The Peter Attia Drive - #263 ‒ Concussions and head trauma: symptoms, treatment, and recovery | Micky Collins, Ph.D.

Episode Date: July 24, 2023

View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter Michael “Micky” Collins is an internationally renowned expert in sports-related concussions and a consultant for multiple professional sports organizations. In this episode, Mickey first explains the definition and diagnosis of a concussion, as well as the diverse signs and symptoms associated with different types of concussions. He discusses the risk factors that contribute to increased susceptibility and/or severity of concussions in certain individuals, emphasizes the significance of prompt treatment, and uses case studies to illustrate the latest in treatment protocols and recovery process. Additionally, Mickey provides insight into the evolving field of concussion treatments, including the exploration of hyperbaric oxygen and synthetic ketones. He gives advice to parents of kids who play sports and discusses the promising prospects in the realm of concussion management. We discuss: Micky’s interest in concussion and how he started the first concussion clinic [3:15]; Concussion: definition, pathophysiology, and risk factors making someone more susceptible [9:45]; Symptoms of concussion, predictors of severity, and the importance of early and effective treatment [20:00]; The six types of concussion, the effectiveness of treatment, and factors that impact recovery [25:45]; The importance of seeing a specialist and the prognosis for recovery [30:00]; Case study of a racecar driver who suffered a vestibular concussion [32:15]; Why vestibular concussions are particularly problematic [42:45]; A treatment plan for the racecar driver, possible use of medications, and how to address the root cause [45:45]; Exploring alternative treatments: hyperbaric oxygen, synthetic ketones, and more [52:00]; The natural history of a concussion if untreated and the effect, if any, of concussion on subsequent risk of brain disease [57:15]; Chronic traumatic encephalopathy (CTE) [1:01:45]; Advice for parents of kids who play sports: when and where to seek treatment for a possible concussion [1:04:45]; Is there any evidence that the APOE4 genotype increases susceptibility to concussion or TBI? [1:10:15]; The increased risk of concussions in older adults and a case study of a 90-year-old patient who suffered a head injury in a fall [1:11:15]; Funding for concussion research and fellowship programs to train concussion specialists [1:15:30]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

Hey everyone, welcome to the Drive Podcast. I'm your host, Peter Atia. This podcast, my website, and my weekly newsletter, I'll focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, full stop, and we've assembled a great team of analysts to make this happen. If you enjoy this podcast, we've created a membership program that brings you far more in-depth content if you want to take your knowledge of this space to the next level. At the end of this episode, I'll explain

what those benefits are, or if you want to learn more now, head over to peteratia MD dot com forward slash subscribe. Now without further delay, here's today's episode. My guess this week is Dr. Michael Collins, an internationally renowned expert in sports-related concussions. Mickey, as he goes by, is the clinical and executive director of the University of Pittsburgh Medical Center Sports Medicine Concussion Program, the largest research and clinical program focused on the assessment, treatment, rehabilitation, research, and education of sports related

mild traumatic brain injuries in athletes of all levels. Mickey has published more than 150 peer-reviewed research articles and was also the co-lead author of the CDC's Concussion Toolkit for Physicians, an Education Standard for Concussion Management. He is also co-founder of Impact, the immediate post-concussion assessment and cognitive testing, the most widely used computerized sports concussion evaluation system that has become the standard of care in organized sports.

He has been instrumental in the development of numerous concussion management programs for youth, collegiate and professional sports leagues in teams. Mickey is currently a consultant for several athletic organizations, including the Pittsburgh Steelers and the Pittsburgh Penguins. I won't hold either of those against him. In this episode, we focus the entire conversation around head trauma and concussions. This includes the definition and diagnosis of a concussion includes the definition and diagnosis of a concussion, the signs and symptoms of concussion, and the various types of concussions. We speak about the risk factors that can cause someone to be more susceptible to concussions or can cause more severe concussions in certain individuals. We speak about the importance of quick treatment and

recovery from concussions and what to do as part of that recovery, whether the concussion is in a child or an adult, including in the elderly population. Lastly, we speak about what we know and don't know about hyperbaric oxygen specifically and synthetic ketones as treatments for concussion. Overall, this was a really interesting episode to me. A lot of times I come into podcasts already having a pretty 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 so excited to do this. It came away from this far more optimistic and upbeat about the prognosis for people with

concussions. And in the short time since we recorded this episode, I've already sent several people to Mickey who have been suffering. I now believe needlessly for so long post-concussive. So without further delay, please enjoy my conversation with Dr. Mickey Collins. I know you're particularly busy today, so I really appreciate it.

This is a conversation I've wanted to have for quite a while. It's a topic that comes up over and over again in my life personally and even professionally, whether it be patients or children of patients, things like that. And that's basically that of head trauma. And particularly, you know, what happens when someone has a concussion, what are their options? I think before we get to that, I'd kind of like to give folks a bit of a sense of your background.

How did you come to do this? It's a really interesting question and it's kind of a long-winded response, but I went to college and didn't really know what I wanted to do in life. I had a bunch of family members that were physicians and in the medical field. I also went to college to play baseball as much as I did to be a student. And I was playing baseball my junior year and my coach came up to me and said, Mickey, if you don't declare a major today, you're going to be a student. And I was playing baseball my junior year and my coach came up to me and said, Mickey, if you don't declare a major today, you're going to be an eligible. So I was like, okay, and I was taking a neuroscience course at that time, like a biosecology course and it kind

of hit my buttons when they needed to be hit. And I was very intrigued by it. So I just kind of dove in and studying biology and psychology and really the neurosciences and graduated college went to graduate school and knew I wanted to do brain behavior studies and I got involved in a program at Michigan State University. I got my PhD from there and studied in clinical psychology with emphasis in neurocyclineical neuropsychology, which is a study of brain behavior. It took some of the medical classes there through Michigan State, but also did psychology, clinical psych, and neuroscience courses, and combined that into my PhD.

And maybe two or three years into studying that at Michigan State, I said to myself, I really miss sports. And I wanted somehow wanted to combine traumatic brain injury and sports into something. And no one had really done that before, really. I mean, there wasn't, there was no concussion specialty when I went to school, period. Sorry, just to make sure I understand that, Mickey, you're meaning that even a patient

that has a concussion in a sport, if they saw a neurologist, that neurologist wouldn't really have any particular insight on it. This field did not exist in 1998 or 99, 97 when I was in school. The field simply did not exist. Honestly, when I arrived here at UPMC in 2000,

I really didn't know how I was going to make a living doing this. I didn't know if I was going to be able to see this. I didn't know if I was going to be able to see patients. I didn't, no one would care my research. There was very little traction in anyone studying this topic, like literally nobody. We had the first clinic in the world here at UPMC. I came here in 2000 and we started the clinic. But long story short, back when I was getting into this, I wanted to study concussion or malchementary brain injury and I somehow want to involve sports.

And right now, if you think back, I mean, that sounds kind of intuitive. It's a hot topic now. At the time, no one could care about it. But that was around the time that Troy Ackman and Steve Young and Paul Carria, remember that name, Ricky Craven, race car driver, and others started to talk about this topic of concussion. And I remember watching Al Michaels on Monday Night Football, talking about Steve Young's concussion in 1997, in 1996, whenever it was.

And he basically said, no one knows anything about this injury, this topic. This is just a lot of speculation, but no one really understands about the injury. This topic is just a lot of speculation, but no one really understands about the injury. And I said to myself at that moment, not to be too dramatic here, but I said to myself at that moment, that's what I can do.

Because it was a perfect sort of marriage of brain trauma and sports, which is what I want to do for a living. And long story short, I ended up having a mentor, got a Mark Lovell and a guy named Joe Maroon, as a neurosurgeon. They were my mentors. And I was at Henry Ford Hospital in Detroit at the time doing my fellowship.

And Mark Lovell came into me and said, hey, Mickey, do you want to move to Pittsburgh? And I'm like, not really. But why? And he said, well, they're starting in big orthopedic sports medicine center there. They want us to do a concussion program there. And I'm like, you know, let's go check it out.

So we came here to Pittsburgh and long story short, I came here with my mentor, Mark Lovell, and Joe Maroon is here, he's a neurosurgeon, and the three of us started this program in 2000. And that was at a time when, I mean, we had no patients. No one could care about concussion literally. We started researching it slowly, but surely we published many papers on it, published a big paper in JAMA in 1999 actually. I was a lead author on that paper where we looked

at college football on concussion. And it was at Michigan State University and we did some baseline testing with guys. Always tell the story. It's kind of a funny story. I wanted to do research on college football players and I was like, okay, we're going to baseline test these guys if they have a concussion, repeat the testing, to see what we can find. And I naively thought I'm just going to go to the medical staff of Michigan State and say, hey, I want to work with your football team. I did do that, but they said, well, we're interested, but you have to meet with a head coach to get approval. So I went into the head coach's office and that coach was Nick Sabin.

And that was the first coach I ever broached this to. And he said, you know what? I think that's a great idea. And we researched the Michigan State. We then started working at University of Florida. We worked at University of Utah. Ironically, Candid Pittsburgh had worked with them. All that data we collected, we published.

And that was published in JAMA in 1999, which was one of the first groundbreaking studies of looking at concussion in sports. And that ended up getting us here to Pittsburgh. And then we started growing this program in Pittsburgh. And the first five years, I swear, I worked in a cubicle. And I would see maybe two or three patients a week if that. And I was doing research, et cetera. And now fast forward, 23 years later, we have 20,000 patient visits a year to our program. We've published over 450, 500 papers. We've written books. We've given talks around the world

and it's probably the hottest topic in sports medicine. So it's been quite a ride, and I'd like to think that we've learned a hell of a lot about this injury over that 23 years. And hopefully we can share some of that wisdom today. That's an awesome overview. And I think it speaks to an interesting and familiar sort of path in medicine. A lot of times people, what looks completely unappealing and uninteresting, becomes the most remarkable direction to pursue. I mean, whether it's immunotherapy and cancer that the 80s look like a total no-man's land, a graveyard for research is now clearly the most promising therapeutic

in oncology. So let's get to some of the semantics. I mean, I think everybody's heard the word concussion, but what actually is it? What is the diagnosis? How subjective versus objective is it? What are the criteria? So the word concusses literally translates from Latin to English to mean to shake violently. And if you think about your brain as like an egg yolk inside a neck shell, the brain is

inside this hard cavity. And if you have acceleration, deceleration, or translational forces that are hard enough, the brain is going to shift inside the skull. And that shifting of the skull is actually what causes concussion. When the brain moves inside the skull, the membrane to the neuron will stretch. And when that membrane stretches, this little chemical called potassium, which is supposed to be inside the neuron, will leak into the extracellular space. And when that does, there's an increase in the man for glucose or energy that occurs

due to the release of potassium. At the same time, does it influx the calcium? So calcium leaks across that same stretch membrane, goes into the cell, and when calcium goes into the cell, we get vasoconstriction and decrease cerebral blood flow. So at the very time, the brain's demanding more energy due to the hypergicolicis, we get an influx of calcium, vasoconstriction, and decrease cerebral blood flowing, decrease energy supply. And so what concussion is a mismatch between demand and supply of energy to the cell.

Now, this is not enough to cause cell death, wallarion degeneration. There's no structural changes to the neuron. There's no death of the neuron, but the cell struggle to operate at their normal efficiency. And we've now learned that when that energy problem happens, different systems in the brain can be decompensated. And that decomposition of certain systems, we've now learned there's different types of concussions. There's actually six different types of problems we see following concussion. And those different types of concussions help to determine how we treat the problem. So as a clinician, my job is to find out where the aberrant signal is coming from and what

system is decompensated, and then we have to apply the right treatment to the right problem. None of anything I just told you, we knew in 2000, none of it. And so we've now really learned a lot about how this injury occurs. We understand the path of physiology fairly well, not completely well as animal model work that's been looked at with that. More importantly, we now clinically know how to evaluate the syndrome in a way where we can kind of figure out what's happening and then apply a more targeted treatment to its treatment.

Now, one thing is, Peter, is that we don't have a biomarker right now for the syndrome. There's no blood test. That's ready for prime time. There's no serum marker. There's no blood test. That's ready for prime time. There's no serum marker. There's no imaging. This is not seen on MRI. It's not seen on PET scan. It's not seen on functional MRI. It's not seen on MRI. It's not seen on Meg. It's not seen on EEG. There's no imaging studies right now that definitively help us with this diagnosis. Even CSF, fluid, if you could access it? No, and we're doing that.

But no, all those things are looked at, very smart people are looking into those things and researching it, but I do not have a biomarker to measure this injury. It's at the cellular level, it's an energy crisis, there's no structural changes in the brain that we see following concussion, and everyone is like searching for that biomarker, but right now we just don't have it. And I don't see that happening in the foreseeable future. I mean, there's a lot of good work being done on it.

There might be a panel of biomarkers that we look at, you know, and there's discussion of certain markers may help us, but no, at this point in time, there's nothing I would tell you that's ready for prime time. Just to go back to the beginning of this, so make sure I understand this. You have this movement of the brain relative to its protection in the skull, the membrane of the neuron stretches. So presumably, you have a passive effusion of potassium out of the neuron as a result

of that is the demand for glycolysis so that you can actively pump potassium back in against an unfavorable gradient. Correct. Okay, so that's why you need glucose, more ATP, force potassium back into where it doesn't want to go. And then tell me about the calcium. Why is the calcium, is the calcium just following a gradient across the stretch membrane at that moment? I don't know if we have an answer to that, but yes, that's my understanding of it.

When that calcium goes into the cell, we get a vasoconstriction decrease for a blood flow, and this is very clearly an energy crisis, or what we call metabolic mismatch that occurs to the cell. The important thing at this point is we don't feel the cells die from this. They're just operating at a different level of efficiency. And what we literally see happen with this is different

systems in the brain that require a lot of energy, don't work as efficiently, and they will literally decompensate from that energy problem. And that's given us some good understanding of how to kind of approach this injury actually. We can get into the different problems we see from concussion, but yeah, it's basically these systems that aren't working as efficiently as they should. How global versus focal is this type of injury? So if you have two athletes, and by the way, I think we're going to talk a lot about athletes, but the reality is you can get into a car accident and have the same injury. This happens a lot more in non-athletes than it does athletes.

But we use sports as a laboratory. It's a great feature just to study this injury. This happens a lot more in non-athletes and it does athletes. But, you know, we use sports as a laboratory. It's a great feature just to study this injury. But this applies to slip and fall, car accident, all kinds of older people fall. And boy, that's a real problem that no one's really addressing. So keep going, I'm sorry. So let's just say we took two individuals

who at the macro level appear to have a very similar insult. Yep. Is this process occurring across the entire spectrum of neurons, or could two people say, no, no, actually this is occurring far more in the temporal lobe in you, and it's occurring more in the frontal lobe in you. And clearly there's going to be a clinical diagnosis that's going to be required to differentiate it.

But again, just at the pathophysiologic level, what's the diffused city of this? It's an interesting question. I wouldn't look at this as more like this affects the hippocampus or this affects the prefrontal gyros or whatever. I wouldn't look at it that way. I'd look at this as it more affects systems in the brain and pathways in the brain. And so there's really no known like you get hit in the head here, you have this symptom. That's antiquated in terms of how we think about this. It's more systematically looking at how the brain's functioning. Now, with that said, interestingly, we do see that posterior, when people hit the back of their head,

you see a very kind of specific presentation of problems from that that I can get into later. But there's really no, like you hit your head this way, you have this problem. Rather, Peter, and this is important. Concussion fights dirty. Like whatever you bring to the table, that's weak, seems to be affected more, more generally in patients.

In other words, there's pre-existing risk factors to have a worse outcome from this injury that will probably be quite surprising to hear for people. Those risk factors not only put you at more risk for less force causing concussion, but they tell you what kind of concussion you're likely to have risk for less force causing concussion, but they tell you what kind of concussion you're likely to have if you do have a concussion. For example, we talked about different types of concussions.

If you have a history of car sickness in your past, we've published a lot of data showing that those patients are more likely to get concussed and have a vestibular problem following concussion. If you have a history of lazy. Sorry, just to make sure I understand that they're more likely to get concussed and have a vestibular problem following concussion. If you have a History Lazy, sorry, just to make sure I understand that they're more likely to get concussed or if they get concussed, they're more likely to have vestibular symptoms. Is it both? Both.

Correct. Less force will cause injury in those patients. Patients that have issued a migraine, less force causes injury and you're going to go down that migraine pathway. If you have a History Lazy I or Strabismus, you're going to go down that migraine pathway. If you have a history of lazy, irstrabismus, you're going to go down the ocular pathway, and yes, less force causes injury. If you have a history of anxiety,

you're going to go down that pathway more ubiquitously. So there's almost a neuronal reserve thing here. We talk about cognitive reserve and movement reserve when we think about Alzheimer's disease and Parkinson's disease respectively. You're now talking about a concussive reserve. I think so. I don't know if I'd use those terms and I'm familiar with that terminology and it's been around for a long, long time and I guess it sort of applies to this.

So research around UCLA catacoin that phrase, cognitive reserve. But generally speaking, we can get in the weeds on that, but I would, yeah, I mean, you're more vulnerable with these different risk factors and you're more likely to get out of different pathways. And girls are more likely to have concussions in boys. Next strength plays a role with that. hormonal influences can play a role with that. And we've also know that girls are six times more likely to have migraine and have car sickness in boys. And so they're more at risk for these problems. 60% of the patients that come through are a clinic or female, 40% are male.

The reason why is because they're a more vulnerable population and we see a lot longer outcomes in females and we do males because of some of those factors. How long is the susceptibility to a subsequent concussion, higher following a concussion? So I'm sure everybody who's watched football highlights has noticed, I think it was a quarterback for the dolphins last year,

just had a series of devastating concussions and you couldn't help but think was the subsequent concussion really a result of not being better from the first one. How long is that vulnerability present? Yeah, not talking about that case specifically, but generally speaking, there is a definite vulnerability when you're recovering from an initial

injury in that less force will cause more serious outcome. If you're still recovering from the first event, do you ever get back to baseline? Yes, absolutely. I firmly believe, and we've published a lot of papers on this, that concussion is a treatable injury. I firmly believe that if you manage the injury effectively and treat it fully, we don't see repetitive chronic cumulative problems. I firmly believe that the best way

to prevent problems from concussion is to manage and effectively when you have one. And we are very good now at determining recovery what that looks like and how we, that looks in our examination, how that looks with the testing that we do and the data points that we use. I am a big proponent of kids playing sports. I'm a big proponent of really managing a syndrome, getting kids back to the sports

they love because it's a very healthy thing for them to be doing. And we haven't found problems down the road in patients that are managed effectively. Now, the key here, though, Peter, is to manage it effectively when you have one. And you don't want to stack these things up. And people that do can get in trouble with it. And this is becoming a very specialist kind of thing to see.

You want to go to someone that knows what they're doing to manage this injury effectively when you have one. You want to make sure you're getting the right assessment done, the right tools. There's definite morbidity when this isn't managed properly, for sure. Let's go back to the person, the athlete, the non-athlete, whatever, who has the injuries. We've already established, we have no biomarker. This person gets their bell run, be it in a car accident or on the football field, and it's a clinical

diagnosis. So tell me if you're at the sidelines or if you're in the clinic when the person shows up the next day, what are they typically complaining of and what are you doing to make that diagnosis? So there's approximately 21 different symptoms on the field that you can see following concussion. And it depends on what type of concussion you have. There are signs and there are symptoms of injury. Signs are what you will outwardly observe.

Symptoms are what the patient reports. Signs of concussion include loss of consciousness. It includes confusion. It includes balance issues. Includes vomiting. Those are all signs of injury. Symptoms of injury are dizziness, fogginess, or feeling detached, feeling one step behind, light-sensitive, noise-sensitive, nauseous,

fatigued, blurred vision, double vision, fuzzy vision, headache. Headache, of course. Yeah, thank you for that one. Another post-traumatic amnesia, retrogrid amnesia, loss of memory before the injury, loss of memory before the injury, loss of memory after the injury. We've done a lot of research looking at these different signs and symptoms and their relative ability to predict outcomes. I'll give you 20 bucks, Pete, if you tell me,

the on field symptom that best predicts a longer recovery from concussion. I mean, I would have guessed loss of consciousness, but that seems too obvious. Yeah, that would be obvious, and it's incorrect, actually. On field dizziness is six times more predictive than any other symptom of predicting a longer out from concussion. Wow. The second symptom that best predicts outcome is fogginess, kind of feeling one step behind, detached, removed. Dizziness is six times more likely to cause a longer being a month or longer recovery than

is losing consciousness. Wow. Yeah, right? You know, what's interesting about that is this, the symptoms of injury way better predict poor outcome than the signs of injury. And the reason for that is because if you lose consciousness, it's very unlikely you're going to go back to play. You're not going to put back to play if you lose consciousness, it's very unlikely you're going to go back to play. You're not going to put back to play if you lose consciousness unless you're in some

archaic sport or in some geographical area that has been exposed to this information. So when you lose consciousness, you get taken out of play and you're not going to put back to play. That may be why these symptoms predict worse outcomes because a lot of patients tend to play through their injury. And we just published a paper and we've published a series of papers and pediatrics, jamma, and other journals. We ask the question, if patients have a head injury and they have symptoms of concussion,

what happens if we take them out of play immediately or what happens if they continue to play? And what do their outcomes look like? And so we did this very cool study. Sorry, this is not done prospectively. This is done retrospectively. Retrospectively, right? Because it's hard to do prospectively. But retrospectively, we looked at a very large database.

We had about, I think, 300 kids in the sample, 150 of them had symptoms or signs of concussion and they came out of play immediately. And then 150 of them continue to play after having those signs and symptoms, okay? The people that got taken out of play immediately, their average recovery time was 18 days. And patients who were returned to play and played for just 15 minutes, beyond the point of their injury or point of having symptoms, their average recovery time was 44 days. So just playing 15 minutes through this event,

added almost close to a month onto the recovery. How were you able to control for the severity of the initial event? Presumably there's a bias there, right? Which is that the kids who came out right away, maybe they were more in tune with something, you know, I mean, it's hard to do that without randomization, right?

We did control for a lot of factors. No group loss conscious is more than another factors. No group loss consciousness more than another group. No group head, no symptoms, except symptoms that are in another group. So we're able to just, just, we control for that. And it's such a big difference. 18 to 44 days is a big enough difference that even if it's not exactly that, there seems to be a signal somewhere in there. There is.

And then we did another paper, a follow-up paper, we looked at dose response and it's really powerful. So for every minute you try to play through your injury, you add on like seven or eight days of recovery. It's quite powerful. And so, yeah, you don't want to play through this stuff. And a lot of kids and parents may not be aware that getting dizzy on the sideline is the most powerful predictor of outcome. Or feeling foggy or feeling tired tired or blurred vision double vision. I mean I played sports my whole life as I'm sure you did Peter. I wouldn't come out of play if I had those symptoms. I probably wouldn't report it at all. We need to do

a really good job of educating parents on that but at the same token I want kids to play sport. I'm not fear mongering here. I truly believe this is an injury that's treatable and we can get kids back to the sports they love. But it just shows you the differences in outcomes when it's not managed properly initially early on. And we're getting now into all our research looking at how we treat this injury, which we're doing really well with.

And we can get kids better faster by applying certain treatments and getting them back to play sooner. Well, I definitely want to hear about that. And I think that's where most people's ears all perk up. But let's go back again to these different types. I think you mentioned that there are sort of six different types. So basically based on presentation and based on subsequent testing that you might do, you would then elucidate these six different types. Is that how it works?

Yeah, so we do an evaluation where we ask about symptoms. Obviously do a very good clinical interview. We have a physical exam that we do called the Volmes, stands for a vestibular ocular motor screening. We do impact testing. I'm familiar with the Neurocon of test. It's a computer-based Neurocon of test that has been FDA approved that allows us to quantify and look at the concussion in a more objective way, looking at their cognition. There's different neuroconvict correlates that we see with these different types of concussions, etc. But you put all this information together and yeah, and we're doing research now looking at these different phenotypes and different

problems we see from concussion. But each of these different types of concussions are going to have different symptoms, are going to have different risk factors, different therapeutic techniques to treat it, and different outcomes and different return to play sort of situations. So do you want to, I mean, I'd love to hear them. Yeah, let's hear what they are. The six different types of concussions, cognitive, we actually call it cognitive fatigue. The second is vestibular, which is not the ear. It's more of the central pathways in the brain. The vestibular system is a very significant system in the brain

that starts in the inner ear and then kind of goes the deep parts of the brain. We're talking about more centrally derived problems from the central part of the vestibular system of the brain part. The third type of concussion is ocular, which is your eyes, working together as a team. It's not your vision as much as ocular motor. The fourth type of concussion is ocular, which is your eyes, working together as a team. It's not your vision as much as ocular motor. The fourth type is migraine, which is what it sounds like, headache, with nausea, and or lighter noise sensitivity, and other symptoms as well. And then the fifth type is anxiety. The sixth subtype is neck. You can have some of these symptoms coming from the neck. Not very common, but you can. So those of the six different problems we will see from concussion. Now patients may have one of

those problems, or they may have all sex, they're not mutually exclusive. And the more you have, the more difficult it is to treat. But you are going to treat each of those problems in a distinct way and a targeted way. You know, if there's 30 different types of knee injuries, why do we think there's one type of concussion? We're starting to really be able to better identify kind of where the signal's coming from with this injury. And is there an age and or gender difference between these? Well, first of all, you may not be aware, but we've published a lot of data on this. The adolescent brain, we looked at high school kids versus college athletes, and then college

athletes versus professional athletes, the high school kids take the longest to recover from concussion. The college athletes take the second longest and the professional athletes recover more quickly than the other two. There's a lot of sort of vulnerabilities of the adolescent brain to this injury. You got to be careful of love, but there is an age relationship that we've published extensively on. What do you think that's a result of? Do you think that the younger brain has a different hormonal milieu? Do you think that it? Do you think that that's the biggest driver of that distinction? I don't know. And we're doing research

on that now. We're actually doing a really cool women's study on concussion, looking at some hormonal influences. And we've found that menstruation can change after a head injury. That was the first question that was gonna come to my mind is it would be so interesting to understand how a woman's menstrual cycle, and therefore, not just menstrual cycle, but also where is she ovulating,

where is she in the follicular and luteal phase, because the estrogen progesterone swings in those phases are enormous. Of course, it begs the question, are those hormones protective? We were just about ready to embark the first women's study on this injury. We're collaborating with McGee Hospital here at UPMC with our clinic and it's exciting work. We just got a grant to look at that.

But we have published a paper already in JAMA neurology, I believe, where we showed that the menstrual cycle does change relative to patients that don't have head injuries. So there's a lot to learn. That's a cool thing is, again, we started doing this work when knowing cared about it. Now there's too much work to be done, and everyone cares about it.

It's fascinating. What do you attribute that to, by the way? How much of that do you think is an indirect or even a direct consequence of the attention that's been brought to brain injury through the light of CTE vis-a-vis the NFL? Yes, an interesting question. I mean, clearly the spotlight in this injury is iridescent, you know, and clearly the NFL is a very powerful enterprise and there's a lot of eyes on it and there's a lot of discussion, open discussion on this topic, which is a very powerful enterprise, and there's a lot of eyes on it, and there's a lot of discussion, open discussion on this topic, which is a good thing.

In a lot of ways, it drives science, and it drives awareness. But too much awareness without a solution is called hysteria. And we see that happen with this injury. When the reality is that there's a lot of misinformation out there about concussion, and I think it actually hurts outcomes a lot of times. Clinicians that aren't aware of the recent advances in knowing how to treat this, clinicians that don't know how to do the right evaluation.

And there's a lot of mismanagement and mistreatment of this injury that leads to very poor outcomes. Again, and you're gonna hear it from me over and over again. If you bring me a patient with concussion, I can pretty much tell you I can treat that and get that patient better and get them back to the sports they love. There are highly effective treatments with this injury. Is this the sort of thing where there's a relatively finite window

in which you or the physician treating has to be able to access the patient and the further a patient is from that window, absent the natural history resolution, the more difficult that gets. Okay, so I'll answer that with data. We just did a study again, published in, I think it was in JAMA neurology as well, where we looked at what factors best predict outcomes from concussion. Migraine is a huge factor of predicting outcome, history of migraine, the certain symptoms that predict outcomes.

But we looked at all those things. The one factor that best predicted outcome was how quickly they get into our clinic. If they were seen by us within seven days, that was the best predictor of someone who got better from the injury. Because we can apply our treatments quickly. If you do wait, it's harder to treat. But I still will argue, even if you're a year out, two years out, three years out from this injury, we can treat it effectively the great majority

of the time. It's not irreversible. You can get patients better even if they've been living with it chronically. Peter, today, I mean, I saw patients all morning. I had 20 patients on my schedule before our podcast. I just saw a race car driver from Phoenix or someplace and they've been going through this for two years and miserable. We will get that patient better. They will be normal when we finish treating them. There's nothing I'm seeing

that worries me about them. If you can without giving any information that would identify this individual, can you give a bit of a sense of this as a case study? So presumably two years ago, this guy was involved in an accident. Yeah, was involved in an accident, had all the hallmark symptoms of a stibular problems. What type of accident, by the way, was this one where it was just a coup, contra coup injury where he whiplash? I mean, you know, we wear a hans in a car, which limits our recoil now in our heads, but I looked at the video on it and this isn't at the highest levels of racing.

So I'm not sure. And we do work a lot with those patients. But this is a small track event or something where the patient got somehow, got hit in a way, their car rotated and went backwards into the wall. And this video, I actually saw the video of the hit and their head hit the back of the headrest.

And there was no loss of consciousness, but the person immediately felt foggy, the slow-wavy dizzy, they had a headache, they felt fatigued, they had bilateral or blurred vision early on. But no loss of consciousness, no memory loss, no confusion. Obviously, the car was totaled, so they didn't race, but they didn't also get medically evaluated after this. They kind of went about their lives and continued to have those symptoms and went back to racing two weeks later and got it in another accident and had the same problem occur, same mechanism even. And that's when everything obviously got worse and when they saw medical attention, but they've been living with that for two years.

They've not improved. They came to me today. They're having everyday headaches that can get up to an 8 out of 10. Light sense of annoy sensitive foggy. They don't like busy environments. They don't like exercising because they get really dizzy. They get headache. They get sick to their stomach. They've got a lot of car sickness.

They have a lot of sympathetic nervous. This sounds debilitating. Oh, it's totally debilitating. This is destroys your life. It destroys your life. And this is a person who is not racing anymore. They're not working because of it. Oh, God. They have massive sympathetic nervous system arousal,

where they can't sleep at night. They're very foggy, very, very worked up. And they very much are isolated. They don't want to be around other people because that triggers of a similar problems and so they become more reclusive. They find themselves exercising minimally. They're socially very inactive.

They're not preoccupied with their mind. So there's a lot, their thoughts are going so fast because the nervous system is racing. So they're in their head all day long. My grains, that's what I just saw this morning, Peter, and I do it all day long. This is an injury that causes so many problems in patients. So notwithstanding the fact that this poor guy has been needlessly suffering, you know, for a couple of years, tell me in broad strokes, what are you going to do to help this person?

And what's a time course that you would give him for a reasonable expectation of recovery? Okay, so we saw the patients today and we have a very good evaluation we do. And the cool thing is we're very used to seeing out of town patients here. A lot of my patients run a town. So they have five appointments in one day. I'm the point guard of it, but we also have a vestibular therapist here. We have what's called exertion therapy here. We have a psychiatrist here. We have a behavioral optometrist that we can use. We have neck people we can use. So it's all under one roof.

So people have appointments scheduled throughout the day. They come to see me. I did the evaluation. I kind of find out what was going on. But what we're able to identify in our evaluation today is the patient has a significant vestibular problem that has not been treated. And the vestibular system,

what's not working well, is going to cause a lot of dizziness, it's going to cause a lot of fogginess, it's going to cause environmental sensitivity, busy environments will bother them, they don't want to exercise because movement bothers them. The vestibular system is responsible for interpreting motion. And when that

system doesn't work, remember this injury decopensates that system that signal comes through aberantly and it will trigger all these really icky symptoms. It's like a bad car sickness that they feel. Now, the vestibular system, the same pathways in the brain that control that system, mediate or sympathetic nervous system. And so the patients will also have massive sympathetic nervous system arousal, fight or flight.

So thoughts go fast or heart rate increases. They get a lot of cortisol, a lot of problems going on from the nervous system arousal, fight or flight. So thoughts go fast, or heart rate increases, they get a lot of cortisol, a lot of problems going on from the nervous system. And that's all triggered by the head injury. And so they're living in this fight or flight situation. And then when patients go into certain environments where they feel crappy, it not only triggers the vestibular problem, but it triggers

that fight or flight response, and patients will then in a very Pavlovian way Avoid those environments and then they don't want to work They don't want to exercise and what do you think happens? It triggers migraine because patients that have a massive sympathetic nervous system arousal they get headaches people get migraines when they're stressed and people get migraines when they don't sleep Consistently and people get migraines when they don't exercise consistently. That's why people get migraines. And so what started off is one problem with a vestibular problem becomes an anxiety problem or sympathetic nervous system problem. And then it becomes a migraine problem. And then migraine actually feeds back through the

vestibular pathways and the ocular pathways. So you can also have a lot of problems from that secondarily to the migraine. Does that all make sense to you? It absolutely does and it's uncanny in how much it reminds me of an injury that someone very close to me had which was riding a bike down the side of the road, 25 miles an hour, 40k, so really at a good clip and a runner jetted out between two cars, you know, it was probably listening for cars, but didn't think about a bike, and there was a head-to-head collision.

So cyclist head into runner's head, I knew the cyclist, not the runner, they both were devastated by this injury. The runner took the brunt of it at a complete fracture of the face, but the cyclist was for two years, couldn't be in a room with the TV on. Any noise that the kids made was, would make this person very irritable.

It's very similar to what you're describing. That's because it's similar, Peter, because that's the pathway these patients go down. And it's very predictable how they get on this. It's not only Pavlovian meaning their condition to go on this pathway, but it's all biological. It really triggers these things in a very robust way, and it's a very, very, very... These people describe it, because I've now spoken with a couple of patients that have gone through this, they describe it in as stark terms as someone would the most severe mental illness, which is to say, I'm not myself anymore.

So whoever I used to be, that person is gone. I am this new person that has nothing in common with the old one, and it's all in the wrong direction. What percentage of people of all comers and concussions? How many are this severe? The patients that come see me from out of town, almost all of them, because they haven't been treated. And now some come to me and they're actually feeling pretty well, they just want to know if they can go back to sports after having ex-motic concussions. And some of those patients aren't sick like that. But I have on my schedule

every week, I have something like, I'll see upwards of 70 to 100 patients a week with this injury. I've got on my schedule slots for probably 12 to 16 out of town patients a week. Probably 80% of those patients are sick as what we're describing here. So it's not fun for these patients to go through. What will be the next step for this gentleman that we're talking about? So we can treat all of that, but it's completely antithetical to how you think we treat it. So what's the one word, Peter Peter that comes to mind when you think about

what should I do when I have a concussion? What's that word? Rest. You're exactly right and you're absolutely wrong in how we approach this injury. I'm old for two Mickey keys. No, I set you up there. But if you look at the literature over the years, it's like, oh, you have a brain injury. It's an energy problem. You need to rest that patient. That makes all of this worse when you take that tact. Because the way we treat a vestibular problem is by retraining it. It's not rest. The way we treat anxieties by increasing parasympathetic nervous system around them, which is exercise.

It's regulated sleep. The way we treat a vestibular problem is by retraining it. So I want them in busy environments. I want them exercising. We got to get them on a good sleep schedule. We got to treat the vestibular problem with very targeted physical therapy. We have exercises that treat that.

We actually have what's called exertion therapy here. If you come see me with a concussion, I don't care how sick you are. I am working you out. And I'm doing me with a concussion, I don't care how sick you are. I am working you out, and I'm doing it aggressively a lot of times. We take a very active, very targeted, very exposure-based model to treating this problem. But you need to see a specialist in how to do that because you can do it the wrong way and make patients worse. It's got to be very targeted in how you approach this with patients and every patient's different

and it's breaking down in different ways. There's different types of vestibular problems. There's different types of ocular motor problems. There's different types of personality characteristics, et cetera, that you have to account for when you're treating this injury. But at the end of the day, if you match the right treatment to the right problem,

you can get better from this and that's what we do all day long here is treat those problems. What I find interesting is that, be it two years ago in the case of this gentleman, that injury took place. So you have the energy crisis takes place. The vasoconstriction takes place. The mismatch of supply and demand takes place. Is it likely the case that if you could biopsy his brain today, or let's give him more creative, you could put yourself onto a nanoparticle spaceship and enter his brain today, everything looks totally normal at the cellular level? Yes. Or do you think that it's still microscopically apparent?

I don't know the answer to that. I wish I did. But my suspicion based on everything I've learned know the answer that I wish I did, but my suspicion, based on everything I've learned about the pathophysiology, this is that we should see a normal brain structurally and anatomically and even physiologically. That's just what happens when this injury happens as to what systems are affected,

and then you can kind of go down these pathways if it's not treated appropriately, and that's what ends up happening. It seems that of those six phenotypes you described, this vestibular one is very problematic because it seems to amplify the other ones. But again, am I interpreting that correct? Yeah, you kind of are. We actually have done research on that. If you looked at the most common types of concussion, we published a study on this as well. The most common problem we see after concussion is post-traumatic headache in migraine. That's the number one profile that we see. Oh, no, I'm sorry, I apologize, let me retract that. The number one profile that we see is anxiety and then migraine and then vestibular and then ocular and then fatigue, cognitive fatigue.

So we actually have done work on that. So anxiety is ubiquitous across this injury and that is what is the most common clinical profile that we'll see is that nervous system issue. It's interesting though because you also said if I recall that no symptom predicts a worse outcome more than dizziness and And that, of course, makes me think, well, dizziness is so tied to vestibular. And I agree with that. There is something about this vestibular problem that, by the way, would also amplify anxiety. You know, we do research and we look at the numbers and you publish that. My gut is the

vestibular stuff carries the day with this injury, the great majority of the time, or at least it kicks it off, Peter. A lot of times I'll see patients that. Right. It's a vicious cycle that spins out of control from that. Exactly. I would agree with that. I'm not going to overgeneralize to every human being because there really is, it's a very different presentation of a lot of different people.

Like I'll see people that come in here that have an ocular motor problem that no one's identified and have no vestibular issues, they have no migraine, they're completely normal except they can't focus when they look at their math homework and they get headaches in the front of their head and they're tired. That's an ocular motor problem that we can fix pretty easily. And that's just a PT program? Yeah, we have to retrain the ocular system

and we have exercises that can do that very effectively. And so we see those patients, but yeah, the vestibular stuff is ubiquitous, and we have exercises that can do that very effectively. And so we see those patients, but yeah, the vestibular stuff is ubiquitous. But there's patients I see where the vestibular problems clearly kicked us off, but that's not present anymore. It's all migraine and anxiety, but it came from that beginning, if that makes sense.

And it sounds like your friend there that got that horrific bike accident. That sounds terrible, by the way. Like it sounds like your friend there that got that horrific bike accident. That sounds terrible, by the way. Like it sounds like he's gone down that profile. The vestibular stuff. Yeah, and here's what's amazing. After two, two and a half, three years maybe, he just kinda got better.

That's good. Maybe part of it is that he did double down on exercise, nutrition and sleep. That's it. He started getting the right information from someone, but that patient, Peter, if you sent him to me a month after this entry, I would have had him better. You to save them within how many months?

How many months is he better? If I had seen him the first week after the injury, now listen, I don't know the case. Was there a subject? Sure, sure, sure, but in general. But in general, we could have gotten a better and definitely weeks, not months. Wow. So this gentleman today that you saw,

he's going to go back to Phoenix or wherever he's from. Yeah. After he's had this amazing e-vail, what's his homework assignment, meaning what, or the actual types of PTs and activities he's going to do and when do you see him again? So I'll see him back in four weeks. They'll come back and see me.

And he has been given a very detailed set of vestibular exercises to complete every morning and evening. He has been given an exercise program. We pretty much kicked him around the gym a little bit and got him moving. When this vestibular system breaks down, you have to move in certain ways to treat it.

And we're very good at doing that. We're in sports medicine, so we know how to move people. And we've given them very specific workout that will train that vestibular system. And while we're doing that, we're also increasing the parasympathetic nervous system by doing exercise. So it's killing two birds if that makes sense. And exercise also treats migraines. So that's three birds were killing by doing the exercise stuff.

He'll do that workout program every day. How long will that be? How many minutes a day will he spend exercising? I'm going to have him walk in the morning for 45 minutes and he does that very rigorous workout in the afternoon and it takes about 45 minutes to an hour. And he's to do that every day until I see him back. Wow. Can you give me an example of some of the exercises he'll do in the afternoon? For this patient, he had a horizontal vestibular ocular reflex problem. So this is your vestibular ocular reflex and when he moves his head side to side,

he can't stay tracking. And he does this. And he also will stir him up with dizziness and fogginess and headaches. So we have him doing like a Russian twist where actually he's got a ball and he throws it against the wall. So we have him really kind of trained

that vestibular system. We have him doing planks with head turns. We have him doing ladder shuffles, you know, that kind of stuff and when you have it more of a vertical plane thing We're doing a lot of burpees, you know We're doing a lot of different things like that where it's more linear or vertical rather than horizontal movements this system will break down in distinct ways. And given he's a race car driver, that vestibular ocular reflex

when he's looking side to side like that affects his racing. That's his money maker. He's better at that than I am. That's why he's such a good racer. That injury affected the very system that makes him who he is. But we can retrain that by giving the reaction. So what this looks like, he goes home,

does the vestibular exercises, morning, night, does our workout program, night. I want a regulated sleep schedule, gets up same time, goes to bed same time, no napping. I want him to do exposures to busy environments, grocery stores, restaurants, parties, whatever. I want him doing a lot of external activities. I don't want him internal. I don't want him like thinking about his symptoms. I don't want him doing a lot of external activities. I don't want him internal. I don't want him like thinking about his symptoms. I don't want him Ruminating because the nervous system is so fired up Down time makes us all worse. So we're gonna challenge him

There's three different types of exposures. I want him to do every day in terms of busy environments and exercise and different Ocular things It's a very detailed program that's all written down and they go home and do it, and I don't want to talk to them for a month. And then he'll come back and see me. Sometimes we do telemedicine a month later, but this guy's coming back to see me because he's pretty sick.

We have medications that can help sometimes with this, depends on what the problem is, but there's meds, I'm not gonna do that. I don't ever try to do meds initially. We want to see if we can treat this behaviorally and then we'll do meds. What are some of the meds that might be kicked in? I mean, are there meds that help with sleep, for example, like trasidone or... I don't like trasidone too much because the sleep is

coming from the nervous system problem. So you're treating a secondary problem by putting them on trasidone. Sometimes it's an SSRI, sometimes it's a tricyclic, sometimes it's, you know, so there's different meds that we'll use for that. There's certain esosterozyres that are a little more effective than others in treating the nervous system profile. I don't like esosterozyres. Which ones are? Certainly is a medication that can actually affect

not only the vestibular system, but the nervous system as well. So we've had decent outcomes with that, but sometimes you need a well-buterin, sometimes you need an effectser, sometimes you need lexapro or eschatelar parameter, there's different meds that will help with these problems. And we have a psychiatrist here that's phenomenal in these models. And is this one of those things where it's just kind of empirical and you have a hunch

as to what you're going to do, but if in a month it's not better, you sort of abort regardless of what the data say. We follow these patients very carefully and I will see them every three to four weeks until they're normal, whether it be via telemedicine. And they need those follow-up appointments, because they can get off the rails with this stuff. Some people aren't as compliant as they should be. Sometimes they hit walls with migraine or anxiety

or different problems, but at the end of the day, Peter, and I'm not just blowing sunshine, we can get the great majority of these patients better. It just needs to be done in a very targeted and diligent way, but I don't want this to come off as whatever, but there's not a patient, I don't believe I can treat. I mean, I really truly believe you come to me with concussion, I'm going to get you better from this. I really do feel- How many of the male patients come in with hypogonatism as a result of this. So something shuts off in their pituitary and all of a sudden

they're just not making testosterone anymore, for example. There's so many downstream things that can happen from a rampant sympathetic nervous system. It affects every bodily organ we have, you know, it affects the gut, it affects hormonal influences, it affects everything we function as, as temperature regulation, migraine, there's so many different things that affects. There's a lot of downstream problems that we can see from this.

I haven't looked at that topic. Would we find something perhaps? I just would wonder how the HPA axis functions after, especially in cases like this gentleman where there's such a chronic insult. I can't help but imagine if both centrally and peripherally there's some manifestation of this. And to your point, like you wouldn't want to just get into a game of

a whack-a-mole where you're just treating all of those things. You'd want to put all your effort, of course, into, like, what's the central problem here? How are we going to address the root cause? Yeah, thank you for that. Because yeah, if you treat the root cause, those secondary downstream problems don't occur. And that's why seeing these patients early can really lead to better outcomes. And we don't see those problems happen in the first place.

I want to ask you about a couple of other things that I get asked about a lot for which I have no answer. One of them is the use of hyperbaric oxygen. Have you guys studied this? Yeah, and I'm not a believer in it, and it's not something that's going to reverse the problems we see with this injury, and quite honestly, I don't want patients doing superfluous treatments that aren't well-founded empirically because it leads them into this sort of anxiety, sort of a model where they're just feeding into the problems.

And we see that a lot with this injury. And I don't blame them because no one's getting them better, so they're trying all kinds of different things. But no, I will not have patients do hyperbaric treatment with this injury because it just leads to more searching and seeking that's not targeted. And we see patients that want to do hyperbarics. But there's no data that has compelled me to tell you that hyperbarics would have any effect positively or negatively on how it comes from the syndrome. Yeah. And the one thing I always discuss with my patients,

they're usually asking me in a different context, which is, hey, does hyperbaric chamber improve longevity? And they always point to this very poorly done study in Israel that supposedly showed that telomere has got longer in a hyperbaric chamber, although I have to break it to them that telomere elongation has nothing to do with longevity. But the point I always make to them is the one of opportunity cost. So we're here in Austin, there's a hyperbaric chamber in town. So if you want to go and do hyperbaric work, you got to go drive 30 minutes to get there. You're going to spend an hour in the chamber at two atmospheres, and then you're going

to drive back. So you just put two hours a day into this for four or five days a week. And so the question is, even if you're completely cost agnostic, are you truly time agnostic? What could you have done with that time vis-a-vis improving your health? And in the case of longevity, I mean, if you spent half that time exercising, you're going to get 10x the value. And I suspect, in the case of your patients, the same is true, right? If they, you're asking for 90 minutes, the two hours of their time in total to do the brisk walk in this vigorous exercise, well, that's more time than they would put into a chamber.

And of course, the data, it sounds like that the chamber isn't efficacious. Is that true? You know, another question I get asked is, if you could get into a hyperbaric chamber the day of the injury, would that move the needle? Has that been studied? No. Because it's hard to study that. But to my knowledge, no, there's no compelling data

and any way she'd performed the Shutter-Purbaric treatments to be effective at treating this problem. And I think you just stated things very well, Peter. I agree entirely with how you just sort of conceptualize that. To add to it, what do you do when you're in a hyperbaric chamber, where you think about crap a lot? You're ruminate. Yeah, and we don't want rumination with this.

It doesn't go well. Another treatment option that I've had an interest in is the use of synthetic ketones, specifically acetoacetate or beta hydroxybutyrate, being in the system if one could do that prior to an injury. So again, this assumes only in certain cases you would do it. It wouldn't help you against the car accident, because you don't know when you're going to have the car accident.

But if football players were drinking head synthetic ketones in their system, such that they had one to two millimole of BHB coursing through their system at the time of an injury, there's at least a very strong theoretical argument. And there's some animal data to suggest that could ameliorate some of these symptoms because of course you immediately have a solution to that energy that short-term energy crisis in that you don't have

to rely on glucose. You get 70% of that injury from ketone. Have you looked at any of those data? No, we're not doing animal model work here nor are we doing that sort of research to my knowledge that has not been done. I think theoretically it's interesting. This injury is such a hot focus on it. I'd be interested to look at that specifically in literature, but I'm not aware of any research, but it makes sense. To study that rigorously, you'd want to have a pool of presumably athletes where the frequency of concussion is high enough that you could basically

study. Is it safe to say like, I don't know, high school or collegiate football players would have the highest incidence of concussion? Yeah, football leads away, but women's soccer is very high as well. Women's basketball is high, but yeah, football is the most. Actually, the sport that carries the highest risk of concussion in terms of lifetime incidence, what do you think that sport is? I mean, I would have to guess boxing. 90% of equestrians have concussions over the course of their equestrian.

I love that I'm now 0 for 3. We got to keep this quiz. Tell me why. Are they falling or is it the bouncing? No, it's not the bouncing. It's the falling. And the horses are very large beasts. You know, you fall from a high degree,

but given that the goal of boxing is to render your opponent can cussed, I would expect that probably is even higher than the question in sports, but the research has been really good there because a lot of patients don't report the problems that occur. Obviously boxing is a very common sport with this happens.

So this is a very common injury. I don't know if you realize, Peter, but 1.8 to 3.6 million concussions per year alone in sports and recreation in this country per year. It's crazy. It's very common. What is the natural history of this if untreated? Let's start with what percentage of patients that sustain a concussion and

let's just take all comers. So we're not going to differentiate how they got their concussion, whether it's in a car or on a horse or whatever. What percentage will end up like the gentleman you saw today where this thing ain't getting better until he sees a specialist. Is that like 5% of people, 25% of people? I wish I knew. No one's done that kind of work. We don't know the denominator, basically. We don't.

If you walk today in my shoes, you'd think it was very common. Because there come, but. You have a huge selection bias, obviously, of a sick-like bias. So basically, I really do feel like a lot of kids won't be fine after concussion, meaning that they probably work out of it and they're fine.

I don't know about you, but I've had moments in my life where I remember playing sports and getting hit and feeling foggy and dizzy, you know, and I didn't have any problems from that that I'm aware of. So this happens, I think fairly commonly, and kids are fine, but certain risk factors, certain personality types, certain biomechanics, it's a confluence of factors that end up with these patients ending up down this pathway where they can really get in trouble with it. So, and I don't think it's that all that infrequent. It does happen. Do we know anything about the effect of concussion

on subsequent risk of brain disease? So one of the things we talk about a lot on this podcast, of course, is dementia, both Alzheimer's dementia and of course, all other types of dementia, everything from Louis body to small vessel, et cetera. Do we have any insight into a relationship between those two people who are identical in every way in terms of predisposition and whatnot and other factors. One person sustains multiple

concussions in their life. The other does not. Do we know if that has any bearing on risk? There's been some pretty good research done on that. A lot of work done out of mass general and Boston, Grand Iverson's written really well in this topic. And the studies that have come out from him and his group, and I respect that group, we can see some relative increases in anxiety in some of those patients. But overall, the studies have been pretty good about showing us we're not seeing any proclivity towards dementia with these patients or proclivity towards Louis body or proclivity towards other neurogegenerative illnesses. Now it depends on what research you're looking at is you know the research world is

highly variable and you know you look at other camps that would support that people that have repetitive head injuries will end up with chronic traumatic and cephalopathy. And but you talk about selection bias. I mean, they're studying patients who are donating their brains because they have problems. And so we have a study going on right now here at UPMC. I think it's one of the best controlled studies done in the area where we have a number of form of NFL players, very large sample size coming to us and we're doing a three-day evaluation.

We're doing a full neuropsych battery. We're doing really fancy imaging with them. We're doing lumbar punctures. We're looking at CSF. we're looking at different biomarkers, we're looking at sleep study, we're doing a full deep dive on their neurological health. I mean, like the deepest dive you could do. And then importantly, we're matching them to controls that haven't had the exposures, and we're doing a very well controlled study looking at the prevalence of neurodegenerative issues in patients that have had repetitive head injury versus patients that have not. And we're year two and a half into that study right now, and we're just about to dive into our first statistical analysis looking at all this information.

So this is one of the better controlled studies out there right now, and there are other groups doing similar work. So we're going to have very good scientific answers on this question and then relatively near future. In the next several years, you'll see studies come out from these different groups. And that's why we do research. You don't want to get your research in the New York Times, that's for sure. You want to do well-controlled empirical work, which we're doing. And I think we're going to have a very good understanding of this issue and more clarity to it and then relatively near future.

Is it, and I know that CTE is not your area of expertise, but is it your intuition that CTE is the result of untreated concussions that accumulate repeated injuries, speaking of the New York Times as my source of information, my vague recollection of this was the idea that CTE was not so much the result of major concussions, but basically constant accumulated, you know, sub-concussive injuries. But again, I could be totally misremembering that. No, I think you're remembering it right. Now, whether that's scientifically accurate and known as a different story, and I don't know the answer to that. And that's why we're doing the research.

But the science hasn't evolved to have a definitive statement on these issues, in my opinion. And what I know anecdotally is I see patients who are absolutely convinced they have CTE that get better with our treatments and don't have problems after we treat them. And there's nothing worse than patients that think they have some debilitating life-threatening disease where there's no possibility for help. It doesn't go well in those patients.

When in fact, a lot of the problems that we see, there are treatments. And a lot of patients aren't aware of that. And it's very sad to see that happen. And we see that a lot of the problems that we see, there are treatments. And a lot of patients aren't aware of that and it's very sad to see that happen and we see that a lot. That's kind of an amazing thought. I never really imagined that, but it's certainly possible that there are going to be a lot of people who either played sports professionally

or at a very high level who could easily think that they're in the stages of CTE. And maybe they're not. Maybe this is a concussion that hasn't been appropriately treated. I'll even take that a step further. We see patients that are suicidal from this. And it's very scary where this will take you. Because remember, we're talking about patients

that have biologically derived sympathetic nervous system arousal and high anxiety and they feel horrible. They're not working, they're not exercising, they're not regularly with a sleep, they're not social. They're ruminating all day long. I mean, the suicide risk in that population is very, very high. And so you wonder where this leads to and some of the suicide alley that we see in patients, like what percentage of those patients didn't have those problems, but they believe they did. And that's a function of, again, when I talked about earlier about how, when you have an

increased awareness with no solution, it can really lead to a lot of hysteria. And unfortunately, we can see that. And it's very devastatingly sad to see that in some of our patients. And I think we need responsible science to lead us to better answers to really understand this. And I understand the need to talk about the stuff in the media.

And you said it earlier, we see so many patients because of that awareness. And that's a good thing. I mean, it's really leading to a lot of people getting help that wouldn't have received help. But on the flip side, it can be very dangerous as well. There's going to be a lot of people listening to this Mickey who are parents. Their athletic heyday might be behind them.

They're not taking the high risk activities. Their risk of concussion will talk about later because that's going to be the car accident the fall. Literally, I know somebody the other day that was bending down to pick something up under a table and when they came up, they had that enormous posterior whack at the head sustained a concussion there. In thinking about their kids who are playing sports, whether it's soccer, football, you name it.

What is the best advice you offer to those parents? So they're saying, I think Little Billy or Little Suzy has a concussion just based on the symptoms. We just took them off the field right away. Do we need to come out and see you in Pittsburgh? How many other centers of excellence are there in the country where we could go and get this level of bespoke treatment? That's a hard question to answer, Peter, but it's a great question. And yes, there are centers around the country that do a really good job with this injury. And you want to start at places that have experience and they call themselves concussion clinics or specialty clinics.

I think they're much more equipped to do the work than a general pediatrician. I mean, you might want to start with your pediatrician. If you have specialist clinics in your area, you want to start there because they're familiar with the literature and the tools and and by and large, you're very well equipped to manage these injuries. Approximately how many of these are, does every major medical center have one now? Isn't that crazy? We were the first program literally in the world doing clinical work or studying this injury. And now I would say that every major geographic area has a center like this now, which is really exciting. It's crazy, isn't it?

Blows my mind to talk about that. It's only 20 years later, you know? So yes, this does exist in most places. If you're in rural Idaho or something, you may not have access to it. But, you know, now that telemedicine is a medium that's widely used. I mean, you have that option available a lot of times, etc. So the access is better than it ever has been with that Just off the top of your head kind of top five programs in the country that you would say would be great places for people to start if

They're willing to travel and there's availability obviously your program What would be the other five that you another program? I have an incredible one on our respect for is a Nova in Washington DC One of my former fellows is there we've had 33 fellows trained under us under me and they're at various sites around the country I think most of them do a really really good job. I would say off the top my head I think Boston children's does a pretty good job overall. I know this clinic's down in Houston, Texas that do a good job this clinic's in Phoenix that do a really good job this clinic's in California that do a good job, this clinic's in Phoenix, that do a really good job, this clinic's in California, that do a good job. I mean, one of my fellows is in North Dakota right now doing great work.

They're out there. You can even go to our website and kind of find out who we train and where those patients are. There's access to places. But there's really good programs out there. I have great respect for it. We're actually collaborating with a lot of these programs and doing research as well, so which is a good thing.

And would your advice, Mickey, to that parent B? So let's just say the child experiences a concussion on Monday afternoon. Is your advice to them? You know what? Why don't you just kind of keep the kid doing his thing, her thing. And if in two weeks it's not better, go see the specialty clinic. Or is your advice no? Go to the clinic right away on Tuesday.

I agree with that. Because again, based upon our research, the earlier we see someone, the quicker they get better. And you do want to start these treatments pretty quickly. And I would say if you can be seen within seven days of an, you know, the first thing you had to do, Peter, is make sure there's not an intracranial bleed, right? I mean, you think, yeah, you have to do the medical thing. You have to make sure this, you sure that the red flags aren't there,

et cetera, and rule that out. But once that's ruled out, I do think seeking specialty care within a week of injury is gonna lead to a much quicker outcome, which is what we're looking for. So basically, it's never too early and it's never too late to seek help for this. I agree with that, yes.

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 playing with my kids and they somehow talk me into climbing a tree, which they often do, 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 bleed, there's nothing going on. Let's say I feel totally fine. I'm like, I got a bump on my head, but I feel fine and I and I medically cleared should I go and get evaluated or only if I have a symptom?

If you feel fine, I wouldn't necessarily feel that's necessary. No, but again the symptoms can be subtle You know what we talked about that's my point is like without someone in the ER who's gonna do the real Oculomotor test or whatever I can speak to the symptoms But I can't speak to the signs on my own correct? Yeah, and it's, I can speak to the symptoms, but I can't speak to the signs on my own, correct? Yeah, and it's even hard to speak to the symptoms. Dizziness, fogginess, fatigue, light-sensitive, noise-sensitivity, headache, obviously. Difficulties falling or staying asleep, nausea, car sickness, difficulty in busy environments, cognitive issues, you know, all those things can...

But as long, if you don't have any of those things can, but as long if you're not having any of those problems and no, live your life, man, it's okay, you know, but it can be subtle. That's for sure. But it's not going to bite you, Peter. You know what I mean? It's not like, I don't want to, if your symptoms are pretty nasty and they're not getting better, yeah, you better see someone you want to get in the sooner you get in the better it's going to be. It's a symptoms are very subtle and improving. I'm not that worried about it honestly. You just don't want another head injury while that's going on. And so that may be a reason if you're a weekend warrior, you've got to pick up a basketball game you want to play in the next weekend. You probably want to get a

checked out to make sure everything's normal. If you're not a weekend warrior, you're not going to hit your head again and it's getting better. I'm not that's so sure you need to see someone. and it's getting better, I'm not that so sure you need to see someone. Do you know anything about the role of the APOE4 genotype in terms of susceptibility to concussion or any traumatic brain injury? So, APOLED lipoprotein has been looked at with this injury and there is no compelling data to suggest that would put you at greater risk. It's not augmentive data, this is just that would put you at greater risk. It's not augmentive concussion plus apoi4 allele leads to x, y or z. So no, I wouldn't say there's any hard data suggesting that to be a big risk factor. Although it's an interesting one to look at. And I don't think the research is definitive nor is it comprehensive in looking at that, but no, nothing to date

has been. I raised that issue in the JAMA paper we published in 1999. It's the same place I went when I wrote that paper. It's like people need to explore that relationship. Nothing has been found to be definitive there, no. And I guess the last thing I want to just chat about it is a little bit more of an understanding of what you said about the older folks. So we talk a lot about this on our podcast, right, which is once you hit about the age of 65, your mortality from falling becomes really high.

It's actually surprising when you look at the population adjusted mortality associated with falls, accidental falls. And we talk about it mostly through the lens of, hey, here's all caused mortality that in the first year post of fall, that results in a fracture of the hip or femur. One of the things that's happening in the aging person,

of course, is their brain is shrinking a little bit and their skull is not. So presumably that's making them more susceptible, they're gonna have more movement of the brain within the head, is that why we're seeing a greater susceptibility in an aging population in addition to the fact that they're obviously more susceptible to a fall.

I don't know. It's a great theory. But yeah, we obviously we see atrophy in that population, et cetera. And the other thing is there's a lot of unprotected falls in that population. There's a lot of sinkable events in that population. And there's a lot less motor control when you do fall. The biomechanics are going to be more violent in that population. And also cerebral spinal fluid is not as robust in that population.

So you don't have as much protection of the brain moving inside the skull either. So there's a lot of reasons for it. But oh my goodness, is that an understudied area? And boy, is it a huge problem that we see day and day out in our clinic? I have a definite passion of working with older people that have this injury. And we're doing some of the first research looking at concussion and geriatric population. And it's a very rewarding population to work with because you can treat it. It's so exciting to see someone. I just saw a 90 year old this morning, Peter, that fell and they want to get better so bad.

They have so much energy and how long ago did this person fall about eight weeks and they're not well. Tell me about the fall. If I remember right, they had a sink up a episode where they hadn't hydrated well, maybe a little stress going on in their life, dysregulated blood flow, you know, dysonomic stuff.

They get up from going to the bathroom, collapse, hit their head on the linoleum floor. Fall forward off the toilet. Correct. Face first, basically. Facial fracture, small subduro, bad concussion. Fortunately, no intracranial intervention, the blood from the subduro reabsorbed, but they're left with this pretty bad concussion.

Very, very dizzy in bed, very, very dizzy in life. Don't like busy environments, feel fatigue all the time, bad headaches they've never had before. A lot of anxiety that they're not even aware of. And of course, they're living alone at the time. And now family members are around. They have to get support from them, and they get enabled, and they get really protective. They think they're going to fall again, so they don't move as quickly. And of course, the fistibular problem doesn't get treated because they're not moving.

They're not doing anything, they're not exercising, they're not going to busy environments. And so the anxiety levels are up. They have benign positional vertigo that no one ever noticed. That's why they get really dizzy and bad. We can fix that. What we get them in the right physical therapy,

the right fistibular therapy, the right approach, we get family members on board and tell them how to approach things and get them more active and challenge them more and make sure the parents aren't protecting them as much as, you know, overprotecting them and explaining how you treat this problem. And oh my God, they do really well.

It's amazing. It's very, very rewarding to treat a patient like that and we'll get that person better and they'll be, they'll look great here in the few weeks, hopefully. This person will be doing how much exercise as a part of their rehabilitation program. Walking for now, you know, they're not a fall risk.

We looked at MCR of a similar therapist and not a fall risk, which is good. So we gave them some balance exercise to work on. We'll give them some vestibular exercise to work on. Tell them to go to grocery stores. Don't hold onto the buggy, you know, walking up and down the aisles, challenging themselves, going out to busy restaurants,

going back to church, you know, explaining to family members how to approach all that stuff. It's really cool to see this stuff wash off the patient. When in fact, they are helpless. They don't think they're ever gonna get better. They think their life's over like literally. And they think it's beginning of the end, when in fact they are helpless. They don't think they're ever gonna get better. They think their life's over, like literally. And they think it's beginning of the end, you know? Yeah, beginning of the end, for sure.

Tell me, your research is mostly funded through NIH? Oh, we got funding from a lot of different places, but we do have NIH funding. We have funding from the NFL. We've got funding from Centers for Disease Control. There's a really cool foundation here in Pittsburgh called the Chuck Nol Foundation for the former coach Chuck Noel. I talked a little bit about baseline testing. Chuck Noel was the Steelers of the first team to ever do

baseline testing and Chuck Noel was a huge proponent of treating head injury the right way and Joe Maroon had a lot to do with that. But anyways the Chuck Noel Foundation gives out grants for researching head injury and we've received a lot of funding from that. And many other grant sources, it's pretty cool. It's a pretty hot topic. And so there's a lot of money's available to study this, which is exciting.

As you mentioned this, but I assume you have neurologists in your group now as well. We have a few, but neurologists do a phenomenal job with this injury, okay? But you're not trained about concussion in medical school. That's not in the curriculum. Just because your neurologist doesn't mean you know concussion. Just because you're a neurosurgeon doesn't mean you know concussion. This is new science, new information, and that's why it's really important to see a specialist. Just don't assume

that you go to one of these people that are going to know the syndrome because most of the time they don't. How many fellowship programs are there in the US now for training concussion specialists? So, I mean, what I'm hearing from you is you have a neurologist that would have to then specialize in concussion. You have a psychiatrist. You have vestibular therapist or ocular therapist. I mean, everybody basically has to be under a concussion training umbrella. How many places are there besides UPMC?

I would say conservatively 15 to 20 fellowship, maybe 10 to 15 fellowship programs. That's off the top of my head. That would do training specific to this topic. So it's not that many, but they do exist. Well, Mickey, this has been really interesting. I know you've got a busy day in clinics, so we were lucky to get time with you today,

but I want you to get back to those patients. I cannot believe the volume of patients you see. That is staggering. It probably also speaks to how amazing your team is, and it's sort of like you've got that almost the executive physical situation where people can come in for two days and they can see every doctor in the medical center.

It sounds like it's that fine-tuned. I came away from this discussion actually, far more optimistic. I don't think I had nearly an appreciation for how positive the prognosis was, even in those patients with longstanding incursion with the right therapy. I thought it was the exception

and not the rule that one could get better if you were two years out and still suffering. No, Peter, it's been great. I've really enjoyed it actually. And you do a phenomenal job with what you do. And you have an interesting job. You get to hear a lot of different people

talk about a lot of different things. And I think you conceptualize this very well. And I really appreciate your time. It was a lot of fun. Thanks, Mickey. Do you want to ask me one more question just to see if I can go O for five? Do you have any other trivia for me? Or we'll just leave it at O for four? Oh, sip with the fun. Thanks, Mickey. Do you want to ask me one more question just to see if I can go 0 for 5? Do you have any other trivia for me?

We'll just leave it at 0 for 4. We'll stick with the 0 for here, yeah. I set you up on all those dope either, I did. No, that's good. I kissed me humble. All right, thanks, Mickey. Take care. Thank you.

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