The Peter Attia Drive - #263 ‒ Concussions and head trauma： symptoms, treatment, and recovery

00:00:00.000 Hey, everyone. Welcome to the drive podcast. I'm your host, Peter Atiyah. This podcast,

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00:00:47.800 here's today's episode. My guest this week is Dr. Michael Collins, an internationally renowned

00:00:54.800 expert in sports-related concussions. Mickey, as he goes by, is the clinical and executive director

00:01:00.220 of the University of Pittsburgh Medical Center Sports Medicine Concussion Program, the largest

00:01:04.980 research and clinical program focused on the assessment, treatment, rehabilitation, research,

00:01:10.200 and education of sports-related mild traumatic brain injuries in athletes of all levels. Mickey has

00:01:16.200 published more than 150 peer-reviewed research articles and was also the co-lead author of the CDC's

00:01:22.960 Concussion Toolkit for Physicians, an education standard for concussion management. He is also

00:01:29.800 co-founder of IMPACT, the immediate post-concussion assessment and cognitive testing, the most widely

00:01:36.060 used computerized sports concussion evaluation system that has become the standard of care in

00:01:41.320 organized sports. He has been instrumental in the development of numerous concussion management

00:01:45.960 programs for youth, collegiate, and professional sports leagues and teams. Mickey is currently a

00:01:51.080 consultant for several athletic organizations, including the Pittsburgh Steelers and the

00:01:55.460 Pittsburgh Penguins. I won't hold either of those against him. In this episode, we focus the entire

00:02:00.340 conversation around head trauma and concussions. This includes the definition and diagnosis of a

00:02:05.300 concussion, the signs and symptoms of concussion, and the various types of concussions. We speak about

00:02:10.520 the risk factors that can cause someone to be more susceptible to concussions or can cause more severe

00:02:15.120 concussions in certain individuals. We speak about the importance of quick treatment and recovery

00:02:19.920 from concussions and what to do as part of that recovery, whether the concussion is in a child

00:02:25.420 or an adult, including in the elderly population. Lastly, we speak about what we know and don't know

00:02:31.060 about hyperbaric oxygen specifically and synthetic ketones as treatments for concussion. Overall,

00:02:37.760 this was a really interesting episode to me. A lot of times I come into podcasts already having a pretty

00:02:42.460 good handle of the subject matter, but that was not the case here and I knew that and that's part of why I was

00:02:47.020 so excited to do this. I came away from this far more optimistic and upbeat about the prognosis for

00:02:53.340 people with concussions. And in the short time since we recorded this episode, I've already sent

00:02:58.260 several people to Mickey who have been suffering, I now believe, needlessly for so long post-concussive.

00:03:05.460 So without further delay, please enjoy my conversation with Dr. Mickey Collins.

00:03:09.320 Well, Mickey, thanks so much for making time to sit down. I know you're particularly busy today,

00:03:18.260 so I really appreciate it. This is a conversation I've wanted to have for quite a while. It's a topic

00:03:23.120 that comes up over and over again in my life personally and even professionally, whether it be

00:03:29.620 patients or children of patients, things like that. And that's basically that of head trauma and

00:03:34.860 particularly, you know, what happens when someone has a concussion? What are their options? I think

00:03:39.340 before we get to that, I'd kind of like to give folks a bit of a sense of your background. How did

00:03:43.360 you come to do this? It's a really interesting question and it's kind of a long-winded response,

00:03:48.120 but I went to college and didn't really know what I wanted to do in life. I had a bunch of family

00:03:53.040 members that were physicians and in the medical field. I also went to college to play baseball

00:03:58.860 as much as I did to be a student. And I was playing baseball my junior year and my coach came up to me

00:04:05.460 and said, Mickey, if you don't declare a major today, you're going to be ineligible. So I was

00:04:09.600 like, okay. And I was taking a neuroscience course at that time, like a biopsychology course, and

00:04:15.380 it kind of hit my buttons when they needed to be hit. And I was very intrigued by it. So I just kind

00:04:21.400 of dove in and studying biology and psychology and really the neurosciences and graduated college,

00:04:30.880 went to graduate school and knew I wanted to do brain behavior studies. And I got involved in a

00:04:37.420 program at Michigan State University. I got my PhD from there and studied in clinical psychology with

00:04:42.380 an emphasis in clinical neuropsychology, which is a study of brain behavior and took some of the

00:04:48.040 medical classes there through Michigan State, but also did psychology, clinical psych and

00:04:53.040 neuroscience courses and combined that into my PhD. And maybe two or three years into studying that at

00:04:59.780 Michigan State, I said to myself, I really miss sports. And I wanted somehow wanted to combine

00:05:07.780 traumatic brain injury and sports into something. And no one had really done that before, really. I mean,

00:05:14.260 there wasn't, there was no concussion specialty when I went to school, period.

00:05:19.860 Sorry, just to make sure I understand that, Mickey, you're meaning that even a patient that has a

00:05:24.660 concussion in a sport, if they saw a neurologist, that neurologist wouldn't really have any particular

00:05:29.660 insight on it?

00:05:30.540 This field did not exist in 1998 or 99, 97 when I was in school. This field simply did not exist.

00:05:37.400 Honestly, when I arrived here at UPMC in 2000, I really didn't know how I was going to make a

00:05:43.880 living doing this. I didn't know if I was going to be able to see patients. I didn't, no one would

00:05:47.540 care in my research. There was very little traction in anyone studying this topic, like literally

00:05:52.960 nobody. We had the first clinic in the world here at UPMC. I came here in 2000. That's when we started

00:05:59.340 the clinic. But long story short, back when I was getting into this, I wanted to study concussion or

00:06:04.460 mild traumatic brain injury. And I somehow don't want to involve sports. And right now, if you think

00:06:09.140 back, I mean, that sounds kind of intuitive. It's a hot topic now. At the time, no one could care

00:06:13.800 about it. But that was around the time that Troy Aikman and Steve Young and Paul Correa,

00:06:19.620 everyone remembers that name, Ricky Craven, race car driver, and others started to talk about this topic

00:06:28.160 of concussion. And I remember watching Al Michaels on Monday Night Football talking about Steve Young's

00:06:35.900 concussion in 1997 or 96, whenever it was. And he basically said, no one knows anything about this

00:06:42.900 injury. This topic is just a lot of speculation, but no one really understands about the injury.

00:06:48.480 And I said to myself at that moment, not to be too dramatic here, but I said to myself at that

00:06:51.880 moment, that's what I can do. Because it was a perfect sort of marriage of brain trauma and sports,

00:06:58.420 which is what I want to do for a living. And long story short, I ended up having a mentor,

00:07:03.680 a guy named Mark Lovell and a guy named Joe Maroon, who's a neurosurgeon. They were my mentors. And

00:07:09.000 I was at Henry Ford Hospital in Detroit at the time doing my fellowship. And Mark Lovell came into me and

00:07:14.460 said, hey, Mickey, do you want to move to Pittsburgh? And I'm like, not really, but why? And he said,

00:07:19.100 well, they're starting a big orthopedic sports medicine center there. They want us to do a

00:07:23.600 concussion program there. And I'm like, you know, let's go check it out. So we came here to Pittsburgh

00:07:27.600 and long story short, I came here with my mentor, Mark Lovell and Joe Maroon is here. He's a neurosurgeon.

00:07:34.660 And the three of us started this program in 2000. And that was at a time when, I mean, we had no

00:07:41.780 patients. No one could care about concussion, literally. And we started researching it slowly,

00:07:46.520 but surely we published many papers on it, published a big paper in JAMA in 1999. Actually,

00:07:51.280 I was the lead author on that paper where we looked at college football and concussion. And it was at

00:07:55.500 Michigan State University. And we did some baseline testing with guys. Always tell the story. It's

00:07:59.900 kind of a funny story. I wanted to do research on college football players. And I was like, okay,

00:08:05.940 we're going to baseline test these guys. If they have a concussion, repeat the testing

00:08:09.680 to see what we can find. And I naively thought I'm just going to go to the medical staff of Michigan

00:08:15.940 State and say, hey, I want to work with your football team. I did do that. But they said,

00:08:20.480 well, we're interested, but you have to meet with the head coach to get approval. So I went into the

00:08:24.480 head coach's office and that coach was Nick Saban. And that was the first coach I ever broached this

00:08:29.820 to. And he said, you know what? I think that's a great idea. And we researched this at Michigan State.

00:08:34.860 We then started working at the University of Florida. We worked at the University of Utah.

00:08:39.300 Ironically came to Pittsburgh and worked with them. All that data we collected, we published.

00:08:44.000 And that was published in JAMA in 1999, which was one of the first groundbreaking studies of

00:08:48.100 looking at concussion in sports. And that ended up getting us here to Pittsburgh. And then

00:08:54.540 we started growing this program in Pittsburgh. And the first five years, I swear, I worked in a

00:08:59.540 cubicle. And I would see maybe two or three patients a week, if that. And I was doing research,

00:09:05.500 et cetera. And now fast forward 23 years later, we have 20,000 patient visits a year to our program.

00:09:11.000 We've published over 450, 500 papers. We've written books. We've given talks around the world. And it's

00:09:16.680 probably the hottest topic in sports medicine. So it's been quite a ride. And I'd like to think that

00:09:21.420 we've learned a hell of a lot about this injury over that 23 years. And hopefully we can share some of

00:09:26.420 that wisdom today. That's an awesome overview. And I think it speaks to an interesting and familiar

00:09:31.820 sort of path in medicine. A lot of times people, what looks completely unappealing and uninteresting

00:09:36.760 becomes the most remarkable direction to pursue. I mean, whether it's immunotherapy and cancer that

00:09:42.980 in the 80s looked like a total no man's land, a graveyard for research is now clearly the most

00:09:48.720 promising therapeutic in oncology. So let's get to some of the semantics. I mean, I think everybody's

00:09:54.100 heard the word concussion, but what actually is it? What is the diagnosis? How subjective versus

00:09:59.520 objective is it? What are the criteria? So the word concussus literally translates from Latin to

00:10:04.580 English to mean to shake violently. And if you think about your brain as like an egg yolk inside an

00:10:08.660 eggshell, the brain is inside this hard cavity. And if you have acceleration, deceleration, or

00:10:15.300 translational forces that are hard enough, the brain's going to shift inside the skull. And that shifting of

00:10:20.740 the skull is actually what causes concussion. When the brain moves inside the skull, the membrane to

00:10:26.120 the neuron will stretch. And when that membrane stretches, this little chemical called potassium,

00:10:30.640 which is supposed to be inside the neuron, will leak into the extracellular space. And when that

00:10:34.500 does, there's an increased demand for glucose or energy that occurs due to the release of potassium.

00:10:39.340 At the same time, does it influx the calcium? So calcium leaks across that same stretch membrane,

00:10:44.540 goes into the cell. And when calcium goes into the cell, we get vasoconstriction and decreased

00:10:49.680 cerebral blood flow. So at the very time the brain's demanding more energy due to the hyperglycolysis,

00:10:55.600 we get an influx of calcium vasoconstriction and decreased cerebral blood flow and decreased energy

00:10:59.660 supply. And so what concussion is, is a mismatch between demand and supply of energy to the cell.

00:11:05.740 Now, this is not enough to cause cell death, wall area and degeneration. There's no structural changes

00:11:13.320 to the neuron. There's no death of the neuron. But the cells struggle to operate at their normal

00:11:18.220 efficiency. And we've now learned that when that energy problem happens, different systems in the

00:11:24.360 brain can be decompensated. And that decompensation of certain systems, we've now learned there's

00:11:29.860 different types of concussions. There's actually six different types of problems we see following

00:11:33.920 concussion. And those different types of concussions help to determine how we treat

00:11:39.140 the problem. So as a clinician, my job is to find out where the aberrant signal is coming

00:11:45.200 from and what system is decompensated. And then we have to apply the right treatment to the right

00:11:49.900 problem. None of anything I just told you, we knew in 2000, none of it. And so we've now really

00:11:57.060 learned a lot about how this injury occurs. We understand the path of physiology fairly well,

00:12:03.240 not completely well as animal model work that's been looked at with that. More importantly, we now

00:12:07.440 clinically know how to evaluate this injury in a way where we can kind of figure out what's happening

00:12:13.360 and then apply a more targeted treatment to its treatment. Now, one thing is, Peter, is that we

00:12:18.780 don't have a biomarker right now for this injury. There's no blood test that's ready for prime time.

00:12:24.100 There's no serum marker. There's no imaging. This is not seen on MRI. It's not seen on PET scan. It's

00:12:30.380 not seen on functional MRI. It's not seen on MRI. It's not seen on MEG. It's not seen on EEG.

00:12:37.600 There's no imaging studies right now that definitively help us with this diagnosis.

00:12:44.600 Even CSF fluid, if you could access it?

00:12:47.400 No. And we're doing that. But no, all those things are looked at. Very smart people are looking into

00:12:54.900 those things and researching it. But I do not have a biomarker to measure this injury. It's at the

00:13:00.940 cellular level. It's an energy crisis. There's no structural changes in the brain that we see following

00:13:06.180 concussion. And everyone is, like, searching for that biomarker. But right now, we just don't have

00:13:12.020 it. And I don't see that happening in the foreseeable future. I mean, there's a lot of good

00:13:16.020 work being done on it. There might be a panel of biomarkers that we look at, you know. And there's

00:13:21.260 discussion of certain markers may help us. But no, at this point in time, there's nothing I would tell

00:13:26.540 you that's ready for prime time.

00:13:28.160 Just to go back to the beginning of this, so make sure I understand this. You have this movement of the

00:13:33.180 brain relative to its protection in the skull, the membrane of the neuron stretches. So presumably,

00:13:39.040 you have a passive effusion of potassium out of the neuron as a result of that. Is the demand for

00:13:45.360 glycolysis so that you can actively pump potassium back in against an unfavorable gradient?

00:13:50.700 Correct.

00:13:51.340 Okay. So that's why you need glucose, more ATP, force potassium back into where it doesn't want to go.

00:13:57.220 And then tell me about the calcium. Why is the calcium, is the calcium just following a gradient

00:14:02.440 to cross the stretched membrane at that moment?

00:14:04.140 I don't know if we have an answer to that, but yes, that's my understanding of it.

00:14:07.760 And when that calcium goes into the cell, we get a vasoconstriction, decreased cerebral blood flow.

00:14:12.740 And this is very clearly an energy crisis for what we call a metabolic mismatch that occurs to the

00:14:18.180 cell. The important thing at this point is we don't feel the cells die from this. They're just

00:14:24.940 operating at a different level of efficiency. And what we literally see happen with this is different

00:14:31.660 systems in the brain that require a lot of energy don't work as efficiently and they will literally

00:14:36.900 decompensate from that energy problem. And that's given us some good understanding of how to kind of

00:14:42.140 approach this injury. Actually, we can get into the different problems we see from concussion,

00:14:46.060 but yeah, it's basically these systems that aren't working as efficiently as they should.

00:14:50.480 How global versus focal is this type of injury? So if you have two athletes, and by the way,

00:14:56.100 I think we're going to talk a lot about athletes, but the reality of it is you can get into a car

00:14:59.260 accident and have the same injury. This happens a lot more in non-athletes than it does athletes.

00:15:03.880 But you know, we use sports as a laboratory. It's a great petri dish to study this injury,

00:15:07.700 but this applies to slip and falls, car accident, all kinds of older people fall. And boy,

00:15:12.820 that's a real problem that no one's really addressing. So keep going. I'm sorry.

00:15:16.720 So let's just say we took two individuals who at the macro level appear to have a very similar

00:15:22.480 insult. Is this process occurring across the entire spectrum of neurons? Or could two people

00:15:29.720 say, no, no, actually, this is occurring far more in the temporal lobe in you, and it's occurring more

00:15:35.000 in the frontal lobe in you. And clearly, there's going to be a clinical diagnosis that's going to

00:15:39.300 be required to differentiate that. But again, just at the pathophysiologic level, what's the diffusity

00:15:43.540 of this?

00:15:44.140 It's an interesting question. I wouldn't look at this as more like this affects the hippocampus,

00:15:48.100 or this affects the prefrontal gyrus, or whatever. I wouldn't look at it that way. I'd look at this

00:15:53.160 as it more affects systems in the brain and pathways in the brain. And so there's really no known,

00:15:59.600 like, you get hit in the head here, you have this symptom. That's antiquated in terms of how we think

00:16:04.280 about this. It's more systematically looking at how the brain's functioning. Now, with that said,

00:16:10.260 interestingly, we do see the posterior, when people hit the back of their head, you see a very

00:16:14.920 kind of specific presentation of problems from that that I can get into later.

00:16:18.660 But there's really no, like, you hit your head this way, you have this problem. Rather,

00:16:22.900 Peter, and this is important, concussion fights dirty. Like, whatever you bring to the table

00:16:27.620 that's weak seems to be affected more generally in patients. In other words, there's pre-existing

00:16:34.140 risk factors to have a worse outcome from this injury that will probably be quite surprising to

00:16:38.820 hear for people. Those risk factors not only put you at more risk for less force-causing concussion,

00:16:44.320 but they tell you what kind of concussion you're likely to have if you do have a concussion.

00:16:48.660 For example, we talked about different types of concussions. If you have a history of car

00:16:54.080 sickness in your past, we've published a lot of data showing that those patients are more likely

00:16:59.320 to get concussed and have a vestibular problem following concussion. If you have a history of

00:17:04.020 lazy... Sorry, just to make sure I understand that, they're more likely to get concussed,

00:17:08.380 or if they get concussed, they're more likely to have vestibular symptoms. Is it both?

00:17:12.680 Both. Correct. Less force will cause injury in those patients. Patients that have a history of

00:17:17.740 migraine, less force causes injury, and you're going to go down that migraine pathway.

00:17:21.840 If you have a history of lazy eye or strabismus, you're going to go down the ocular pathway. And

00:17:27.620 yes, less force causes injury. If you have a history of anxiety, you're going to go down that

00:17:32.560 pathway more ubiquitously. So there's almost a neuronal reserve thing here. We talk about

00:17:38.060 cognitive reserve and movement reserve when we think about Alzheimer's disease and Parkinson's

00:17:42.920 disease respectively. You're now talking about a concussive reserve. I think so. I don't know if I'd

00:17:48.140 use those terms, and I'm familiar with that terminology, and it's been around for a long,

00:17:53.920 long time. And I guess it sort of applies to this. So a researcher out of UCLA kind of coined that

00:17:58.980 phrase, cognitive reserve. But generally speaking, we can get in the weeds on that. But I would say,

00:18:04.120 yeah, I mean, you're more vulnerable with these different risk factors, and you're more likely to

00:18:08.820 go down different pathways. And girls are more likely to have concussions than boys. Neck strength

00:18:13.660 plays a role with that. Hormonal influences can play a role with that. And we've also know that

00:18:19.040 girls are six times more likely to have migraine and have car sickness in boys. And so they're more

00:18:23.380 at risk for these problems. 60% of the patients that come through our clinic are female, 40% are male.

00:18:29.220 The reason why is because they're a more vulnerable population, and we see a lot longer outcomes in

00:18:34.020 females than we do males because of some of those factors.

00:18:36.380 How long is the susceptibility to a subsequent concussion higher following a concussion? So I'm

00:18:45.060 sure everybody who's watched football highlights has noticed that, I think it was the quarterback

00:18:49.160 for the Dolphins last year, just had a series of devastating concussions. And you couldn't help

00:18:54.840 but think, was the subsequent concussion really a result of not being better from the first one?

00:19:00.680 How long is that vulnerability present?

00:19:02.520 Yeah, not talking about that case specifically, but generally speaking,

00:19:06.000 there is a definite vulnerability when you're recovering from an initial injury

00:19:10.160 and that less force will cause more serious outcome if you're still recovering from the first event.

00:19:15.620 Do you ever get back to baseline?

00:19:17.200 Yes, absolutely. I firmly believe, and we've published a lot of papers on this,

00:19:22.640 that concussion is a treatable injury. I firmly believe that if you manage the injury effectively

00:19:27.840 and treat it fully, we don't see repetitive, chronic, cumulative problems. I firmly believe

00:19:34.000 that the best way to prevent problems from concussion is to manage it effectively when you

00:19:38.580 have one. And we are very good now at determining recovery, what that looks like and how that looks

00:19:45.740 in our examination, how that looks with the testing that we do and the data points that we use.

00:19:50.740 I am a big proponent of kids playing sports. I'm a big proponent of really managing this injury

00:19:57.000 effectively and getting kids back to the sports they love because it's a very healthy thing for

00:20:01.080 them to be doing. And we haven't found problems down the road in patients that are managed

00:20:05.880 effectively. Now, the key here though, Peter, is to manage it effectively when you have one

00:20:10.280 and you don't want to stack these things up. And people that do can get in trouble with it.

00:20:15.120 And this is becoming a very specialist kind of thing to see. You want to go to someone that

00:20:22.360 knows what they're doing to manage this injury effectively when you have one. You want to make

00:20:25.820 sure you're getting the right assessment done, the right tools. There's definite morbidity when

00:20:29.620 this isn't managed properly, for sure. Let's go back to the person, the athlete, the non-athlete,

00:20:35.540 whatever, who has the injury. So we've already established we have no biomarker. So this person

00:20:39.760 gets their bell rung, be it in a car accident or on the football field, and it's a clinical

00:20:45.400 diagnosis. So tell me if you're at the sidelines or if you're in the clinic when the person shows

00:20:50.360 up the next day, what are they typically complaining of and what are you doing to make that diagnosis?

00:20:58.480 So there's approximately 21 different symptoms on the field that you can see following concussion.

00:21:03.760 And it depends on what type of concussion you have. There are signs and there are symptoms of

00:21:08.720 injury. Signs are what you outwardly observe. Symptoms are what the patient reports.

00:21:13.460 Signs of concussion include loss of consciousness. It includes confusion. It includes balance issues.

00:21:20.540 It includes vomiting. Those are all signs of injury. Symptoms of injury are dizziness,

00:21:27.300 fogginess, or feeling detached, feeling one step behind, light sensitive, noise sensitive,

00:21:32.420 nauseous, fatigued, blurred vision, double vision, fuzzy vision.

00:21:37.180 Headache. Headache, of course. Yeah. Thank you for that one. Another post-traumatic amnesia,

00:21:43.280 retrograde amnesia, loss of memory before the injury, loss of memory after the injury.

00:21:47.340 We've done a lot of research looking at these different signs and symptoms and their

00:21:50.920 relative ability to predict outcomes. I'll give you 20 bucks, Peter, if you tell me the on-field

00:21:56.340 symptom that best predicts a longer recovery from concussion.

00:22:01.340 I mean, I would have guessed loss of consciousness, but that seems too obvious.

00:22:04.540 Yeah, that would be obvious, and it's incorrect, actually. On-field dizziness is six times more

00:22:10.820 predictive than any other symptom or predicting a longer outcome from concussion.

00:22:14.300 Wow.

00:22:14.680 The second symptom that best predicts outcome is fogginess, kind of feeling one step behind,

00:22:19.140 detached, removed. Dizziness is six times more likely to cause a longer being a month or longer

00:22:25.060 recovery than is losing consciousness.

00:22:28.200 Wow.

00:22:28.520 Yeah, right. You know, what's interesting about that is this, the symptoms of injury way better

00:22:34.200 predict poor outcome than the signs of injury. And the reason for that is because if you lose

00:22:41.040 consciousness, it's very unlikely you're going to go back to play. You're not going to get put back

00:22:45.820 to play if you lose consciousness, unless you're in some archaic sport or in some geographical area

00:22:53.400 that hasn't been exposed to this information. So when you lose consciousness, you get taken out of

00:22:57.740 play and you're not going to get put back to play. That may be why these symptoms predict

00:23:01.960 worse outcomes because a lot of patients tend to play through their injury. And we just published

00:23:06.580 a paper and we've published a series of papers in pediatrics, JAMA, and other journals.

00:23:11.660 We asked the question, if patients have a head injury and they have symptoms of concussion,

00:23:17.120 what happens if we take them out of play immediately or what happens if they continue to play?

00:23:21.400 And what do their outcomes look like? And so we did this very cool study.

00:23:24.440 Sorry, this is not done prospectively. This is done retrospectively?

00:23:29.200 Retrospectively, right. Because it's hard to do prospectively. But retrospectively,

00:23:33.180 we looked at a very large database. We had about, I think, 300 kids in the sample.

00:23:38.280 150 of them had symptoms or signs of concussion and they came out of play immediately.

00:23:43.020 And then 150 of them continued to play after having those signs and symptoms, okay?

00:23:48.280 The people that got taken out of play immediately, their average recovery time was 18 days.

00:23:53.580 And patients who returned to play and played for just 15 minutes beyond the point of their injury

00:23:58.540 or point of having symptoms, their average recovery time was 44 days. So just playing 15 minutes through

00:24:04.920 this event added almost close to a month onto the recovery.

00:24:08.960 How were you able to control for the severity of the initial event? Presumably there's a bias there,

00:24:13.020 right? Which is that the kids who came out right away, maybe they were more in tune with something.

00:24:19.560 You know, I mean, it's hard to do that without randomization, right?

00:24:21.800 We did control for a lot of factors. No group lost consciousness more than another group. No

00:24:27.240 group had more symptoms, specific symptoms than another group. So we were able to statistically

00:24:31.520 control for that. And it's such a big difference. 18 to 44 days is a big enough difference that

00:24:36.340 even if it's not exactly that, there seems to be a signal somewhere in there.

00:24:40.300 There is. And then we did another paper, a follow-up paper. We looked at dose response

00:24:43.920 and it's really powerful. So for every minute you try to play through your injury, you add on like

00:24:50.860 seven or eight days of recovery. It's quite powerful. And so, yeah, you don't want to play

00:24:56.900 through this stuff. And a lot of kids and parents may not be aware that getting dizzy on the sideline

00:25:02.060 is the most powerful predictor of outcome or feeling foggy or feeling tired or blurred vision,

00:25:07.840 double vision. I mean, I played sports my whole life as I'm sure you did, Peter.

00:25:11.140 I wouldn't come out of play if I had those symptoms. I probably wouldn't report it at all.

00:25:15.880 We need to do a really good job of educating parents on that. But at the same token,

00:25:21.200 I want kids to play sport. I'm not fear-mongering here. I truly believe this is an injury that's

00:25:27.280 treatable and we can get kids back to the sports they love. But it just shows you the differences

00:25:31.440 in outcomes when it's not managed properly initially early on. And we're getting now into all

00:25:36.420 our research, looking at how we treat this injury, which we're doing really well with. And

00:25:39.840 we can get kids better faster by applying certain treatments and get them back to play sooner.

00:25:44.500 Well, I definitely want to hear about that. And I think that's where most people's ears will perk

00:25:47.860 up. But let's go back again to these different types. I think you mentioned that there are

00:25:51.640 sort of six different types. So basically, based on presentation and based on subsequent testing

00:25:57.580 that you might do, you would then elucidate these six different types. Is that how it works?

00:26:02.540 Yeah. So we do an evaluation where we ask about symptoms, obviously do a very good clinical

00:26:08.000 interview. We have a physical exam that we do called the VOMS, stands for vestibular ocular

00:26:12.720 motor screening. We do impact testing. I'm familiar with the neurocognitive test. It's a computer-based

00:26:19.600 neurocognitive test that has been FDA approved that allows us to quantify and look at the concussion in

00:26:25.780 a more objective way, looking at their cognition. There's different neurocognitive correlates that we see

00:26:30.940 with these different types of concussions, et cetera. But you put all this information together

00:26:34.460 and yeah, and we're doing research now looking at these different phenotypes and different problems

00:26:39.900 we see from concussion. But each of these different types of concussions are going to have different

00:26:44.360 symptoms, are going to have different risk factors, different therapeutic techniques to treat it,

00:26:49.500 and different outcomes and different return to play sort of situations. So do you want to, I mean-

00:26:54.720 I'd love to hear them. Yeah, let's hear what they are.

00:26:56.280 The six different types of concussions, cognitive, we actually call it cognitive fatigue. The second

00:27:02.520 is vestibular, which is not the ear, it's more the central pathways in the brain. You know, the vestibular

00:27:09.040 system is a very significant system in the brain that starts in the inner ear and then kind of goes to the

00:27:13.380 deep parts of the brain. We're talking about more centrally derived problems from the central part of the

00:27:18.180 vestibular system or the brain part. The third type of concussion is ocular, which is your eyes

00:27:23.760 working together as a team. It's not your vision as much as ocular motor. The fourth type is migraine,

00:27:29.900 which is what it sounds like, headache with nausea and or lighter noise sensitivity,

00:27:34.060 and other symptoms as well. And then the fifth type is anxiety. The sixth subtype is neck. You can have

00:27:40.220 some of these symptoms coming from the neck. Not very common, but you can. So those are the six

00:27:45.500 different problems we will see from concussion. Now, patients may have one of those problems or they

00:27:50.560 may have all six. They're not mutually exclusive. And the more you have, the more difficult it is to

00:27:55.340 treat. But you are going to treat each of those problems in a distinct way or in a targeted way.

00:28:01.520 You know, if there's 30 different types of knee injuries, why do we think there's one type of

00:28:04.500 concussion? We're starting to really be able to better identify kind of where the signal's coming

00:28:09.620 from with this injury. And is there an age and or gender difference between these?

00:28:15.880 Well, first of all, you may not be aware, but we've published a lot of data on this.

00:28:19.820 The adolescent brain, if we looked at high school kids versus college athletes and then college

00:28:25.320 athletes versus professional athletes, the high school kids take the longest to recover from

00:28:29.620 concussion. The college athletes take the second longest. The professional athletes recover more

00:28:34.280 quickly than the other two. There's a lot of sort of vulnerabilities of the adolescent brain to this

00:28:39.440 injury. You got to be careful of. But there is an age relationship that we've published extensively on.

00:28:44.700 What do you think that's a result of? Do you think that the younger brain has a different

00:28:50.860 hormonal milieu? Do you think that it, do you think that that's the biggest driver of that

00:28:55.880 distinction? I don't know. And we're doing research on that now. We're actually doing a really cool

00:29:00.780 women's study on concussion, looking at some hormonal influences. And we've found that menstruation can

00:29:06.620 change after a head injury. And that was the first question that was going to come to my mind is it

00:29:10.940 would be so interesting to understand how a woman's menstrual cycle and therefore, you know,

00:29:16.100 not just menstrual cycle, but also like, where is she ovulating? Where is she in the follicular and

00:29:20.540 luteal phase? Because the estrogen progesterone swings in those phases are enormous. Of course,

00:29:26.160 it begs the question, are those hormones protective?

00:29:28.660 We were just about ready to embark the first women's study on this injury. We're collaborating

00:29:34.560 with McGee Hospital here at UPMC with our clinic and it's exciting work. We just got a grant to look

00:29:41.240 at that. But we have published a paper already in JAMA Neurology, I believe, where we showed that

00:29:46.300 the menstrual cycle does change relative to patients that don't have head injuries. So there's a lot to

00:29:51.540 learn. That's a cool thing is, again, we started doing this work when no one cared about it. Now

00:29:55.540 there's too much work to be done and everyone cares about it. It's fascinating.

00:29:59.860 What do you attribute that to, by the way? How much of that do you think

00:30:02.940 is an indirect or even a direct consequence of the attention that's been brought

00:30:07.580 to brain injury through the light of CTE vis-a-vis the NFL?

00:30:14.060 Yeah, it's an interesting question. I mean, clearly the spotlight in this injury is iridescent,

00:30:19.560 you know, and clearly the NFL is a very powerful enterprise and there's a lot of eyes on it and

00:30:25.160 there's a lot of discussion, open discussion on this topic, which is a good thing in a lot of

00:30:29.580 ways. It drives science and it drives awareness, but too much awareness without a solution is called

00:30:34.600 hysteria. And we see that happen with this injury. When the reality is, is that there's a lot of

00:30:41.100 misinformation out there about concussion and I think it actually hurts outcomes a lot of times.

00:30:45.120 Clinicians that aren't aware of the recent advances in knowing how to treat this, clinicians that don't

00:30:49.380 know how to do the right evaluation. And there's a lot of mismanagement and mistreatment of this

00:30:54.340 injury that leads to very poor outcomes. Again, and you're going to hear it from me over and over

00:31:00.620 again, if you bring me a patient with concussion, I can pretty much tell you I can treat that and

00:31:05.620 get that patient better and get them back to the sports they love. There are highly effective

00:31:10.460 treatments with this injury. Is this the sort of thing where there's a relatively finite window in

00:31:16.480 which you or the physician treating has to be able to access the patient? And the further a patient

00:31:23.000 is from that window absent the natural history resolution, the more difficult that gets?

00:31:29.140 Okay. So I'll answer that with data. We just did a study again published in, I think it was in JAMA

00:31:34.000 Neurology as well, where we looked at what factors best predict outcomes from concussion. You know,

00:31:39.980 migraine is a huge factor predicting outcome, history of migraine, the certain symptoms that predict

00:31:45.220 outcomes. But we looked at all those things. The one factor that best predicted outcome was

00:31:49.540 how quickly they get into our clinic. If they were seen by us within seven days,

00:31:54.100 that was the best predictor of someone who got better from their injury because we can apply our

00:31:57.880 treatments quickly. And if you do wait, it's harder to treat. But I still will argue, even if you're a

00:32:04.640 year out, two years out, three years out from this injury, we can treat it effectively the great

00:32:08.640 majority of the time. It's not irreversible. You can get patients better even if they've been living

00:32:14.200 with it chronically. Peter, today, I mean, I saw patients all morning. I had 20 patients on my

00:32:18.940 schedule before our podcast. I just saw a race car driver from Phoenix or someplace, and they've

00:32:26.840 been going through this for two years and miserable. We will get that patient better. They will be normal

00:32:33.420 when we finish treating them. There's nothing I'm seeing that worries me about them.

00:32:37.560 If you can, without giving any information that would identify this individual, can you give a bit of a

00:32:42.440 sense of this as a case study? So presumably two years ago, this guy was involved in an accident?

00:32:47.140 Yeah, I was involved in an accident, had all the hallmark symptoms of vestibular problems.

00:32:52.060 What type of accident, by the way, was this one where it was just a coup,

00:32:55.340 contra coup injury where he whiplash? I mean, you know, we wear a Hans in a car,

00:32:59.060 which limits our recoil now in our heads.

00:33:01.540 I looked at the video on it, and this isn't at the highest levels of racing, so I'm not-

00:33:05.600 Sure, sure, yeah.

00:33:06.240 And we do work a lot with those patients, but this is a small track event or something where the patient

00:33:11.300 somehow got hit in a way. Their car rotated and went backwards into the wall. In this video,

00:33:17.300 I actually saw the video of the hit, and their head hit the back of the headrest, and there was

00:33:22.700 no loss of consciousness, but the person immediately felt foggy, this slow, wavy, dizzy. They had a

00:33:28.940 headache. They felt fatigued. They had bilateral blurred vision early on, but no loss of consciousness,

00:33:35.880 no memory loss, no confusion. Obviously, the car was totaled, so they didn't race,

00:33:40.380 but they didn't also get medically evaluated after this. They kind of went about their lives

00:33:44.800 and continued to have those symptoms and went back to racing two weeks later and got in another

00:33:51.840 accident and had the same problem occur, same mechanism even, and that's when everything

00:33:57.600 obviously got worse and when they sought medical attention, but they've been living with that for

00:34:01.800 two years. They've not improved. They came to me today. They're having everyday headaches that can

00:34:06.880 get up to an eight out of 10, light-sensitive, noise-sensitive, foggy. They don't like busy

00:34:11.380 environments. They don't like exercising because they get really dizzy. They get headaches. They

00:34:15.800 get sick to their stomach. They've got a lot of car sickness. They have a lot of sympathetic nervous.

00:34:20.140 This sounds debilitating.

00:34:21.520 Oh, it's totally debilitating.

00:34:23.220 This destroys your life.

00:34:24.660 It destroys your life, and this is a person who is not racing anymore. They're not working because of it.

00:34:31.660 Oh, God.

00:34:32.720 They have massive sympathetic nervous system arousal where they can't sleep at night.

00:34:37.420 They're very foggy, very, very worked up, and they very much are isolative. They don't want to

00:34:44.780 be around other people because that triggers the vestibular problems, and so they become more

00:34:48.940 reclusive. They find themselves exercising minimally. They're socially very inactive. They're not

00:34:55.820 preoccupied with their mind, so their thoughts are going so fast because the nervous system is racing.

00:35:00.900 So they're in their head all day long. Migraines. That's what I just saw this morning, Peter,

00:35:06.520 and I do it all day long. This is an injury that causes so many problems in patients.

00:35:11.640 So notwithstanding the fact that this poor guy has been needlessly suffering for a couple of years,

00:35:16.740 tell me in broad strokes, what are you going to do to help this person, and what's a time course

00:35:22.160 that you would give him for a reasonable expectation of recovery?

00:35:25.660 Okay. So we saw the patients today, and we have a very good evaluation we do.

00:35:30.080 And the cool thing is that we're very used to seeing out-of-town patients here. A lot of my

00:35:34.200 patients are out of town, so they have five appointments in one day. I'm the point guard of it,

00:35:39.280 but we also have a vestibular therapist here. We have what's called exertion therapy here.

00:35:44.120 We have a psychiatrist here. We have a behavioral optometrist that we can use. We have neck people

00:35:49.820 we can use. So it's all under one roof, so people will have appointments scheduled throughout the day.

00:35:53.400 They come to see me. I did the evaluation. I kind of find out what was going on.

00:35:57.700 But what we're able to identify in our evaluation today is the patient has a significant vestibular

00:36:02.740 problem that has not been treated. And the vestibular system, when it's not working well,

00:36:06.640 is going to cause a lot of dizziness. It's going to cause a lot of fogginess. It's going to cause

00:36:10.700 environmental sensitivity. Busy environments will bother them. They don't want to exercise because

00:36:16.020 movement bothers them. The vestibular system is responsible for interpreting motion. And when that

00:36:20.780 system doesn't work, remember, this injury decompensates that system. That signal comes

00:36:26.140 through aberrantly, and it will trigger all these really icky symptoms. It's like a bad car sickness

00:36:30.980 they feel. Now, the vestibular system, the same pathways in the brain that control that system

00:36:35.780 mediate our sympathetic nervous system. And so the patients will also have massive sympathetic

00:36:41.440 nervous system arousal, fight or flight. So thoughts go faster, heart rate increases. They get a lot of

00:36:46.980 cortisol, a lot of problems going on from the nervous system. And that's all triggered by the

00:36:51.440 head injury. And so they're living in this fight or flight situation. And then when patients go into

00:36:57.660 certain environments where they feel crappy, it not only triggers the vestibular problem, but it

00:37:02.540 triggers that fight or flight response. And patients will then, in a very Pavlovian way, avoid those

00:37:07.960 environments. And then they don't want to work. They don't want to exercise. And what do you think

00:37:12.500 happens? It triggers migraine. Because patients that have a massive sympathetic nervous system

00:37:17.060 arousal, they get headaches. People get migraines when they're stressed. And people get migraines

00:37:22.360 when they don't sleep consistently. And people get migraines when they don't exercise consistently.

00:37:26.580 That's why people get migraines. And so what started off as one problem with a vestibular problem

00:37:31.980 becomes an anxiety problem or a sympathetic nervous system problem. And then it becomes a migraine

00:37:36.760 problem. And then migraine actually feeds back through the vestibular pathways and the ocular

00:37:41.940 pathways. So you can also have a lot of problems from that secondarily to the migraine. Does that

00:37:46.600 all make sense to you? It absolutely does. And it's uncanny in how much it reminds me of an injury

00:37:52.420 that someone very close to me had, which was riding a bike down the side of the road, 25 miles an hour,

00:37:58.360 you know, 40K. So really at a good clip. And a runner jetted out between two cars, you know,

00:38:04.660 was probably listening for cars, but didn't think about a bike. And there was a head-to-head collision.

00:38:08.720 So cyclist head into runner's head. I knew the cyclist, not the runner. They both were devastated

00:38:14.620 by this injury. The runner took the brunt of it, had a complete fracture of the face,

00:38:18.840 but the cyclist was for two years, couldn't be in a room with the TV on. Any noise that the kids made

00:38:25.960 was, would make this person very irritable. It's very similar to what you're describing.

00:38:31.460 That's because it's similar, Peter, because that's the pathway these patients go down.

00:38:36.420 And it's very predictable how they go down this. It's not only Pavlovian, meaning they're conditioned

00:38:41.880 to go down this pathway, but it's all biological. It really triggers these things in a very robust

00:38:46.360 way. And it's a very, very, very... These people describe it, because I've now spoken with a couple

00:38:51.040 of patients that have gone through this, they describe it in as stark terms as someone would

00:38:56.300 the most severe mental illness, which is to say, I'm not myself anymore. So whoever I used to be,

00:39:03.000 that person is gone. I am this new person that has nothing in common with the old one,

00:39:08.520 and it's all in the wrong direction. What percentage of people, of all comers in concussions,

00:39:13.680 how many are this severe?

00:39:15.760 The patients that come see me from out of town, almost all of them, because they haven't been

00:39:20.580 treated. And now some come to me and they're actually feeling pretty well. They just want to know if

00:39:24.760 they can go back to sports after having X amount of concussions. And some of those patients aren't

00:39:28.760 sick like that. But I have on my schedule every week, I have something like, I'll see upwards of

00:39:34.740 70 to 100 patients a week with this injury. I've got on my schedule slots for probably 12 to 16 out-of-town

00:39:42.100 patients a week. Probably 80% of those patients are as sick as what we're describing here. So it's not

00:39:48.460 fun for these patients to go through.

00:39:50.160 What will be the next step for this gentleman that we're talking about?

00:39:53.580 So we can treat all of that, but it's completely antithetical to how you think we treat it.

00:40:01.460 So what's the one word, Peter, that comes to mind when you think about what should I do when I have

00:40:07.120 a concussion? What's that word?

00:40:08.880 Rest.

00:40:09.500 You're exactly right. And you're absolutely wrong in how we approach this injury.

00:40:14.840 I'm 0 for 2, Mickey. Jeez.

00:40:16.700 No, I set you up there. But if you look at the literature over the years, it's like,

00:40:22.800 oh, you have a brain injury, it's an energy problem, you need to rest that patient. That

00:40:27.780 makes all of this worse when you take that tact. Because the way we treat a vestibular problem

00:40:34.740 is by retraining it. It's not rest. The way we treat anxiety is by increasing parasympathetic

00:40:40.000 nervous system arousal, which is exercise. It's regulated sleep. The way we treat a vestibular

00:40:45.220 problem is by retraining it. So I want them in busy environments. I want them exercising.

00:40:50.040 We've got to get them on a good sleep schedule. We've got to treat the vestibular problem with

00:40:53.760 very targeted physical therapy. We have exercises that treat that. We actually have what's called

00:40:59.500 exertion therapy here. If you come see me with a concussion, I don't care how sick you are,

00:41:04.400 I am working you out. And I'm doing it aggressively a lot of times. We take a very active, very targeted,

00:41:12.780 very exposure-based model to treating this problem. But you need to see a specialist in how to do that

00:41:19.020 because you can do it the wrong way and make patients worse. It's got to be very targeted in

00:41:26.000 how you approach this with patients. And every patient's different. And it's breaking down in

00:41:29.900 different ways. There's different types of vestibular problems. There's different types of

00:41:33.780 oculomotor problems. There's different types of personality characteristics, etc., that you have

00:41:39.080 to account for when you're treating this injury. But at the end of the day, if you match the right

00:41:43.280 treatment to the right problem, you can get better from this. And that's what we do all day long here

00:41:46.580 is treat those problems. What I find interesting is that, be it two years ago in the case of this

00:41:52.400 gentleman, that injury took place. So you have the energy crisis takes place. The vasoconstriction

00:41:59.720 takes place. The mismatch of supply and demand takes place. Is it likely the case that if you

00:42:06.060 could biopsy his brain today, or let's get even more creative, you could put yourself onto a

00:42:11.820 nanoparticle spaceship and enter his brain today, everything looks totally normal at the cellular

00:42:17.300 level? Yes. Or do you think that it's still microscopically aberrant? I don't know the answer

00:42:23.260 to that. I wish I did. But my suspicion, based on everything I've learned about the pathophysiology

00:42:28.780 of this, is that we should see a normal brain structurally and anatomically and even physiologically.

00:42:36.000 That's just what happens when this injury happens as to what systems are affected. And then you can

00:42:40.960 kind of go down these pathways if it's not treated appropriately, and that's what ends up happening.

00:42:44.680 It seems that of those six phenotypes you described, this vestibular one is very problematic because it

00:42:53.620 seems to amplify the other ones. But again, am I interpreting that correct?

00:42:57.640 Yeah, you kind of are. We actually have done research on that. If you looked at the most common

00:43:01.680 types of concussion, we published a study on this as well. The most common problem we see after

00:43:07.880 concussion is post-traumatic headache and migraine. That's the number one profile that we see.

00:43:13.700 Oh no, I'm sorry. I apologize. Let me retract that. The number one profile that we see is anxiety

00:43:18.820 and then migraine and then vestibular and then ocular and then fatigue, cognitive fatigue.

00:43:25.560 So we actually have done work on that. So anxiety is ubiquitous across this injury. And that is what

00:43:32.380 is the most common clinical profile that we'll see is that nervous system issue.

00:43:37.580 It's interesting though, because you also said, if I recall, that no symptom predicts a worse outcome

00:43:45.020 more than dizziness. And that of course makes me think, well, dizziness is so tied to vestibular.

00:43:50.620 Yeah, right. I agree with that.

00:43:52.580 And there is something about this vestibular problem that, by the way, would also amplify anxiety.

00:43:57.420 You know how we do research and we look at the numbers and you publish that? My gut is the

00:44:01.400 vestibular stuff carries the day with this injury the great majority of the time, or at least it kicks

00:44:06.320 it off, Peter. A lot of times I'll see patients-

00:44:08.820 Right. It's a vicious cycle that spins out of control from that.

00:44:12.280 Exactly. I would agree with that. I'm not going to overgeneralize to every human being because

00:44:15.680 there really is, it's a very different presentation to a lot of different people. Like I'll see people

00:44:19.740 that come in here that have an oculomotor problem that no one's identified and have no vestibular

00:44:24.360 issues. They have no migraine. They're completely normal, except they can't focus when they look at

00:44:29.620 their math homework and they get headaches in the front of their head and they're tired.

00:44:33.320 That's an oculomotor problem that we can fix pretty easily.

00:44:35.940 And that's just a PT program?

00:44:37.980 Yeah. We have to retrain the ocular system and we have exercises that can do that very

00:44:43.700 effectively. And so we see those patients, but yeah, the vestibular stuff is ubiquitous.

00:44:49.160 But there's patients I see where the vestibular problems clearly kicked us off, but that's not

00:44:55.720 present anymore. It's all migraine and anxiety, but it came from that beginning, if that makes sense.

00:45:01.120 And it sounds like your friend there that got that horrific bike accident, that sounds terrible

00:45:06.180 by the way. Like it sounds like he's gone down that profile, the vestibular stuff.

00:45:10.400 Yeah. And here's what's amazing. After two, two and a half, three years, maybe,

00:45:14.740 he just kind of got better.

00:45:17.580 That's good.

00:45:18.360 Maybe part of it is that he did double down on exercise, nutrition, and sleep.

00:45:25.440 That's it. He started getting the right information from someone, but that patient,

00:45:30.040 Peter, if you send him to me a month after this injury, I would have had him better.

00:45:33.120 You'd have saved him within how many months? How many months is he better?

00:45:36.960 If I had seen him the first week after the injury, now listen, I don't want to,

00:45:40.580 I don't know the case. Was there a subject?

00:45:42.080 Sure, sure, sure. But in general.

00:45:43.420 But in general, we could have gotten him better in definitely weeks, not months.

00:45:47.340 Wow. So this gentleman today that you saw, he's going to go back to Phoenix or wherever he's from

00:45:51.740 after he's had this amazing eval. What's his homework assignment? Meaning what are the actual

00:45:57.280 types of PTs and activities he's going to do? And when do you see him again?

00:46:00.500 So I'll see him back in four weeks. They'll come back and see me. And he has been given a very

00:46:08.640 detailed set of vestibular exercises to complete every morning and evening.

00:46:12.280 He has been given an exercise program. We pretty much kicked him around the gym a little bit and

00:46:17.480 got him moving. When this vestibular system breaks down, you have to move in certain ways

00:46:22.660 to treat it. And we're very good at doing that. We're in sports medicine, so we know how to move

00:46:26.840 people. And we've given him very specific workout that will train that vestibular system.

00:46:32.060 And while we're doing that, we're also increasing the parasympathetic nervous system by doing

00:46:35.480 exercise. So it's killing two birds, if that makes sense. And exercise also treats migraines. So that's

00:46:40.080 three birds we're killing by doing the exercise stuff. He'll do that workout program every day.

00:46:44.720 How long will that be? How many minutes a day will he spend exercising?

00:46:47.600 I'm going to have him walk in the morning for 45 minutes. And then he does that

00:46:50.800 very rigorous workout in the afternoon. And it takes about 45 minutes to an hour.

00:46:54.820 And he's to do that every day until I see him back.

00:46:57.780 Wow. Can you give me an example of some of the exercises he'll do in the afternoon?

00:47:02.080 For this patient, he had a horizontal vestibular ocular reflex problem. So this is your

00:47:07.060 vestibular ocular reflex. And when he moves his head side to side-

00:47:10.420 He can't stay tracking when he does this?

00:47:12.340 Correct. And he also will stir him up with dizziness and fogginess and headaches.

00:47:16.120 So we have him doing like a Russian twist where actually he's got a ball and he throws it against

00:47:20.820 the wall. So we have him really kind of train that vestibular system. We have him doing planks with

00:47:25.980 head turns. We have him doing lateral shuffles, you know, that kind of stuff. And when you have

00:47:30.840 more of a vertical plane thing, we're doing a lot of burpees, you know. We're doing a lot of

00:47:35.240 different things like that where it's more linear or vertical rather than horizontal movements.

00:47:40.180 This system will break down in distinct ways. And given he's a race car driver, that vestibular

00:47:46.740 ocular reflex, when he's looking side to side, like that affects his racing. That's his moneymaker.

00:47:52.480 He's better at that than I am. That's why he's such a good racer. That injury affected the very

00:47:57.380 system that makes him who he is. But we can retrain that by giving the reaction. So what this looks

00:48:03.020 like, he goes home, does the vestibular exercises morning, night, does our workout program night.

00:48:10.040 I want a regulated sleep schedule, gets up same time, goes to bed same time, no napping.

00:48:14.500 I want him to do exposures to busy environments, grocery stores, restaurants, parties, whatever.

00:48:20.620 I want him doing a lot of external activities. I don't want him internal. I don't want him

00:48:24.740 like thinking about his symptoms. I don't want him ruminating because the nervous system is so fired

00:48:31.020 up. Downtime makes us all worse. So we're going to challenge him. There's three different types

00:48:36.140 of exposures I want him to do every day in terms of busy environments and exercise and different

00:48:40.620 ocular things. It's a very detailed program that's all written down and they go home and do it. And

00:48:47.040 I don't want to talk to him for a month. And then he'll come back and see me. Sometimes we do

00:48:50.940 telemedicine a month later, but this guy's coming back to see me because he's pretty sick.

00:48:54.820 We have medications that can help sometimes with this. Depends on what the problem is,

00:48:58.340 but there's meds. I'm not going to do that. I don't ever try to do meds initially. We want to

00:49:02.400 see if we can treat this behaviorally and then we'll do meds.

00:49:04.220 What are some of the meds that might be kicked in? I mean, are there meds that help with sleep,

00:49:08.200 for example, like trazodone or? I don't like trazodone too much because the sleep is coming

00:49:13.220 from the nervous system problem. So you're treating a secondary problem by putting them on trazodone.

00:49:18.420 Sometimes it's an SSRI. Sometimes it's a tricyclic. Sometimes it's, you know, so there's different

00:49:23.540 meds that we'll use for that. There's certain SSRIs that are a little more effective than

00:49:27.960 others in treating the nervous system profile. I don't like SSRIs. Which ones are? Sertraline is

00:49:33.880 a medication that can actually affect not only the vestibular system, but the nervous system as

00:49:38.520 well. So we've had decent outcomes with that, but sometimes you need a Wellbutrin. Sometimes you

00:49:43.220 need an Effexor. Sometimes you need Lexapro or Escatella or Pram or whatever. There's different

00:49:47.080 meds that will help with these problems. And we have a psychiatrist here that's phenomenal.

00:49:53.240 And is this one of those things where it's just kind of empirical and you have a hunch as to

00:49:57.320 what you're going to do, but if in a month it's not better, you sort of abort regardless of what

00:50:00.860 the data say? We follow these patients very carefully and I will see them every three to

00:50:06.480 four weeks until they're normal, whether it be via telemedicine. And they need those follow-up

00:50:11.660 appointments because they can get off the rails with this stuff. Some people aren't as compliant

00:50:15.300 as they should be. Sometimes they hit walls with migraine or anxiety or different problems. But

00:50:21.140 at the end of the day, Peter, and I'm not just blowing sunshine, we can get the great majority

00:50:26.800 of these patients better. It just needs to be done in a very targeted and diligent way. But

00:50:31.920 I don't want this to come off as whatever, but there's not a patient I don't believe I can treat.

00:50:36.480 I mean, I really truly believe you come to me with concussion, I'm going to get you better from this.

00:50:41.760 I really do feel-

00:50:42.580 How many of the male patients come in with hypogonadism as a result of this? So

00:50:48.240 something shuts off and they're pituitary and all of a sudden they're just not making

00:50:51.740 testosterone anymore, for example.

00:50:53.580 There's so many downstream things that can happen from a rampant sympathetic nervous system.

00:50:59.500 It affects every bodily organ we have. It affects the gut, it affects hormonal influences,

00:51:06.420 it affects everything we function as, as temperature regulation, migraine. There's so many different

00:51:12.260 things it affects. There's a lot of downstream problems that we can see from this. I haven't

00:51:17.560 looked at that topic. Would we find something, perhaps?

00:51:21.040 I just would wonder how the HPA axis functions after, especially in cases like this gentleman,

00:51:26.280 where there's such a chronic insult. I can't help but imagine if both centrally and peripherally

00:51:33.680 there's some manifestation of this. And to your point, you wouldn't want to just get into a game

00:51:38.280 of whack-a-mole where you're just treating all of those things. You'd want to put all your

00:51:41.880 effort, of course, into like, what's the central problem here? How are we going to address the

00:51:45.460 root cause? Yeah, thank you for that. Because yeah, if you treat the root cause, those secondary

00:51:50.020 downstream problems don't occur. And that's why seeing these patients early can really lead to

00:51:55.900 better outcomes and we don't see those problems happen in the first place. I want to ask you about

00:52:00.160 a couple of other things that I get asked about a lot for which I have no answer. One of them is

00:52:05.180 the use of hyperbaric oxygen. Have you guys studied this?

00:52:08.840 Yeah, and I'm not a believer in it. And it's not something that's going to reverse the problems

00:52:13.740 we see with this injury. And quite honestly, I don't want patients doing superfluous treatments

00:52:19.560 that aren't well-founded empirically because it leads them into this sort of anxiety sort of model

00:52:25.160 where they're just feeding into the problems. And we see that a lot with this injury. And I don't

00:52:30.180 blame them because no one's getting them better. So they're trying all kinds of different

00:52:33.660 things. But no, I will not have patients do hyperbaric treatment with this injury because

00:52:37.300 it just leads to more searching and seeking that's not targeted. And we see patients that

00:52:42.660 want to do hyperbarics. But there's no data that has compelled me to tell you that hyperbarics would

00:52:48.300 have any effect positively or negatively on outcomes from this injury. Yeah. And the one thing I

00:52:55.060 always discuss with my patients, they're usually asking me in a different context, which is,

00:53:00.160 hey, does hyperbaric chamber improve longevity? And they always point to this very poorly done

00:53:05.240 study in Israel that supposedly showed that telomeres got longer in a hyperbaric chamber. Although I have

00:53:10.720 to break it to them that telomere elongation has nothing to do with longevity. But the point I always

00:53:15.700 make to them is the one of opportunity cost. So we're here in Austin. There's a hyperbaric chamber

00:53:22.040 in town. So if you want to go and do hyperbaric work, you got to go drive 30 minutes to get there.

00:53:27.300 You're going to spend an hour in the chamber at two atmospheres, and then you're going to drive back.

00:53:32.180 So you just put two hours a day into this for four or five days a week. And so the question is,

00:53:38.640 even if you're completely cost agnostic, are you truly time agnostic? What could you have done with

00:53:44.720 that time vis-a-vis improving your health? And in the case of longevity, I mean, if you spent half that

00:53:50.900 time exercising, you're going to get 10x the value. And I suspect in the case of your patients,

00:53:56.680 the same is true, right? If you're asking for 90 minutes to two hours of their time in total

00:54:01.100 to do the brisk walk and this vigorous exercise, well, that's more time than they would put into

00:54:05.700 a chamber. And of course, the data, it sounds like that the chamber isn't efficacious. Is that true?

00:54:11.260 Another question I get asked is, if you could get into a hyperbaric chamber the day of the injury,

00:54:16.380 would that move the needle? Has that been studied?

00:54:18.820 No, because it's hard to study that. But to my knowledge, no, there's no compelling data

00:54:25.280 in any way, shape, or form that shows hyperbaric treatments to be effective at treating this

00:54:29.260 problem. And I think you just stated things very well, Peter. I agree entirely with how you just

00:54:34.800 sort of conceptualize that. To add to it, what do you do when you're in a hyperbaric chamber? Well,

00:54:40.480 you think about crap a lot.

00:54:41.760 You ruminate.

00:54:42.460 Yeah. And we don't want rumination with this. It doesn't go well.

00:54:45.060 Another treatment option that I've had an interest in is the use of synthetic ketones,

00:54:52.300 specifically acetoacetate or beta-hydroxybutyrate, being in the system if one could do that prior to

00:54:59.660 an injury. So again, this assumes only in certain cases you would do it. It wouldn't help you against

00:55:05.260 the car accident because you don't know when you're going to have the car accident. But

00:55:07.940 if football players were drinking, had synthetic ketones in their system such that they had one

00:55:13.340 to two millimole of BHB coursing through their system at the time of an injury, there's at least

00:55:19.220 a very strong theoretical argument, and there's some animal data to suggest that could ameliorate

00:55:24.500 some of these symptoms. Because of course, you immediately have a solution to that energy,

00:55:28.640 that short-term energy crisis, in that you don't have to rely on glucose. You get 70% of that

00:55:32.840 injury from ketone. Have you looked at any of those data?

00:55:36.440 No. We're not doing animal model work here, nor are we doing that sort of research. To my knowledge,

00:55:42.220 that has not been done. I think theoretically it's interesting. This injury is such a hot focus on it.

00:55:49.400 I'd be interested to look at that specifically in the literature, but I'm not aware of any research,

00:55:53.180 but it makes sense.

00:55:54.060 To study that rigorously, you'd want to have a pool of presumably athletes where the frequency

00:56:01.680 of concussion is high enough that you could basically study. Is it safe to say like, I don't

00:56:05.420 know, high school or collegiate football players would have the highest incidence of concussion?

00:56:11.440 Yeah. Football leads the way, but women's soccer is very high as well. Women's basketball is high,

00:56:17.380 but yeah, football is the most. Actually, the sport that carries the highest risk of concussion in

00:56:22.800 terms of lifetime incidence, what do you think that sport is?

00:56:26.560 I mean, I would have to guess boxing.

00:56:28.700 90% of equestrians have concussions over the course of their equestrian sports.

00:56:33.320 I love that I'm now 0 for 3. We got to keep this quiz up. Tell me why. Are they falling or is it the

00:56:39.200 bouncing?

00:56:39.740 No, it's not the bouncing. It's the falling. And the horse is a very large beast. You fall from a high

00:56:45.060 degree, but given that the goal of boxing is to render your opponent concussed, I would expect that

00:56:51.840 probably is even higher than equestrian sports, but the research just hasn't been really good there

00:56:56.040 because a lot of patients don't report the problems that occur. Obviously, boxing is a very common

00:57:01.360 sport where this happens. So this is a very common injury. I don't know if you realize, Peter, but

00:57:07.040 1.8 to 3.6 million concussions per year alone in sports and recreation in this country per year.

00:57:15.060 It's crazy. It's very common.

00:57:17.840 What is the natural history of this if untreated? Let's start with what percentage of patients

00:57:25.060 that sustain a concussion, and let's just take all comers, so we're not going to differentiate

00:57:29.480 how they got their concussion, whether it's in a car or on a horse or whatever.

00:57:33.320 What percentage will end up like the gentleman you saw today where this thing ain't getting better

00:57:40.080 until he sees a specialist? Is that like 5% of people, 25% of people?

00:57:44.760 I wish I knew. No one's done that kind of work.

00:57:47.900 We don't know the denominator, basically.

00:57:49.660 We don't. If you walked a day in my shoes, you'd think it was very common because they're

00:57:54.680 common.

00:57:55.400 You have a huge selection bias, obviously, of the sickest people.

00:57:58.480 Huge selection bias. So basically, I really do feel like a lot of kids will be fine after

00:58:03.580 concussion, meaning that they probably work out of it and they're fine. I don't know about you,

00:58:08.880 but I've had moments in my life where I remember playing sports and getting hit and feeling

00:58:13.280 foggy and dizzy. I didn't have any problems from that that I'm aware of. So this happens,

00:58:18.920 I think, fairly commonly, and kids are fine. But certain risk factors, certain personality

00:58:24.640 types, certain biomechanics, it's a confluence of factors that end up with these patients ending

00:58:32.040 up down this pathway where they can really get in trouble with it. And I don't think it's

00:58:36.780 that all that infrequent. It does happen.

00:58:39.800 Mickey, do we know anything about the effect of concussion on subsequent risk of brain disease?

00:58:49.460 So one of the things we talk about a lot on this podcast, of course, is dementia,

00:58:53.200 both Alzheimer's dementia and, of course, all other types of dementia, everything from Lewy

00:58:57.540 body to small vessel, et cetera. Do we have any insight into a relationship between those?

00:59:05.140 Two people who are identical in every way in terms of predisposition and whatnot and

00:59:09.920 other factors. One person sustains multiple concussions in their life, the other does not.

00:59:15.720 Do we know if that has any bearing on risk?

00:59:17.400 There's been some pretty good research done on that. A lot of work done out of Mass General in

00:59:22.300 Boston. Grant Iverson's written really well on this topic. And the studies that have come out from him

00:59:29.620 and his group, and I respect that group, we can see some relative increases in anxiety in some of

00:59:36.300 those patients. But overall, the studies have been pretty good about showing this. We're not seeing any

00:59:43.960 proclivity towards dementia with these patients or proclivity towards Lewy body or proclivity towards

00:59:49.760 other neurodegenerative illnesses.

00:59:52.060 Now, it depends on what research you're looking at. As you know, the research world is highly variable. And,

00:59:59.660 you know, you look at other camps that would support that people that have repetitive head injuries will

01:00:05.100 end up with chronic traumatic encephalopathy. And, but you talk about selection bias. I mean, they're studying

01:00:10.900 patients who are donating their brains because they have problems. And so we have a study going on right now

01:00:18.620 here at UPMC. I think it's one of the best controlled studies done in the area where we

01:00:25.120 have a number of former NFL players, very large sample size coming to us. And we're doing a three

01:00:31.920 day evaluation. We're doing a full neuropsych battery. We're doing really fancy imaging with

01:00:38.440 them. We're doing lumbar punctures. We're looking at CSF. We're looking at different biomarkers.

01:00:44.760 We're looking at sleep study. We're doing a full deep dive on their neurological health. I mean,

01:00:51.880 like the deepest dive you could do. And then importantly, we're matching them to controls

01:00:57.200 that haven't had the exposures. And we're doing a very well-controlled study looking at the

01:01:02.760 prevalence of neurodegenerative issues in patients that have had repetitive head injury versus patients

01:01:08.060 that have not. And we're year two and a half into that study right now. And we're just about to dive

01:01:14.760 into our first statistical analysis looking at all this information. So this is one of the better

01:01:19.740 controlled studies out there right now. And there are other groups doing similar work.

01:01:24.100 So we're going to have very good scientific answers on this question. And then relatively near future,

01:01:30.040 in the next several years, you'll see studies come out from these different groups. And that's why we do

01:01:35.780 research. You don't want to get your research in the New York Times. That's for sure. You want to do

01:01:40.580 well-controlled empirical work, which we're doing. And I think we're going to have a very good

01:01:46.780 understanding of this issue and more clarity to it in the relatively near future.

01:01:51.460 Is it, and I know that CTE is not your area of expertise, but is it your intuition that CTE

01:01:57.320 is the result of untreated concussions that accumulate repeated injuries? Speaking of the New York

01:02:04.620 Times as my source of information, my vague recollection of this was the idea that CTE was

01:02:10.880 not so much the result of major concussions, but basically constant accumulated, you know,

01:02:17.960 sub-concussive injuries. But again, I could be totally misremembering that.

01:02:21.760 No, I think you're remembering it right. Now, whether that's scientifically accurate or not,

01:02:25.640 it's a different story. And I don't know the answer to that. And that's why we're doing the research.

01:02:31.040 But the science hasn't evolved to have a definitive statement on these issues, in my opinion.

01:02:37.620 And what I know anecdotally is I see patients who are absolutely convinced they have CTE that get

01:02:45.580 better with our treatments and don't have problems after we treat them. And there's nothing worse than

01:02:50.360 patients that think they have some debilitating, life-threatening disease where there's no possibility

01:02:56.480 for help. It doesn't go well in those patients. When in fact, a lot of the problems that we see,

01:03:03.060 there are treatments. And a lot of patients aren't aware of that. And it's very sad to see that happen.

01:03:07.840 And we see that a lot.

01:03:09.480 That's kind of an amazing thought. I never really imagined that. But it's certainly possible that

01:03:14.240 there are going to be a lot of people who either played sports professionally or at a very high level

01:03:19.260 who could easily think that they're in the stages of CTE. And maybe they're not. Maybe this is

01:03:25.440 a concussion that hasn't been appropriately treated.

01:03:28.380 I'll even take that a step further. We see patients that are suicidal from this. And it's very scary

01:03:36.480 where this will take you. Because remember, we're talking about patients that have biologically derived

01:03:41.900 sympathetic nervous system arousal and high anxiety, and they feel horrible. They're not working.

01:03:47.980 They're not exercising. They're not regularly with their sleep. They're not social.

01:03:51.820 They're ruminating all day long. I mean, the suicide risk in that population is very, very high.

01:03:59.020 And so you wonder where this leads to. And some of the suicidality that we see in patients,

01:04:06.920 like what percentage of those patients didn't have those problems, but they believe they did.

01:04:11.960 And that's a function of, again, when I talked about earlier about how when you have an increased

01:04:18.620 awareness with no solution, it can really lead to a lot of hysteria. And unfortunately,

01:04:23.460 we can see that. And it's very devastatingly sad to see that in some of our patients. And

01:04:28.880 I think we need responsible science to lead us to better answers to really understand this.

01:04:35.100 And I understand the need to talk about this stuff in the media. And you said it earlier,

01:04:40.620 we see so many patients because of that awareness. And that's a good thing. I mean,

01:04:45.580 it's really leading to a lot of people getting help that wouldn't have received help.

01:04:48.920 But on the flip side, it can be very dangerous as well.

01:04:52.340 There's going to be a lot of people listening to this, Mickey, who are parents. Their athletic

01:04:55.800 heyday might be behind them. They're not taking the high risk activities. Their risk of concussion,

01:05:00.060 we'll talk about later because that's going to be the car accident, the fall. Literally,

01:05:03.960 I know somebody the other day that was bending down to pick something up under a table. And when

01:05:07.560 they came up, they had that enormous posterior whack of the head, sustained a concussion there.

01:05:13.920 In thinking about their kids who are playing sports, whether it's soccer, football, you name it,

01:05:18.940 what is the best advice you offer to those parents? So they're saying,

01:05:22.420 I think little Billy or little Susie has a concussion just based on the symptoms. We just took

01:05:28.380 off the field right away. Do we need to come out and see you in Pittsburgh? How many other centers

01:05:33.800 of excellence are there in the country where we could go and get this level of bespoke treatment?

01:05:40.460 That's a hard question to answer, Peter, but it's a great question. And yes, there are centers around

01:05:45.280 the country that do a really good job with this injury. And you want to start at places that have

01:05:50.380 experience and they call themselves concussion clinics or specialty clinics. I think they're much

01:05:55.700 more equipped to do the work than a general pediatrician. I mean, you might want to start

01:05:59.580 with your pediatrician. If you have specialist clinics in your area, you want to start there

01:06:04.020 because they're familiar with the literature and the tools and by and large are very well equipped to

01:06:08.760 manage these injuries. Approximately how many of these are there? Does every major medical center

01:06:13.320 have one now? Isn't that crazy? We were the first program literally in the world doing clinical

01:06:18.200 work or studying this injury. And now I would say that every major geographic area has a center

01:06:24.500 like this now, which is really exciting. It's crazy, isn't it? Blows my mind to talk about that.

01:06:29.960 It's only 20 years later, you know? So yes, this does exist in most places. If you're in rural

01:06:36.240 Idaho or something, you may not have access to it. But you know, now that telemedicine is a medium

01:06:41.240 that's widely used, I mean, you have that option available a lot of times, et cetera. So

01:06:44.980 the access is better than it ever has been with that.

01:06:48.860 Just off the top of your head, kind of top five programs in the country that you would say would be

01:06:52.640 great places for people to start if they're willing to travel and there's availability.

01:06:56.600 Obviously your program, what would be the other five that you would put on that list?

01:06:59.060 Another program I have an incredible amount of respect for is Inova in Washington, D.C. One of

01:07:03.000 my former fellows is there. We've had 33 fellows train under us, under me, and they're at various

01:07:09.380 sites around the country. I think most of them do a really, really good job. I would say off the top

01:07:14.720 of my head, I think Boston Children's does a pretty good job overall. I know there's clinics down in

01:07:20.960 Houston, Texas that do a good job. There's clinics in Phoenix that do a really good job. There's

01:07:25.060 clinics in California that do a good job. I mean, one of my fellows is in North Dakota right now

01:07:29.820 doing great work. They're out there. You can even go to our website and kind of find out who we train

01:07:34.140 and where those patients are. There's access to places, but there's really good programs out there

01:07:37.900 I have great respect for. And we're actually collaborating with a lot of these programs and

01:07:42.460 doing research as well, which is a good thing.

01:07:44.900 And would your advice, Mickey, to that parent be, so let's just say the child experiences a

01:07:50.760 concussion on Monday afternoon. Is your advice to them, you know what, why don't you just kind of

01:07:56.140 keep the kid doing his thing, her thing, and if in two weeks it's not better, go see the specialty

01:08:01.700 clinic? Or is your advice, no, go to the clinic right away on Tuesday?

01:08:05.500 I agree with that. Because again, based upon our research, the earlier we see someone, the quicker

01:08:10.620 they get better. And you do want to start these treatments pretty quickly. And I would say if you

01:08:15.860 can be seen within seven days of an... You know, the first thing you got to do, Peter, is make sure

01:08:19.400 there's not an intracranial bleed, right? I mean, like...

01:08:21.580 Yeah, you have to do the medical thing.

01:08:22.720 You got to make sure there's, you know, the red flags aren't there, et cetera, and rule that out.

01:08:26.060 But once that's ruled out, I do think seeking specialty care within a week of injury is going to lead

01:08:32.460 to a much quicker outcome, which is what we're looking for.

01:08:35.820 So basically, it's never too early and it's never too late to seek help for this is what I'm hearing.

01:08:39.920 I agree with that. Yes.

01:08:41.420 Does all of that apply as we now move from the kid to the parent? So if it's me and I'm out there

01:08:47.820 playing with my kids and they somehow talk me into climbing a tree, which they often do,

01:08:52.040 but I fall, whack my noggin, same thing. Let's say I go to the ER, we get the CT scan, I don't have a

01:08:58.380 bleed, there's nothing going on. Let's say I feel totally fine. I'm like, I got a bump on my head,

01:09:03.700 but I feel fine and I medically cleared. Should I go and get evaluated or only if I have a symptom?

01:09:09.000 Yeah. If you feel fine, I wouldn't necessarily feel that's necessary. No. But again, the symptoms

01:09:13.680 can be subtle. You know, we talked about. That's my point is like without someone in the ER who's

01:09:18.480 going to do the real oculomotor test or whatever, I can speak to the symptoms, but I can't speak to

01:09:24.700 the signs on my own. Correct? Yeah. And it's even hard to speak to the symptoms. Dizziness, fogginess,

01:09:31.040 fatigue, light sensitivity, noise sensitivity, headache, obviously difficulties following or staying

01:09:36.140 asleep, nausea, car sickness, difficulty in busy environments, cognitive issues, you know, all

01:09:42.860 those things can, but as long, if you're not having any of those problems and no, live your life, man,

01:09:47.740 it's, it's okay. You know, but it can be subtle. That's for sure. But it's not going to bite you,

01:09:53.780 Peter. You know what I mean? It's not like, I don't want to, if your symptoms are pretty nasty and

01:09:57.960 they're not getting better. Yeah. You better see someone you want to get in. The sooner you get in,

01:10:01.380 the better it's going to be. If the symptoms are very subtle and improving, I'm not that worried

01:10:05.820 about it, honestly. You just don't want another head injury while that's going on. And so that

01:10:10.520 may be a reason if you're a weekend warrior, you got to pick up a basketball game you want to play

01:10:13.960 in the next weekend. You probably want to get it checked out to make sure everything's normal.

01:10:17.700 If you're not a weekend warrior, you're not going to hit your head again and it's getting better.

01:10:20.940 I'm not so sure you need to see someone. Do you know anything about the role of the APOE4

01:10:28.420 genotype in terms of susceptibility to concussion or any traumatic brain injury?

01:10:34.320 So apolipoprotein has been looked at with this injury and there is no compelling data to suggest

01:10:40.860 that would put you at greater risk. It's not augmentative concussion plus APOE4 allele leads to

01:10:47.600 X, Y, or Z. So no, I wouldn't say there's any hard data suggesting that to be a big risk factor,

01:10:54.860 although it's an interesting one to look at. And I don't think the research is definitive nor is

01:11:00.800 it comprehensive in looking at that, but no, nothing to date has been. I raised that issue in

01:11:06.020 the JAMA paper we published in 1999. That's the same place I went when I wrote that paper. It's like

01:11:11.220 people need to explore that relationship. Nothing has been found to be definitive there, no.

01:11:16.960 And I guess the last thing I want to just chat about it is a little bit more of an understanding of

01:11:20.360 what you said about the older folks. So we talk a lot about this on our podcast, right? Which is once

01:11:25.320 you hit about the age of 65, your mortality from falling becomes really high. It's actually

01:11:31.680 surprising when you look at the population adjusted mortality associated with falls, accidental falls.

01:11:37.940 And we talk about it mostly through the lens of, hey, here's all cause mortality that in the first

01:11:43.920 year post a fall that results in a fracture of the hip or femur. One of the things that's happening in

01:11:49.080 the aging person, of course, is their brain is shrinking a little bit and their skull is not.

01:11:53.260 So presumably that's making them more susceptible. They're going to have more movement to the brain

01:11:57.380 within the head. Is that why we're seeing a greater susceptibility in an aging population? In addition

01:12:01.400 to the fact that they're obviously more susceptible to a fall? I don't know. It's a great theory,

01:12:05.240 but yeah, I mean, obviously we see atrophy in that population, et cetera. And the other thing is,

01:12:10.260 there's a lot of unprotected falls in that population. There's a lot of syncopal events in that

01:12:13.740 population. And there's a lot less motor control when you do fall. The biomechanics are going to be

01:12:19.860 more violent in that population. And also cerebral spinal fluid is not as robust in that population.

01:12:24.820 So you don't have as much protection of the brain moving inside the skull either. So there's a lot

01:12:29.620 of reasons for it, but oh my goodness, is that an understudied area? And boy, is it a huge problem

01:12:35.240 that we see day in, day out in our clinic. I have a definite passion of working with older people that

01:12:40.760 have this injury. And we're doing some of the first research looking at concussion and geriatric

01:12:46.500 population. And it's a very rewarding population to work with because you can treat it. It's so

01:12:51.320 exciting to see someone. I just saw a 90 year old this morning, Peter, that fell and they want to get

01:12:57.600 better so bad. They have so much energy. How long ago did this person fall? About eight weeks and

01:13:02.740 they're not well. Tell me about the fall. If I remember right, they had a syncopal episode where they

01:13:08.600 hadn't hydrated well, maybe a little stress going on in their life, dysregulated blood flow,

01:13:14.760 you know, dysautonomic stuff. They get up from going to the bathroom, collapse, hit their head on

01:13:20.420 the linoleum floor. Fall forward off the toilet? Correct. Face first, basically. Facial fracture,

01:13:26.340 small subdural, bad concussion. Fortunately, no intracranial intervention. The blood from the

01:13:34.440 subdural reabsorbed, but they're left with this pretty bad concussion. Very, very dizzy in bed.

01:13:40.600 Very, very dizzy in life. Don't like busy environments. Feel fatigued all the time. Bad

01:13:46.580 headaches they've never had before. A lot of anxiety that they're not even aware of. And of course,

01:13:51.560 they were living alone at the time. And now family members are around. They have to get support from

01:13:57.340 them and they get enabled and they get really protective. They think they're going to fall

01:14:03.200 again so they don't move as quickly. And of course, the vestibular problem doesn't get treated because

01:14:08.200 they're not moving. They're not doing anything. They're not exercising. They're not going to busy

01:14:11.660 environments. And so the anxiety levels are up. They have benign positional vertigo that no one ever

01:14:16.840 noticed. That's why they're getting really dizzy in bed. We can fix that. But we get them in the right

01:14:22.140 physical therapy, the right vestibular therapy, the right approach. We get family members on board and

01:14:26.180 tell them how to approach things and get them more active and challenge them more and make sure the

01:14:31.540 parents aren't protecting them as much as they, you know, overprotecting them and explaining how

01:14:36.040 you treat this problem. And oh my God, they do really well. It's amazing. It's very, very rewarding

01:14:41.120 to treat a patient like that. And we'll get that person better and they'll be, they'll look great

01:14:46.620 here in another few weeks, hopefully. This person will be doing how much exercise as a part of their

01:14:52.460 rehabilitation program. Walking for now, you know, they're not a fall risk. We looked at them,

01:14:56.920 see our vestibular therapists, they're not a fall risk, which is good. So we gave them some

01:15:01.360 balance exercise to work on. We gave them some vestibular exercise to work on, tell them to go

01:15:06.260 to grocery stores, don't hold onto the buggy, you know, walking up and down the aisles, challenging

01:15:10.880 themselves, going out to busy restaurants, going back to church, you know, explaining to family

01:15:15.800 members how to approach all that stuff. It's really cool to see this stuff wash off the patient

01:15:20.500 when in fact they are helpless. They don't think they're ever going to get better. They think

01:15:23.820 their life's over, like literally. And they think it's beginning of the end, you know?

01:15:27.700 Yeah. Beginning of the end, for sure. Tell me, your research is mostly funded through NIH?

01:15:33.100 Oh, we got funding from a lot of different places, but we do have NIH funding. We have funding from

01:15:37.240 the NFL. We've got funding from Centers for Disease Control. There's a really cool foundation here in

01:15:43.640 Pittsburgh called the Chuck Knoll Foundation for the former coach Chuck Knoll. I talked a little bit

01:15:48.680 about baseline testing. Chuck Knoll was, the Steelers were the first team to ever do baseline

01:15:53.080 testing. And Chuck Knoll was a huge proponent of treating head injury the right way. And Joe Maroon

01:15:58.420 had a lot to do with that. But anyways, the Chuck Knoll Foundation gives out grants for researching

01:16:03.080 head injury. And we've received a lot of funding from that and many other grant sources. It's pretty

01:16:08.600 cool. It's a pretty hot topic. And so there's a lot of monies available to study this, which is exciting.

01:16:14.460 I assume you mentioned this, but I assume you have neurologists in your group now as well?

01:16:17.500 We have a few, but neurologists do a phenomenal job with this injury, okay? But you're not trained

01:16:22.660 about concussion in medical school. It's not in the curriculum. Just because you're a neurologist

01:16:27.260 doesn't mean you know concussion. Just because you're a neurosurgeon doesn't mean you know

01:16:31.200 concussion. This is new science, new information, and that's why it's really important to see a

01:16:36.680 specialist. Just don't assume that you go to one of these people that are going to know this injury

01:16:40.960 because most of the time they don't. How many fellowship programs are there in the U.S. now for

01:16:45.300 training concussion specialists? So, I mean, what I'm hearing from you is you have a neurologist that

01:16:51.260 would have to then specialize in concussion. You have a psychiatrist. You have vestibular

01:16:56.080 therapist or ocular therapist. I mean, everybody basically has to be under a concussion training

01:17:00.900 umbrella. How many places are there besides UPMC?

01:17:03.500 I would say conservatively 15 to 20 fellowship, you know, maybe 10 to 15 fellowship programs.

01:17:11.480 That's off the top of my head that would do training specific to this topic. So, it's not

01:17:16.660 that many, but they do exist. Well, Mickey, this has been really interesting. I know you've got a

01:17:22.520 busy day in clinic, so we were lucky to get time with you today, but I want you to get back to those

01:17:27.100 patients. I cannot believe the volume of patients you see. That is staggering. It probably also speaks to

01:17:32.320 how amazing your team is, and it's sort of like you've got that almost the executive physical

01:17:37.320 situation where people can come in for two days and they can see every doctor in the medical center.

01:17:43.000 It sounds like it's that fine-tuned. I came away from this discussion actually far more optimistic.

01:17:48.680 I don't think I had nearly an appreciation for how positive the prognosis was even in those patients

01:17:56.880 with long-standing concussion with the right therapy. I thought it was the exception and not

01:18:01.960 the rule that one could get better if you were two years out and still suffering.

01:18:06.260 No, Peter, it's been great. I've really enjoyed it actually. You do a phenomenal job with what you do,

01:18:12.040 and you have an interesting job. You get to hear a lot of different people talk about a lot of

01:18:15.420 different things, and I think you conceptualized this very well, and I really appreciate your time.

01:18:20.280 It was a lot of fun.

01:18:21.220 Thanks, Mickey. Do you want to ask me one more question just to see if I can go 0 for 5?

01:18:24.540 Do you have any other trivia for me, or we'll just leave it at 0 for 4?

01:18:27.240 We'll stick with the 0 for here, yeah. I set you up on all those though, Peter. I did.

01:18:31.680 No, it's good. It keeps me humble. All right. Thanks, Mickey.

01:18:34.440 Take care. Thank you.

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The Peter Attia Drive - July 24, 2023

#263 ‒ Concussions and head trauma： symptoms, treatment, and recovery ｜ Micky Collins, Ph.D.

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