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.