know, and they're sitting only sitting the ED for four hours in the waiting room if they don't pass out or die, then they get released and they, you know, don't know what to do with themselves. And then, you know, you might be heading back to the GP on Monday if you're lucky and then they'll refer you for a CT which might take, you know, I mean, we've had a bit of an increasing availability here locally with some X-ray radiology places opening up, but we find that, you know, if we're waiting for a CT scan, we can be waiting for a week, you know, or longer maybe even less. So I think, and I know you got a bit of flack at the end Z conference recently about waiting for that CT scan. And there's a few Aussie, Aussie Oceos that, you know, hang on a second and I just think it's, you know, in my world, it's really hard to get a CT scan for us. And so we're probably working in that realm of 24 to 48 hours where we start kind of the education pieces that you're talking about. So it's definitely starting with, you know, right, here's what's, you know, it's, this could be a whole other podcast about returning to play that 21 days. I mean, you know, obviously, but, you know, where we're getting, you know, we need 24 hours rest, but not complete rest because that's not indicated anymore. We do actually want to get people doing daily activities. You don't need to put your phone away. You can look at your phone just don't sit on TikTok for seven hours, you know, like do things at a symptom limiting or, you know, you don't feel make you worse by two out of 10. And then, you know, you can do those things because sitting in a dark room is not what we do anymore. It's like drinking flat lemonade when you add the flu, you just don't do it anymore, you know, so, so you start that process and then people are actually often quite surprised to see that within that 48 hour period or just post that 48 hour period that we're asking them to exercise again. They were saying go for a walk. We need 60% of your maximum capacity exercise to occur. So can you please on, you know, on Wednesday, we'd like you to go through a walk. And they're like, well, hang on a second, I thought I was meant to spend a week in bed. And, and that's the thing that they go and see the GP, the GP goes, oh no, spend a week in a dark room or do a week of doing nothing. And so, you know, it's tough here because we want to get GP's to make, we've been making these diagnoses for us. We want to be seeking the appropriate scans, but in the end, we send them to the GP, they get told to do the wrong thing. And so, we've just kind of started, I guess, taking it on our own a little bit and kind of, we're safe just trying to get this ball rolling because I think there's a start I saw somewhere that if you go and see an allied health professional within the first five days, You 40 or 50% likely to develop persistent symptoms or something like that. And that's because you start this process of cardiovascular exercise, which is fantastic for the brain, and away you go. Yeah, I think it's a challenge here as well, we've got some GPs who are outstanding at what they do. They've kept up with the research, they've kept up to date. You have some GPs who, it's not their specialism, like GPs are the gatekeeper to the rest of the health service effectively and some specialised in areas that aren't concussion, but then that makes it tricky, because they've been cleared by a doctor, yeah, or they've got educated by a doctor, and you hear the now on the head there, the latest concussion consensus statement, the biggest change in that was that first 24, 48 hours of do that activity that does not provide symptoms, because we're still going to try and challenge the brain. It's just like a muscle, or even looking at tendon operties. If we don't load it, and then we suddenly load it, number one is going to get worse, number two, we're going to go about four steps backwards, so we need to continually load but in a safe environment and a controlled environment. I think the guideline said is about zone one, heart rate to increase by, which is a general walk. Yeah, that's all it is, general walk and hey, it's symptoms don't get provided, happy days, then we can start moving a little bit forward. Then obviously reducing the screen time, that's obviously quite key, because of the blue light and what that does, the sleep hygiene, but the important bit is listen to your body and having athletes who are quite in tune, mix, can make life quite useful in this stage, because they know when to push and how hard to push, but it also can give us a little window into how the patient is going to cope long term beyond this. If they're going for a five minute walk and they're still at 72 hours, or maybe slightly further and they can't do it without getting a headache or a white head or a little dizzy, that opens a gate of okay, we've got something else going here that we need to kind of start exploring. Yep, and I mean, I want to come back to the pathophysiology of this, because I think that's important to explain to people and I've got a great little graph that I show people and then you see them go, "Ah, yeah, right, I get it now," and then they, and it actually evails those fears, but like you said, when you don't adhere to the timeline, what do you find, and we will circle back, but what do you find other things that may have gone wrong? What are you looking for, I think, and yeah. When things don't quite go right, so we look at persistent symptoms, sometimes patients will actually try and push themselves too hard, because if we look at the pathophysic of a concussion, the feeling of feeling drained, feeling drowsy, it comes from an energy crisis, because of the implanted depolarises every then, we get depleted glucose and we get depleted oxygen still, so then our brain, so we need time to restore that, and if we don't restore that properly, those effects in our cognition function can be longer term, so hence why we need to just take our time, listen to our body, if we push too hard too early, then we're still sapping what energy we have and what glucose stores we have in the brain, and it's just going to make it worse. So hence why it's quite important to understand the pathophysic of it, because then we start exploring this to patients, and if we can educate patients and educate our practitioners, and go hold a second, the reason why you're still feeling groggy is because your brain is still trying to catch up with you, because you don't have enough oxygen in your head. Oh, and your brain, and if you keep pushing too hard, that oxygen is just not that oxygen that glucose isn't going to restore itself, so we're always going to be playing catch up. So just relax, just rest, yeah, to rest, yeah, that's it, and that's what I think this little graph that I've got for people is at around about that five to seven day mark is usually when your glucose is at its lowest, or when you know when your mitochondria, because it also you're getting your mitochondria get gummed up with all the calcium that's flooding into your neurons, and so that's blocking your energy production there, you've got decreased blood flow going up there, so you're not getting the glucose delivered, and then you say you're not only not getting it delivered, you're not using it effectively, and around that five to seven day mark, I say to people, that's when you're probably going to be at your worst, and we've got this little chart that we use, and they go, oh, okay, cool, and then you start pulling out of it, and around about day 10 to 14 is when you actually feel pretty good. So your symptoms usually go around around around that 10 to 14 day mark, that doesn't mean that you're healed, you're still got another 10 days of brain healing to go on, and this is where you know, it was funny when you still let players go back last year and junior football 14 days, and it was like, well, that's when they felt good, but they're brains still earling, and if they get hit again in that kind of 14 to 21 day mark, then we go, we start the whole process again, and so we've got this year, great little, little visual of the people, and it really helps them feel better about, oh, that's cool, I'm at day seven, so I should be starting to come good, and they're pretty happy about that, but the education piece is really one of the strongest tools we have, and I think somewhere about that initial rest I read, I think it's like 60% of the brain functions like due to it goes into visual interpretation, is that right? And then, if you're sitting there on TikTok or watching, you know, breaking bad series back to back, you're not allowing your brain that time to recalibrate itself and kind of sort everything out. Yeah, definitely, and one of the, one of the, again, visual wise, one of the sensors that we see is light sensitivity, so if we're sensitive to light, the previous instructions or guidance has been, go to that pair of sunnies on, go sit in a dark room, so when these suddenly come out of that dark room, never fit to the deconditioned yourself to sunlight, yeah, so then you take your sunglasses off, and then I've got a headache now, was the headache because you haven't seen natural sunlight for the last two days, so you have to kind of keep up what he's moving in the correct way, still being able to challenge it but challenge it within the safe environment, and that's not sitting down in the dark room as sunglasses on, like we have to expose ourselves to sunlight, because the other addition is sunlight, you get vitamin D, vitamin D is obviously quite crucial for, for nerve healing, yeah, yeah, nerve healing, brain healing, so suddenly like, you're sitting in a dark room for two days, our eyes aren't used to that, our body's been crying out for it, suddenly we go out into the sunshine, we can't, we can't hack it because we've been wearing sunglasses for too long, and then we hide away from the sunshine again, so there's good I think that gradual exposure from elements like that as well. And I think the word that springs to mind for me there is habituation, you know, and I think that that's kind of what I base my whole approach to to concussion management on is whether you've got a visual deficiency or cognitive deficiency or whatever it is, we want to habituate you to it in small doses, so we don't want to go and, you know, like you say, we're this return to plan, and I think we shouldn't, we should kind of touch on that, and maybe even, you know, go through that, because I think that's a pivotal part of, yeah, of people getting, it doesn't need to be a return to sport, it can just be a return to life, you know what I mean, and I think people need to have that expectation around, yeah, habituation, so small doses, whether like we say, we start off with a 60% like a walk to get to your heart rate to 60%, the next day, do you have your kind of procedure around that, like what I mean, obviously the AFL has got their guidelines, and I tend to use that, it's nice and easy, it's color coded, how do you go about bringing your players back, or just people back to life in that time? Yeah, so again with ACC, their framework's quite clear in terms of their, it's almost like a hybrid of the consensus statements that have been released in New Zealand rugby's stages, so education returns, sport returns to work, works over, I think it's five or six stages, six stages, so we've already touched on stage one, we're a relative rest of 24, 48 hours, activities that don't provoke symptoms, gentle walk in, produce screen time, and most of the point else, listen to the body, and when we start rolling into stage two, this is a gradual increase in daily activities, so it can be something simple like during the document for 20 minutes, something simple, get yourself, get your body sort of keeping starting to re-enter what normal life should be, with players and athletes, especially younger ones or in education, kick them away from school, kick them away from work, their brain's still not ready, and exercise could it's could remain very light and between these next stages. So stages two to four, there should be at least the minimum break of 24 hours between each one. So we can't go us, we've done this into one of hours, we can jump to the stage two in that now. We could take 24 hours in between each. And then if symptoms increase, we the whole will drop back another stage. So stage three is increasing that tolerance. I think that key word for me in this is tolerance. So again, we're just adding extra layers onto what we have already done on stage one and stage two. So we increase home work activities. So the beauty of quite a lot of stuff post COVID is a lot of jobs are done now at home. So we can potentially start adding in a few light work duties in at this stage. But really important is remembering our rest periods between activities. Because we've also got to still remember listening to our body. If we go back to that glucose element, you know, our brain is still trying to catch up with us. So if we deplete it too quickly, if we're going to feel rubbish, I'm going to end up going back to stage two. Going back to start, sorry, moving on to stage four. So this is where we're looking at returning to activities in a more, in a wider capacity search, need a return to work, returns to sports training, return to education. But within a part time role, again, it's important that we add another layer onto this. We can't check somebody back straight into full-time work, full-time school, full-time normal activities, because they'll burn out. They won't be able to cope with it. Plus, then we look at activities where we don't have a risk or head injury or we have a very minimum risk or head injury. If we look at our sports players, if we look at school, so if we've got our younger youth athletes returning back to school, are they going to be other balls flying around, et cetera, less bit of common sense? Let's just not put them in that scenario, because it's asking. So, look, all the damage, if you do it once more, then likely do it again. So, we can't be able to go back a couple of minutes. You're still not quite, you know, you're still not quite there, you know, from a cognitive balance perspective. I mean, you know, we're still kind of coming back to ourselves. So, you're going to have a little bit maybe of reduced proper perception or awareness or something like it always seems like the kid gets hit again and you're like, "How did you do that?" Like, it's almost like you moved your head towards the ball. Like, what are you doing? Yeah, it's kind of one of those things where just, yeah, you're more likely to do it again, because you're still kind of healing and still getting your brain back together, really. Yeah, definitely, definitely. And I think, yeah, if you don't want suddenly, you're more aware of things and things have happened around you, it's like the universe is still trying to tell you that you're not ready to do something. Yeah, it's the head. My boys will start fly that year, you know, you start tripping up, stop falling or you're going to hit your head on something and it's like, yeah, common sense approach, really. And I think, I think that's why sort of the pages two to four are really good. And the additional element that they've added in on this concussion statement as well is to move on, that there's, they allow a degree of symptoms to increase. So if we've got, on a 10 point scale, if the symptoms should not increase by two two points on a 10 point scale, yeah, and it's going to be for no longer than 60 minutes. Yeah, so we get a little bit of an increase of symptoms, but it's not massive. Yeah, we should be okay, because again, I think it was a stage, I think it was stage three, increase of tolerance. So we've got to tolerate ourselves, we've got to tolerate symptoms. Because there's nothing worse than getting to day 19, and you think you're doing well and you get a headache on the training and then you're going to go back to, but you walk a lapse around the oval. You're like, I got a second, this is what we want. So I think some kind of common senses provide there as well. Like, you know, you can't, it's to just get, oh, I've got a bit of a headache, it's got a last for 60 minutes. So that's the most important thing is what I tell my patients is, if it's more than two out of 10, if you start with a two, and it stays at a two, I'm cool with that. But if you start with a two, and it goes to four or five, then that's not what we want. Because I mean, you know, headaches, one of those symptoms isn't it? It can be from a number, for a number of reasons, which I think, you know, then try to bring me around as well to that osteopathic management that, that after you've had that CT scan and you feel comfortable, I've had a number of people come to me, they say, I'm just not quite right. I just can't seem to get over this. It's week four. What's going on? You know, I was like, is anyone looked at your neck, and I'm like, no, I've just been doing Vom's exercises and, you know, visual exercises and, you know, four stars and Cades or four, but I haven't, no one's looked at my neck. And we treat their neck and their symptoms almost immediately resolve. And what kind of treatment are you engaging in in your clinic? I know, you know, I know, I like to look at, you know, treating that whiplash from pelvis to, to some idols, personally, make sure that people are aligned and, and try to clear that those facial drugs or facial kind of issues and restore that up a neck and that brainstem kind of function. Yeah, osteopaths, this is what we can do. This is, this is the difference that we can make in this area. If you're not trained in concussion and everything we've been talking about for the last kind of 45 minutes, seems a bit like gobbledygurg, the one thing you probably can do, if it's safe, is to, to have a look at your patient's neck and whiplash yet. Yeah, 100%. So my, this is my standard protocol and clinic with neck patients. Oh, not with neck patients, I said, more concussion patients is if they present to me with a confirmed concussion, usual in that first symptom, or that first treatment, I don't tend to manipulate. That's just my, that's just the way how I work out. I have done previously where we have manipulated and symptoms just flare up quite significantly, because we're still going to think of the nervous system here, like if we're, if we've just had a trauma, if we've hit our head, and we've had some of rotational movements going on, the nervous system's still going to remember this, and as we're going to put it in a flight response, so if we go and manipulate something, and I know there's, there's probably the classical osteos or, or, experience osteosibular, no, I'll manipulate it. There's, there's no contraindications, you know, for me dealing with these patients is, we've seen a lot, and I've manipulated a few, and it doesn't really get the outcomes that we want, because we're already addressing one element of, of everything, and then this is, this is where we have a, a hand on physiotherapy, on GPs, is that our skill is number one in our hands, number two is seeing as, seeing our patient as a whole, within what we have in our clinic, and then on top of that is, is how our patients can fit into their social model, or their family model, but we can touch on that in a second, that would take a whole point. Of course, that's, that's a fact, yeah, yeah. But, you know, we, we, we all have different strengths as osteopath, you know, some people are more adept at cranial treatments, some are more visceral, some are a little bit more structural like myself, however, you know, if, if we think about it, like, we've, we've got the, got access going on as well. So, with concussion, we don't necessarily have to spend a lot of time up at the head, let's see what's going on in the abdomen, let's see what's going on there, you know, diaphragm wise, you know, are we restricted through the diaphragm, are we restricted through the ribs, obviously, then that's not causing the normal movement, and it's not going to encourage peristouses within the intestines, which means our absorption is going to be different. So, how can we, how can we influence that? Like, there's, there's so much that we can go through with this, and it's probably traditional osteopathic thinking. Yeah. Well, if anyone, there's no, this obviously is in a visual podcast, you know, but if anyone could see Neil there, he's like, super excited. He's up and about like, and this is I grant, this is probably, we're touching on this at the end of this thing. So, I think that's, that's the glory of being an osteopath and helping with concussion is, you know, yes, if you want to, you can get involved in pitch side management, you can, you can do assessments, and there's a number of tools that you can use, you know, and you can go as a number of courses that you can do. And there's, there's a number of apps you can use to keep it objective. And I, I know, I do that myself. We've got a lot of apps and objective data that we use. So, we're, you know, we're not just guessing. And I, I really love that process of educating people and helping them back. And it does mean that you can be a little bit hands off initially, but as an osteopath, you don't need to know everything about concussion to be able to help a person who's suffering the symptoms of it if they walk into your office. Because realistically, what we're talking about is the, the, the teetatotter that is the parasympathetic and sympathetic net assistance, right? And so, a lot of those people do go into fright of flight. You know, there is, they are stuck in that in with a sympathetic overdrive or autonomic dysfunction. And so as I see a path, it doesn't get needed to get to post concussion territory. You can help now, right? So you can be lucky, you know, working the diaphragm to loosen it off so that it's rubbing the vagus nerve, you know, and crann and stimulating the vagus nerve to, you know, increase parasympathetic out flight. You know, I read some, I was reading somewhere that is, I think, and this is an animal studies, I think, but, you know, as soon as you have a blow to the, to the head and you have a concussion, that then your gut reacts as well. And so both, both of those tight junctions in the brain and gut open. And so like, and then, and you actually get a changing in the microbiome, like that, just because. It's not like, so, so I think as an osteopath, we start all going, wow, hang on, you know, yeah, we love doing rib raising, I love rib raising. I love, I love functional and fascial release through the abdomen. You know, some of us might have a bit of advanced knowledge in nutrition and dietetics. And so we can talk about, about those things. But also, you know, that, that, that sympathetic outflow, you know, or the visceral somatic, you know, areas that you can start working on, like, you don't necessarily necessarily need to be a concussion nerd like us to, to do all that stuff. You can start somewhere and that could just be getting your hands on the ribs, getting your hands on the diaphragm, getting your hands on the abdomen. This is a racco lumbar junction, upper lumbars. C1 to 3, you know, trying to influence the brainstem and that kind of, those, you know, afference into the brainstem. There's so much we can, oh, we're both excited now. There's so much we can do. And I think, I think this is where, in my past, the humble view, this is where we've got this, this, I'd say, new breed of osteopaths who are evidence and formed versus our traditional osteopathic principles and the way how we go. You know, we can, we can look at the patient as a harm. Yeah, we can go really traditional here. We can, we can work viscillary, we can work within the nervous system. We can be indirect. We can be direct. But then we can start combining that with our evidence and formed practice. Like, for example, like, if we, if we have a concussion, the likelihood of a low extremity injury, there's a few studies out there that say, you know, 58% increase likely within the first 12 months. A concussion about a low extremity injury. Yeah, this is where, this is where our rehab aspects can start coming in. So what, why aren't we challenging the body straight away? Why aren't we doing coordination? Why aren't we doing balance exercises straight away? So here we can combine that. I said that to additional element of osteopathy, where we're looking at the global picture, but introducing our rehab principles of and the dates are out there. Go actually, we're more likely to do something more serious down the line here. Let's, let's crack on with this. Let's be real proactive. Let's, let's attack this from, from different directions. Because ultimately the, patients, the whole, if we go treat one element, we're only treating one element, we're still neglecting things and the research is out there to say that, you know, we, we're at risk of certain injuries afterwards. So if we're not addressing both then elements, we're not serving the patient as best as what we can. And I think that's my favorite thing about being a, oh, I can't start looking cash and I was too fat because I can. I get to throw balls at people like I just get to, I get people in the gym and I start, you know, doing the peripheral work where we throw balls at each other. You know, it's great fun or we're getting people working. I'm saving up to buy some blaze pods. I can't wait. I just can't wait. You know, blaze pods, if you're listening, I'm happy for you to sponsor me. And, and just getting people to do those fun things, standing on a phone block on one leg and turning their head left and right. You know, just, it opens up a whole pathway. And I'm only really, just recently, I'm starting this from kind of week one now with people where I feel like it's actually the thing that stops people from developing those progressive symptoms. And if you're into those, you know, everyone just basically now for me gets a four star, some circadian chart. And we started in week one and I get them doing it, you know, in tandem stance or feet together or on one leg or whatever. And just start getting that going from the get go because I think the evidence now is emerging that that actually helps people avoid that progressive pathway. Yeah. Definitely because there's, there's one element of concussion that I feel like if we can nip it in the bud earlier or it will help patients quite considering that's the vestibuleo cochlear element. And sometimes like with, with those kind of patients, they, they can get through tests quite comfortably and it's not until we get them on the field where suddenly they start tracking a player, they start tracking a ball and suddenly on my headaches come back, my light hedgerous, my dizziness has come back. But if we start adding in these literally from day one day two where they can tolerate it, man, that's going to help them sort of four or five weeks down the line. When they return them, we're going to get less failure of that happening. Yeah, and it's fun. You know, I look over to Nostybath for 24 years and I've been trying to find ways to give my heads off and have more fun with my patients for a long time. So taking them, taking them out with head lasers and making them, and then they, it empowers them, it gives them a sense of agency makes them feel feel really good about themselves and feel like they're doing something for themselves. And you're right, it does, you know, we're looking to reduce that risk because of the ACL guys and it on Instagram and he talks about how concussion increases the likelihood by a fair margin. So I think for, yeah, for osteopaths out there, just getting your hands on getting moving and then just using your principles and thinking about how, you know, we've got to connect the vestibular system with the visual system with the upper neck, you know, like this and obviously to work. And often I feel like, you know, my, this might be my layman's way of explaining it to my patients, I say, when you, when those three, when that triangle's not communicating with each other, that's only our problems. Like when the neck's not telling them that if the eyes are, if the neck's saying one thing to the eyes and the eyes are going, that's not what I'm getting, you know, hang on, what's going on? We're tilted left and then the neck's saying, no, no, we're turned right. All of a sudden, that's when you get dizzy, that's when you get these symptoms, when you get confused. So if we can help with freeing up the neck, but then also giving people balance exercises, you know, vestibular exercises, then we're going to, we're going to be a lot further ahead when that come that 21-day mark. And then do you reckon that this might just be us postulating here? Does that then decrease the potentials? I feel like incussions become recurrent and we've been dutch on that before, like, but outside the 21-day zone, I still feel like people collect concussions, generally. And I haven't, maybe with the babies, this is a study we need to do together. I love New Zealand, I couldn't roll it out about, you know, whether or not, if early intervention with vestibular and kind of visual exercises actually reduce the likelihood of further concussions. Like it certainly makes sense. If we can, we have early stages, then if we've got a visual of balance, work a bit better, the patient should theoretically be at less risk, would be my thoughts. But then do we, we haven't even touched on strength exercises for the neck? Yeah. Do we need to start adding that in? I don't know, I thought I can't remember when the study was, but there was a study, or we were a go-and-and ropey players, and is it unsurprisingly the bigger the neck is, the less concussion risk? Yeah, which was, which was pretty good a while ago, and now they're, now they're, I think it was, was it in Brisbane? There was like a Brisbane unit, but the Brisbane road, roadbie team, and they were finding that, you know, I think there was still more research to be done, but the early kind of findings were that, yeah, if you had better neck strength, you, yeah, yeah, the less likelihood of concussions. So I think, yeah, I mean, it's simple to do in clinic, it's just isometrics. Yeah, yeah, you can do it, you don't need anything fancy, you can use a band, you can use your own hand, you can use a ball. And you'd be careful with the bands when you put the bands around the door and your clinic, and it's actually in the face. Well, that's always the way we do it, and you get a raking gust, it's rather embarrassing when you, that are in front of your staff as well. Just, yeah, it's, yeah, speaking of the shrimp experience. No, so that, I mean, that's awesome, and it sounds like, and I mean, getting into those, like rehab approaches, so are you using baseline testing with patients at the moment? I know it's a bit of a, again, it's maybe a little bit of a touchy subject. Some people do, some people don't. What's your, what's your thought on it at this point in time? And in an ideal world, if we had the resources and the budget to do with our football rugby teams, that I would do a baseline test. Yep. And you can get it, again, it doesn't have to be that, that expensive. It's, you can easily do the, I think they've released the SCAT, SCAT test six now, and you can use it as a baseline level. I was going to hire up in more professional sports, they have more, more technical tests that they do. But for baseline levels, yeah, using the SCAT test six will be perfectly fine. It does take time to do it some minimum of 10 minutes. If we can try and do it in clinic, we can. The tricky part is if you've got a patient who's already presented with concussion and you're trying to base line, how do you know what their new base line is? So that's the tricky part. But yeah, if you're working with a team and you have the time to do it, it is a lot of leg work. I would do it. I'd try my best to try to get these base lines done. Because then it's obviously they get concussed and you're like, well, hold on a second, we're now six weeks down the line and our base line is still not quite what we've got now. It's just a lot more objective and tangible measures that we have that we can demonstrate to patients that we're not quite ready to return. It's a bit of a rena. Computer says no, type scenario where you don't have to be the bad guy. And there's a lot of there are a lot of apps out there. There's a lot of FDA approved. If you're hanging out on FDA approval, there's a lot of FDA approved apps out there that you can use as well. And obviously you just got to keep the data collection relatively clean and keep that good hygiene around your data collection. But yeah, there's a lot of things you can do these days, I think, to help objectively with this as well. But I think where we do have a lot of patients and pleads who are trying to get back quite quickly and they see some of the stuff potentially is quite fluffy. I'm not quite right, I'm not quite. If we have an objective measure, it makes life a lot easier. Like athletes in general, like numbers, they like facts, they like figures, they like targets. If you can give them a fact to figure a target of, mate, this is still too high. We're still not at the realm. I find that they're more accepting of the position that they're in. And they'll hopefully do their recap a little bit more as well. I think that's, it keeps them accountable. Like as you know, they can tick off those, hopefully, you know, tick off those days. A lot of the ones where you use can be sent on the internet or you can do it on your phone, you just send a code and again, hopefully they do it in a quiet setting and get it done. But we find that that works quite well. I don't know, had you had much more to wax lyrical on here for anyone out there? Or we pretty much covered off most of the things that we kind of have written down there. I think we've definitely covered the role that osteopathy has to play in this space. And I think whether that is in the acute stages of diagnosis and management, if anyone wanting to go and do further research, there's a lot of great courses out there that people can do. And you know, you can definitely then be quite confident working with clubs to a degree. Obviously not in an emerging care like you are, but you can definitely help them set up their policies and procedures. Or just as an osteopath, I think it's pretty clear our role here is just helping that autonomic nervous system calm down, you know, gut health, vestibular health, cervical health, you know, cervical spinal. So there's all those things that we can do as osteopaths to help. And I think like he said, gives us a bit of an edge. I know talking with Nick Brascher and the guys from the College of Foodie Club, the one thing they were saying was they love what Nick does because he puts his hands on and helps people and that the outcomes of a ginormous. So that was a really nice thing to hear about osteopaths. - Oh, it's a part of the hearing and such a big sport in Australia, like, I think when I presented something similar at conference, I was at conference certainly around this year, you know, osteopaths, we have a unique opportunity to spend time with our patients, to get to understand our patients, to understand the position of our patients in. But we see and listen to patients as a whole and we see them in their own context and how they are placed within their life and how it affects the rest of the family. We have an opportunity here both in New Zealand and Australia, like if we get our standards up to a good level and knowing how to manage this, recognize a treat it, refer it correctly, get our policies and procedures in place. Now, we can be leaders on this with an allied health profession because we can get hands on with patients, we can do our rehab. We have time that we can spend with our patients and we can guide them through where we need to guide them through. So it's a massive opportunity that we can get into, which will not only just help our patients, it will help their wider family, it will help, it will help obviously their athletes as well because obviously the more successful teams are the less injured. But if we can successfully rehab, we're even pre-hab some of this. Now, it's a unique position for us to be in and it's an exciting position to be in. Definitely not, I couldn't agree more and I think it's something that's not going away like I don't know whether we're moving faster, whether the pitch is a harder, we haven't had a lot of rain here in Australia or in Victoria especially, or whether people are just training more, they're quicker, they're faster, they're fitter. But we are definitely, I think, or whether we're just more aware of it. But there's definitely seems to be an increase in the number of concussions that I've seen or that we're seeing on TV. So this isn't a thing that's going away. Obviously, tragic circumstances, we're looping back to delicate guitar. You know, but it's necessary that it brings it, so if there's one thing that comes from that tragic occurrence and it's great to see that he's doing well and recovering, if there's one thing that comes of this is that it's brought it to light and that people hopefully are now going to take it seriously. We don't need to freak out. And I think that's an important thing. I know we mentioned it in when we chat in pre-production about how maybe New Zealand's got a little bit too far, the other way, you know, that everybody's coming off and no one's going back and playing. I don't want to change the game. I don't want to change footy. I love lacrosse. I don't want to change lacrosse. My kids play it. But I want to make sure that we acknowledge that concussions happen and that when they do happen, that we're doing the right things to remove players and keep them safe. And I think that's the message that we need to, don't stop playing footy or don't stop playing rugby or lacrosse or soccer basketball happens. Sport is sport. You can get a head impact, you know, walk, put in cardboard paper and a bin, you know, like in the big places on your head. I mean, you know, anything can happen. Concussions happen a lot in motor vehicle accidents and in work-covered situations as well. So keep playing the sport you love. But just put the policies in place. Have the parameters there. Make sure that we're making play a safety paramount and that we're then taking the players away and affording them the care through our light health that they need to get? Yeah, definitely couldn't agree with you more. You know, I think what we did touch about, you know, is that we're seeing less participation here in New Zealand and rugby. And is that because there's a fear of concussion like I've been talking to some junior players or junior parents that their kids are not going to go next year because it's tackle. And they've seen everybody getting concussions. I think there's going to be a bit of research out there to show actually how confidence is concussion and head and rear impacts versus no injuries day-to-day life. I think we've got to take it into context. And then we've hit the nail on the head there, you know, we're more aware of it because we've done this great amount of education. But again, it's going to be in context. So what scenario, what situation and what it's like in general life, like they say, you know, you could be walking under a tree and hit your head on a branch and get concussions. Like it's going to be in context. Yeah, 100%, 100%. And yeah, well, hopefully we can keep, you know, moving things forward. We're obviously both passionate about concussion and hopefully reasonably well-researched in it. And hopefully it just keeps. And obviously we've obviously got a national framework that's come out here now in Australia and New Zealand. We touched on it again before we chatted it was the ANZ concussionguidelines.com that takes you through a little bit of a toolbox. So any osteos out there wanting to kind of, you know, know what to do. Should you have a concussion patient walk in your door? There's some really great guidelines and tools and toolboxes there that you can use to have a look at and feel confident with directing your treatment and management. So that's another resource which I, you know, point people to which is fantastic. Fantastic. I think the more resources we have out there, the better. And then the one resource that I definitely touch on is the Wild Rugby Medical. So Wild Rugby Passport, you can create account. It's free and there are different modules on there. There's one specifically on concussion. There's one on the video element that we spoke to right at the beginning of how you detect concussion with them. Video is that we can obviously, without a video, we can still go through that same process and it's free. And all you have to do, Wild Rugby Passport, create an account and you rent. I'm going to jump on that. That sounds mighty good. Hey, man, it was awesome talking to you. I think we've, I think we've hopefully covered off. everything. We kind of started slow, but we got going there in the end and kind of excited towards the end. Have you ever had a funny excuses to why someone's tried to stay on the ground when they're being in cuss? Can you think of anything come to mind? They wanted a rest. They're holding their head or the lane flat on their front and you get to them and they just tell them how to go, "Oh no, it's just happened a bit of a rest." Yeah, so did everything go black and suddenly the light sun back on? I'd still reckon that going to the top of this building was pretty, was pretty sparse, but awesome to chat. Hopefully we can catch up again. I'm sure there's more we can unpack. There's a whole persistent post-concussion element that we could talk about where, again, I think Osteo has really come into the fore there with their work. That becomes quite a multi-disciplinary approach, but we're definitely a big player in that. I did run an article on that. I was given myself a plug in the Osteo Life. It was a digital version, which is disappointing. It would have been nice if it was on paper, but go and check that out if you're interested to know more about how Osteepass can help with persistent concussion symptoms. Maybe we can jump back on at some point and talk our way through that. That'll be awesome. Yeah, it would be happy to. Thank you very much for having me. Really enjoyed this, and hopefully what we've done today can help educate our professions. And if there's any patients listening or any coaches listening to help educate them and understand them, we take this seriously. As a profession, we're doing our best to follow our guidelines and to ensure that our patients and athletes return to play efficiently, effectively and safely. We're going to be able to reach a new one if they want to get in contact, and kind of, are you happy that people are getting in contact? You're going to throw another bus there. Yeah, no more than happy. So they can email my clinic directly, which is Adnan at thehomesclinic.co.nz. They can find me on Instagram. I can put that in the and the post post podcast notes of where my Instagram I'd like you to direct, not my personal, but more my professional one. Yeah, I'd be happy if anyone's got any questions or want some guidance or anything like that. Be more than happy to discuss through anything. Have you only courses coming up or anything you're doing in the near future or you're in a bit of a hiatus for now? So within New Zealand, I probably should have put this in the introduction. I'm on the Austin Pasley, New Zealand board. Yeah, part of our segway is, as we've got our specialist interest group within sport and exercise and rehabilitation up and running thanks to some terrific work by Jim Webb. We have a few courses planned for 2026 within students, and we've got a level one coming up. I believe there's also a trauma course coming up in New Zealand as well. So pitch side trauma related. So we're trying to get the word out there. Me personally, I haven't got any courses apart from those. My life is very far at the moment, which is great. But yeah, if people want me to come and do some concussion courses, I can't sit there in a problem. Or I can we should or I can we should do that? Maybe should that be a cliff in Niels concussion course. So yeah, I know what you can catch me. I'm happy, you know, to answer any questions or if anyone's kind of stuck, it's Clifford Williamstown Health and Lifestyle.com.au. Yeah, all concussion osteopath is my handle on Instagram. And you can see lots of videos of my head really close up on that, which is fantastic. Yeah, so four kids are embarrassed as hell about that. But yeah, you don't have to listen to my voice though. The captions are on. So get around it in the morning when you sit on the tub and have a bit of a watch. Yeah, this has been awesome, mate. And hopefully we can catch up and do it again. Awesome. No, look forward to it. And yeah, there's plenty more to talk about. So I'll be more than happy to jump on again. Yeah, beautiful. All right. Take good.