#263 ‒ Concussions and head trauma: symptoms, treatment, and recovery | Micky Collins, Ph.D.

Hey everyone. Welcome to the Drive Podcast. I'm your host Peter Attia. This podcast, my website and my weekly newsletter all 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 peterattiamd.com subscribe Now without further delay. Here's today's episode. My guest 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 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 and 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, 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. I 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. Well, Mickey, thanks so much for making time to sit down. 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 was 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 ineligible. So I was like, okay. And I was taking a neuroscience course at that time, like a biopsychology 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 a emphasis in clinical neuropsychology, which is a study of brain behavior, and took some of the medical classes there through Michigan State, but also did psychology, clinical psych and neuroscience courses and combine 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. This 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 patients. I didn't know no one would care. In 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. That's when we started the clinic. But long story short, back when I was getting into this, I wanted to study concussion or mild traumatic brain injury, and I somehow wanted to involve sports. And right now, if you think back, I mean, that sounds counterintuitive. It's a hot topic now. At the time, no one could care about it. But that was around the time that Troy Aikman and Steve Young and Paul Correa, everyone remembers 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 or 96, whenever it was. And he basically said, no one knows anything about this 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, a guy named Mark Lovell and a guy named Joe Maroon, who's 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 an orthopaedic, 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 patience. 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 the lead author on that paper where we looked at college football and 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 the head coach to get approval. So I went into the head coach's office, and that coach was Nick Saban. 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 this at Michigan State. We then started working at the University of Florida. We worked at University of Utah, ironically, came to Pittsburgh and 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, you know, immunotherapy and cancer that the 80s looked like it 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 concussus literally translates from Latin to English to mean to shake violently. And if you think about your brain as like an egg yolk inside an eggshell, the brain is inside this hard cavity. And if you have acceleration, deceleration, or translational forces that are hard enough, the brain's 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 increased demand 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 decreased cerebral blood flow. So at the very time the brain's demanding more energy due to the hyperglycolysis, we get an influx of calcium, vasoconstriction, and decreased cerebral blood flow and decreased energy supply. And so what concussion is is a mismatch between demand and supply of energy to the cell. Now, this is not enough to cause cell death. Wallerian degeneration. There's no structural changes to the neuron. There's no death of the neuron. But the cells 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 decompensation 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 pathophysiology 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 this injury in a way where we can kind of figure out what's happening and then apply a more targeted treatment to his treatment. Now, one thing is, Peter, is that we don't have a biomarker right now for this injury. There's no blood test that's ready for prime time. There's no serum marker. There's no imaging. This is not seen in 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.

And 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. 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, 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 stretched 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 and decrease cerebral blood flow. And this is very clearly an energy crisis, or what we call a 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 of it 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, you know, we use sports as a laboratory. It's a great petri dish to study this injury. But this applies to slip and falls, car accidents, 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 @ the macro level, appear to have a very similar insult. 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 that. But again, just at the pathophysiologic level, what's the diffusity 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 gyrus 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 the 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 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 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 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 issue of migraine. Less force causes injury and you're gonna go down that migraine pathway. If you have a history of lazy eye or strabismus, you're gonna 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. You know, 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 researcher out of UCLA kind of coined that phrase cognitive reserve. But generally speaking we can get in the weeds on that. But I would say, yeah, I mean, you're more vulnerable with these different risk factors and you're more likely to go down different pathways. And girls are more likely to have concussions than boys. Neck 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 our clinic are female, 40% are male. The reason why is because they're a more vulnerable population and we see a lot longer outcomes in females than 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, and 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 it effectively when you have one. And we are very good now at determining recovery, what that looks like and how 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 this injury effectively and 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 injury. So we've already established we have no biomarker. So this person gets their bell rung 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, but there are signs and there are symptoms of injury. Signs are what you outwardly observe. Symptoms are what the patient reports. Signs of concussion include loss of consciousness. It includes confusion, it includes balance issues, it 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, retrograde amnesia, 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, Peter, 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 route 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 long, 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 get 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 get 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 in Pediatrics, JAMA 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 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 lost consciousness more than another group. No group had more symptoms, specific symptoms than another group. So we were able to statistically 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, 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, 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 get them back to place.

Sooner. Well, I definitely want to hear about that. And I think that's where most people's ears will 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 VOMS stands for vestibular Oculomotor Screening. We do impact testing. I'm familiar with the neurocognitive test. It's a computer based neurocognitive 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 neurocognitive correlates that we see with these different types of concussions, et cetera. 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 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 to the deep parts of the brain. We're talking about more centrally derived problems from the central part of the vestibular system or 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 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 are the six different problems we will see from concussion. Now patients may have one of those problems or they may have all six. 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 or in 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. If 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 gotta be careful of. 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 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 going to 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. And luteal phase? Because the estrogen progesterone swings in those phases are enormous. Of course, it begs the question, are those hormones.

Protective? We're 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. Cool thing is, again, we started doing this work when no one cared about it. Now there's too much work to be done, and everyone cares about it. It's.

Fascinating. And 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? Yeah, it's an interesting question. I mean, clearly the spotlight in this injury is iridescent, 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 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 going to 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 him 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. You know, migraine is a huge factor predicting outcome, history of migraine. There's 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 their injury. Because we can apply our treatments quickly, and 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 vestibular.

Problems. What type of accident, by the way, was this one where it was just a coup contre coup injury where he whiplashed? I mean, you know, we wear a Hans in a car which limits our recoil. Now in.

Our. I looked at the video on it and this isn't at the highest levels of racing, so I'm not.

Sure. Sure.

Yeah. 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 in 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 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 in another accident and had the same problem occur, same mechanism even. And that's when everything obviously got worse and when they sought medical attention. But they've been living with that for two years. They have not improved. They came to me today. They're having everyday headaches that can get up to an 8 out of 10. Light sensitive, noise 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 isolative. They don't want to be around other people because that triggers the vestibular problems. And so they become more reclusive. You know, 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, migraines. 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 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 patient 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 are out of 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 will have appointments scheduled throughout the day. They come to see me, I did the evaluation. I kind of found 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, when it'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 decompensates that system. That signal comes through aberrantly, and it will trigger all these really icky symptoms. It's like a bad car sickness, they feel. Now, the vestibular system, the same pathways in the brain that control that system mediate our sympathetic nervous system. And so the patients will also have massive sympathetic nervous system arousal, fight or flight. So thoughts go faster, 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 as one problem with a vestibular problem becomes an anxiety problem or a sympathetic nervous system problem. And then it becomes a migraine problem. And then migraine actually feeds back through the vestibular pathways in 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, you know, 40K, so really at a good clip. And a runner jetted out between two cars, you know, 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, had 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 go down this. It's not only Pavlovian, meaning they're conditioned 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 in 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 X amount of 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 as 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, 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 0 for 2.

Mickey. 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 anxiety is by increasing parasympathetic nervous system arousal, 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 gotta get them on a good sleep schedule. We gotta 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 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 oculomotor 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 get even 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.

Aberrant? I don't know the answer to that. I wish I did. But my suspicion, based on everything I've learned about the pathophysiology of this, is that we should see a normal brain structurally and anatomically and even physiologically. It's just what happens when this injury happens, as to what systems are affected, and. 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 and 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 that, of course, makes me think, well, dizziness is so tied to.

Vestibular. I agree with.

That. There is something about this vestibular problem that, by the way, would also amplify.

Anxiety. You know how 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. 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, a lot of different people. Like, I'll see people that come in here that have an oculomotor 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 oculomotor 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. 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 he's gone down that profile, the.

Vestibulos. Yeah. And here's what's amazing. After two, two and a half, three years, maybe he just kind of 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 injury, I would have had him.

Better. You'd have saved him 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.

Sub? Sure, sure, sure. But in.

General. But in general, we could have gotten him better in 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 after he's had this amazing eval. What's his homework assignment? Meaning? What are 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 him 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 we're 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 then 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 when 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 train that vestibular system. We have him doing planks with head turns. We have him doing lateral shuffles, you know, that kind of stuff. And when you have a 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 right exercise. 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 ruminating because the nervous system is so fired up. Downtime makes this all worse. So we're going to 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 him 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 going to 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 Trazodone.

Or. I don't like Trazodone too much because the sleep is coming from the nervous system problem. So you're treating a secondary problem by putting them on trazodone. 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 SSRIs that are a little more effective than others in treating the nervous system. Profile. I don't like.

Ssri. Which ones.

Are. Sertraline 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 Wellbutrin, sometimes you need an effects, or sometimes you need Lexapro or Eschatelopram or whatever. There's different meds that will help with these problems. And we have a psychiatrist here that's.

Phenomenal. 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 gonna get you better from this. I really do.

Feel. How many of the male patients come in with hypogonadism 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 is temperature regulation, migraine. There's so many different things it 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 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 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 outcomes from this.

Injury. 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 telomeres 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, you know, 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 2 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 to two hours of their time in total to do the brisk walk and 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 in any way, shape or form that shows hyperbaric 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? Well, you think about crap a.

Lot. You.

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, had synthetic ketones in their system such that they had 1 to 2 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 the literature, but I'm not aware of any.

Research. But it's 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 the way, 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 incidents. 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.

Equestrians. I love that I'm now 0 for 3. Just we got to keep this quizza. Tell me why are they falling or is it the.

Bouncing? No, it's not the bouncing. It's the falling and the horses of very large beasts, you know, you fall from a high degree. But given that the goal of boxing is to render your opponent concussed, I would expect that probably is even higher than equestrian sports. But the research just hasn't been really good there because a lot of patients don't report the problems that occur. Obviously, boxing is a very common sport where 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 walked a day in my shoes, you'd think it was very common, because they're.

Coming. But you have a huge selection bias, obviously, of the sickness.

Bias. So, basically, I really do feel like a lot of kids will 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. Mickey, 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 Lewy 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 in Boston. Grant Iverson's written really well on 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 this. We're not seeing any proclivity towards dementia with these patients or proclivity towards Lewy Body or proclivity towards other neurodegenerative illnesses. Now, it depends on what research you're looking at. As 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 encephalopathy. 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 former 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 in the 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 or not is 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 in 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. 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 regular with their 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 suicidality 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 till we really understand this. And I understand the need to talk about this 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 gonna be a lot of people listening to this, Mickey, who are parents or their athletic heyday might be behind them. They're not taking the high risk activities. Their risk of concussion we'll talk about later, because that's gonna 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 of 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 Susie 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 are very well equipped to manage these.

Injuries. Approximately how many of these are there? 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, et cetera. 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 amount of respect for is inova in Washington, D.C. one of my former fellows is there. We've had 33, three fellows train 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 of my head, I think Boston Children's does a pretty good job overall. I know there's clinics down in Houston, Texas, that do a good job. There's clinics in Phoenix that do a really good job. There's clinics 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 could even go to our website and kind of find out who we trained and where those patients are. There's access to places, but there's really good programs out there I have great respect for. And 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 be 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 gotta do, Peter, is make sure there's not an intracranial bleed, right? I mean, like, yeah, you have.

To do the medical.

Stuff. You gotta make sure there's, you know, the red flags aren't there, et cetera, and rule that out. But. But once that's ruled out, I do think seeking specialty care within a week of injury is going to 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 is what I'm.

Saying. I totally 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 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, we talked.

About. That's my point is like without someone in the ER who's going to 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 even hard to speak to the symptoms. Dizziness, fogginess, fatigue, light sensitivity, 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 problems and. No. Live your life, man, it's. 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. If the 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 got to pick up basketball game you want to play in next weekend, you. You probably want to get it 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 so sure. You need to see.

Someone. Do you know anything about the role of the APOE 4 genotype in terms of susceptibility to concussion or any traumatic brain.

Injury. So apolipoprotein 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. Concussion +APOE4 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. That's the same place I went when I wrote that paper is 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 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 cause mortality that in the first year post a 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 going to 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, I mean, 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 syncopal 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 in, 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 in 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 sinkable episode where they hadn't hydrated well, maybe a little stress going on in their life, dysregulated blood flow, you know, dysautonomic stuff. They get up from going to the bathroom, collapse, hit their head on.

The linoleum floor, fall forward off the.

Toilet face first, basically facial fracture, small subdural, bad concussion. Fortunately, no intracranial intervention. The blood from the subdural 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 fatigued 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 were 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 vestibular 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're getting really dizzy in bed. We can fix that, but we get them in the right physical therapy, the right vestibular 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 they, 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 another few.

Weeks. Hopefully this person will be doing how much exercise as a part of their.

Rehabilitation? Walking for now, you know, they're not a fall risk. We looked at them see our vestibular therapists and not a fall risk, which is good. So we gave them some balance exercise to work on. We give them some vestibular exercises 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 going to get better. They think their life's over, like, literally. 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 Noel foundation for the former coach Chuck Noel. I talked a little bit about baseline testing. Chuck Noel was. The Steelers were the first team to ever do baseline testing. And Chuck Noll 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 Noah 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 monies available to study this, which is.

Exciting. I assume 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 you're a 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 this injury, 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 oculotherapist 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. You know, 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 clinic, 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 long standing concussion. 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 zero for.

It. Let's stick with the O for here. Yeah, I set you up on all those though.

Peter. I did. No, it's good. Keeps me humble. All right, thanks.

Mickey. Take care. Thank.

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