Friday, May 22, 2015

Concussions Linked to Brain Atrophy

Permanent brain damage, such as brain atrophy, is the fear post concussions.  More and more studies are showing changes in the brain post concussion especially as our imaging becomes better.  What should we be fearing?  Do we need to fear every concussion?  The good news is that many people with multiple concussions have no brain damage on advanced scans.  The other good news is that people with brain damage are showing improvements in brain scan 2-5 years post concussion.

So what damage do we fear?  Atrophy from other studies has been a permenant change in those older than 30.  Research studies that look for atrophy are more interesting for this reason. Several articles have come out in the past month about the use of imaging.  The goal is to see if imaging can tell us if we are going to have cognitive problems in the future.   Is there are correlation between neuropsych testing and brain atrophy?  I reviewed 2 articles that speak to this.  These articles look at people in there fifties who had mild traumatic brain injury playing college or professional sports.   The first article found that there was no deficits in cognition, but there was clear loss in brain size between the controls and the athletes with concussion.  The 2nd study looked at NFL players who had minor concussion and more serious concussion with loss of consciousness.   Those with LOC (loss of consciousness) were much more likely to have brain atrophy than those that did not.

It is important to understand that none of these individuals likely did not have any treatment beyond 48 hours of rest as this was the standard of care.  We know that exertion can decrease blood flow and likely increased the probability of brain changes.   Seven to ten days without extreme exertion is likely to lessen likelihood of brain atrophy.  The understand of what the atrophy means is still evolving. 

1. Front Aging Neurosci. 2013; 5: 41. Published online 2013 Aug 22. doi:   History of mild traumatic brain injury is associated with deficits in relational memory, reduced hippocampal volume, and less neural activity later in life Jim M. Monti,1,2,* Michelle W. Voss,3 Ari Pence,2 Edward McAuley,2,4 Arthur F. Kramer,1,2,5 andNeal J. Cohen1,2,5

The first study enrolled 20 young-to-middle-aged subjects, who reported two or more sports-related mild TBIs, with the last mildvTBI > 6 months prior to study enrolment (mTBI group), and 21 age-, sex- and education matched controls with no history of mTBI (control group). 

Our data suggest that recurrent mTBIs exerts detrimental effects on cognitive function and cortical thickness in the chronic phase in young-to-middle-aged adults. Specifically, cognitive testing revealed small but consistent deteriorations in cognitive scores, most pronounced for verbal fluency, in the chronic phase after mTBIs.. Moreover, we found that subjects with recurrent mTBIs showed dose-dependent cortical thinning within right temporal lobe and bilateral insula, as compared to subjects without history of mTBI.

2.   2015 May 18. doi: 10.1001/jamaneurol.2015.0206.  Imaging Correlates of Memory and Concussion History in Retired National Football League Athletes.

Participants included 28 retired National Football League athletes, 8 of whom had MCI and a history of concussion, 21 cognitively healthy control participants, and 6 control participants with MCI without concussion.

Athletes with a history of G3 concussion were more likely to have Mild cognitive impairment (MCI) (7 of 7) compared with retired athletes without a history of G3 concussion (1 of 5) older than 63 years (P = .01). In addition, the left hippocampal volume in retired athletes with MCI and concussion was significantly smaller compared with control participants with MCI (P = .03).

Tuesday, April 28, 2015

Medicine Changes Quickly

The Need for a Research Blog

      I was taught that more than 50% of what I learned in medical school will be proven false within a 50 year period. This was true for the generation before me, and medical knowledge has been expanding at a faster in the last 10 years.  This idea that doctors don't have all the answers is scary for a lot of people.   In 1955, the US president (Eisenhower) was given cocaine for a heart attack. Today we believe that cocaine causes more heart attacks than it helps.   So how do we know what part of western medicine actually helps? Good research can be very helpful in guiding our medical decisions.  Unfortunately too many medical decisions are made on expert opinion alone or on poor research studies.

      I think it is exciting time for science and medicine because every day we are discovering more. Gone are the days when we just give patients "rest" therapy.  (Although many doctors are still saying this about head injuries).  Our knowledge of science is helping us learn real interventions that can alter the course of illness.    We must ask our health care providers what they do to stay on top of the knowledge. I do a literature review on any new information on treatment of brain injury every month. That way I and you the readers of this blog know what treatments will actually make a difference in treatment and diagnosis.
        Most  of what we know about treating brain injury has been discovered in the last 14 years.   Western medicine has been focused on helping people survive.  We are just starting to focus on optimum recovery.   The military has lead the way in understanding how much mild brain injury affects people long term.   In is estimated that 10% of veterans from Iraq have a brain injury.  In 2011, The military released a report that the earlier brain injured patients were fed, the better they did.  This may seem obvious, but most brain injured patients are not fed early.  They do not eat because they are not hungry due to symptoms and for some the consciousness is questionable and there are worries over choking.   The brain needs nutrients to help build new tissue to replace the damaged tissue.  Multiple studies have shown a diet of Omega 3 fatty acids and rich in proteins have helped the brain recover. 

     Since 2011 multiple other reports have been released on treatments.  My goal is to stay up to date on all studies on brain injury.  I am happy to answer questions or comment on a study to help us all understand the brain a little better.  Thanks for reading. 

Thursday, April 23, 2015

Extended Complete Rest Is Not The Answer

This was one of the most quoted articles at the Harvard Concussion conference in May.  We have no research data on how long to rest post concussion.  The experts are basing their opinions on the scary cases of people who did not rest and became significantly worse.  Some people aren't healing from concussions for months, could they have done better with more rest?  There are many unanswered questions.  I think this article helps us to say, "Don't prescribe extended rest without a reason.

In the Journal of Pediatrics on 1/5/2015

Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial

Children's Hospital of Wisconsin in Madison Wisconsin tested 11-22 year old individuals.  They found that individuals who received a random recommendation of 5 days of complete rest did worse than those who received a recommendation of 2 days of complete rest.  Individuals who rested longer had more symptoms and more intense symptoms and they took longer to recover completely.   Although there was no difference between the 2 groups in neurocognition or balance.  The idea of being forced to rest when there is no need can lead to worsening of symptoms theorized due to the time to focus on symptoms.

A recommendation of complete rest is not an answer to concussion recovery.  Patients should be encouraged to slowly return to activities as soon as possible.  Movement can decrease stress and provide deeper rest and recovery.

I, Dr. Lansky, encourage controlled exercise early in the concussion recovery and have seen faster recovery results than others are reporting. 

Exertion Testing in Youth to Assess Brain Function.

How do we know when kids are ready to return to learn?  Is being symptom free the answer?  Waiting till kids are symptom free at rest causes some kids to sit too long and causes problems for other kids.  It is not good to look at symptoms at rest.   The new goal by many experts is to return when symptoms are mild with exertion.  It seems that youth are not a good judge of brain irritation at rest.  With cognitive stress or physical stress symptoms usually will worsen.  It is important to have injuried individuals gradually increase their activity.  It is hard to measure cognitive work, but it is easy to measure physical work.  Is it possible just to assess symptoms with physical work to see how youth will do?  I believe that it gives us many answers.  As heart rate increases, it can create a change in pressure in the brain and let us know whether brain swelling is still a factor in the healing process. 

Exertion Testing in Youth Helps Assess Brain Function

In Medicine and Science in Sports and Exercise April 11th 2015, authors studied how to assess return to sport.   They studied 54 people age 8.5 to 18.3 years old with symptoms for 0.7 months (21 days) to 35 months (almost 3 years). 63% had increase in symptoms at 50% of peak mechanical power on a progressive continuous Cycling test.  Testing in the medical office should include exercising to determine when someone is safe to return to activities.   Patients who brains have not fully developed have an increase in symptoms with exercise more so than adults.   It is important to ask about symptoms after being active rather than asking about symptoms at rest.

My office, Concussion Healing Clinic, always tests people on a treadmill before returning to work or school.