Episode 71: Spilling the Tea on TBI
Traumatic Brain Injuries, more commonly referred to as Concussions are a condition with widespread prevalence. It is estimated there is between 1.6-3.8 million sports and recreation related concussions each year in the US alone. Dr. Mindy Mar joins AOR to discuss the causes, timelines and potential repercussions of TBI if left untreated.
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Welcome to Supplementing Health, a podcast presented by Advanced Orthomolecular Research. We are all about applying evidence based and effective dietary lifestyle and natural health product strategies for your optimal health. In each episode, we will feature very engaging clinicians and experts from the world of functional and naturopathic medicine to help achieve our mission to empower people to lead their best lives naturally.
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[01:10] Cassy Price: Thanks for tuning into Supplementing Health. Concussions are a common occurrence for all ages and yet many North Americans know very little about this topic. In 2016 to 2017, 46,000 children aged five to 19 had concussions and according to the CDC estimates about 1.6 to 3.8 million sports and recreation related concussions occur every single year in the US. So, today I am excited to introduce Dr. Mindy Mar, a board-certified chiropractic sport physician. Dr. Mar has over 20 years of professional experience with pro athletes and teams to draw on and is a spokesperson for The Foundation of Chiropractic Progress and TIPS speaking nationwide on concussion management and sports injury. Welcome Dr. Mar. Thank you so much for joining me today.
[01:55] Dr. Mindy Mar: Thank you very much for having me.
[01:56] Cassy Price: So, you have obviously had a lot of experience with concussions in your practice dealing with so many different athletes at various different levels. Can you share how concussions can affect mood and personality if at all and what kind of changes you have observed within your practice?
[02:17] Dr. Mindy Mar: Concussions absolutely do effect personality and mood and in fact I would say knowing whether it is your athletes or your patients or even just family members it is one of the easiest ways to determine if something unusual has happened rather than just the complaint of a headache or a little bit of dizziness is understanding that maybe someone is behaving in a way that is ‘not normal’ for them. A concussion is essentially a contusion or a bruising of the brain. It is a few things but think of a concussion as a bruise on the brain. When it bruises different aera of the brain that is when we see the symptomology related to where the concussion effects the brain that effects the signs and symptoms that someone is experiencing thereafter. So, mood swings, emotional expressions often caused by damage to certain areas of the brain that control emotions and behaviour. It is also important to understand that the brain is really susceptible to overstimulation post head trauma. There are various types of mild traumatic brain injuries but things like bright lights, loud noises, cognitive activities like thinking, problem solving, reading, working on the computer or doing homework. Those are normal day activities that when someone sustains concussion or a different type of head trauma it can easily overwhelm the brain as far as how the brain works.
[03:48] As a result, on top of where the concussion may bruise the brain, someone that is experiencing the over stimulation of the brain post-concussion, they can react confused, frustrated and angry because they know that the brain isn’t functioning the way it should at that point in time. So, on top of the actual bruising of the brain, frustration that comes out of the brain not healing or working as normal as it usually does.
[04:16] Cassy Price: How long is it normal after a brain injury to experience these symptoms? Is there are time frame that would be normal and at some point, it would be concerning if they persist?
[04:32] Dr. Mindy Mar: Typically, seven to ten days is the usual time frame for an adult having concussive like symptoms and resolving on their own. With children it is more of a three to four week timeline. So, usually the first time someone has a concussion or a head trauma they tend to resolve pretty quickly within the time frame that I just mentioned but it is so hard to say exactly the time frame when you’re going to get better. Everyone that sustains a concussion, it is very individualized reaction and symptomatology and healing time. There are factors that can influence how long a concussion may linger. A history of previous head injuries for example, anyone who is predisposed to headache disorders such as migraines, someone who has perhaps been diagnosed with a learning disability such as ADD or dyslexia, those are all factors that might indicate or explain why someone is taking a little bit longer for their concussion symptoms to resolve as supposed to textbook normal but again the seven to ten time frame with adults, it is anywhere from an 80-90% recovery time frame. With children it does take a little bit longer because their brains take a little bit longer to heal because with bones and muscles and everything that grows over time in the paediatric ages, it is the same thing with brains. They have less white matter. The neurons don’t fire as fast. That is why in children it does take a little bit longer for those concussions to heal.
[06:07] There are some other predictions as far as when we are talking post concussive symptoms. Concussions that don’t resolve within the normal seven to ten days for adults, three to four weeks within children, there have been a few variables which have been linked to the prediction of someone developing post concussive syndrome which in that case the symptoms can last anywhere from two to 12 months. Females sex we know is a predictable variable. Those again that have been diagnosed with migraine or learning disabilities, someone who has had a concussion previously where their symptoms lasted for more than a week, we do know that is actually a variable for getting post-concussive symptoms. Fatigue, phonophobia, headache, some of those classic signs and symptoms that someone has sustained after a concussion, if those are a little bit more on the severe side that can be a predictable variable as well for a little bit of a longer recovery time.
[07:07] Cassy price: Now when we think of concussions, many of us think of major head traumas like you are getting smacked around but concussions can occur from smaller injuries as well. Can you share the less common or less known causes of concussions or what they could be?
[07:27] Dr. Mindy Mar: Good point. I think more and more of us are starting to realize with the information being more readily available and discussed that you don’t have to be hit directly on the head or losing consciousness to sustain a concussion. Obviously, it is something very common that we see in sports and athletics, you can be hit anywhere in the body and it is a little bit more of that whiplash in the head region, not a direct blow to the head, but more a whiplash that can cause trauma. I think a lot of people sometimes are curious or surprised that someone like myself, a sports chiropractor or chiropractors in general along with physical therapists, that we do know quite a bit about concussions, or maybe more than people realise or give us credit for. The reason for that is a lot of people coming into our offices, again physical therapists, occupational therapists, chiropractors, people come in very routinely for headaches, dizziness, and neck pain and because it wasn’t something directly on their head or it wasn’t blunt force trauma, they think it is your classic headache or “I need an adjustment” or “I got a knot in my neck”. It is then going through detailed history and discussion and examination and going back to what I said before, knowing your patients and you can kind of tell that there is something behavioural that is off, that is when you can ask the right questions and realize that someone tripped down the stairs and caught themselves and didn’t realize and they actually had quite a bit of whiplash when they gathered their balance and that could have shaken the brain enough internally within the cranium to scratch up and bruise up the brain.
[09:11] Probably one of the most unusual concussions that I have ever had walk into my office, so to speak, is someone that fell out of bed having a nightmare and I had known this patient for quite some time so they came to see me a few years ago, classic “I think I need an adjustment I had a weird dream and knocked my head and I have a headache can you just check my neck and check everything is in alignment” and it was through further discussion it was deemed that actually no the balance is off when we confirmed through some examination and testing, cognitively I can tell something is a bit off and a bit slow with the way he spoke. So, there can be really unusual ways that someone sustains a contusion or a bruising of the brain a.k.a concussion. It is not just blunt force trauma. That is something that I think we are starting to realize more in everyday life and practice. It is not just the hard hits or the serious motor vehicle accidents or on the football field that people can bruise up their brain.
[10:15] Cassy Price: Now, like you mentioned there, football, a lot of people do think of sports obviously as one of the primary causes of concussions and is usually high contact sports like football and hockey, can you also get them in individualized sports or sports where you are not getting that impact then to if it is as easy as tripping and falling to get a concussion?
[10:39] Dr. Mindy Mar: You can. I would say it is definitely more common in sports where it is contact sports like boxing or rugby. It is much more common to sustain a concussion that way. If you are talking of a sport like tennis for example where it is individualized sport, the chances are, not so much of being hit with a tennis ball so to speak but the running back and forth, track and field for example, it is probably not as common sustaining a concussion in those sports but obviously someone could trip and fall. There could be that weird tennis ball or lacrosse ball flying at your head and again anything that induces some sort of whiplash trauma to the body that works its way up the cervical spine in the cranium where the brain lives, that can definitely lead to a concussion for sure but it is a bit more common in contact sports. Basketball and soccer however, those as far as statistically females are at greater risk of concussion in those two sports compared to their counterparts, we have the data and the research on that now. Basketball and soccer, that is an in between, it is not always direct contact but sometimes it is. It just depends but the stats definitely show that the ice hockey or the football is where we see the higher rate of concussions. It is also important to note that not all concussions go reported so the stats that you mentioned, they are all true stats and figures, but we definitely believe that how many people, whether it be through a sports related concussion or a mild traumatic brain injury concussion, we believe that the stats are much higher than is what is being reported. Not everyone goes to the hospital or doctor when they sustain a whiplash injury that could technically be a concussion. Not everyone in sports reports it to their athletic trainer or coach.
[12:37] Cassy Price: It is interesting that women or females tend to have a higher rate in basketball or soccer than their male counterpart. Is there any evidence as to why that is?
[12:46] Dr. Mindy Mar: It is thought that one of the main reasons with females in mind is that their neck strength isn’t as strong as their male counterparts. So, that is definitely something that we do implement as far as therapeutic exercise and strength and conditioning, definitely neck strengthening. Women tend to be, generally speaking, a bit smaller, smaller muscles, smaller craniums. So, that is a big reason. It could go back to how training practices and how they are being coached. We also think, as I mentioned previously, there is part of that is that females tend to report their injuries more readily than their male counterparts. That might have something to do with it as well. Basketball and soccer are becoming increasingly popular with females so all of those factors I think is why we are seeing now present day more concussions being reported in basketball and soccer female verses males.
[13:50] Cassy Price: Is there any detriment to not reporting a concussion to your doctor if you do sustain one?
[13:57] Dr. Mindy Mar: Absolutely. A lot of the times, concussions, the signs and symptoms show up right away, but it is an evolving condition and injury so sometimes you don’t have signs or symptoms for 24 to 72 hours. I have witnessed that first-hand over the years. A lot of the times, we will just talk specifically about sports and athletes, they just seem as though they got hit from the back and have a little bit of whiplash and they feel fine and they can get up and play, pretty much every athlete is going to want to stay on the field. So, athletes especially at the professional level, they are instructed or know enough not to hide injuries but at the end of the day a lot of them want to stay on the field. A lot of them might not have immediate symptoms that they think that they need to walk off the field and speak to the trainer or the sports chiro or their coach about. With the symptoms, when they creep up however, even if it is just a few minutes later that is when we risk something called Second Impact Syndrome. That is very unusual, Second Impact Syndrome, but it does happen. Second Impact Syndrome is essentially when there is a concussion that gets sustained. Think of it as though you injure your wrist or your ankle and there is some immediate swelling that takes place.
[15:17] The problem is that when we have a concussion and there is some immediate swelling of the brain you might be asymptomatic or even lucid to some degree but at some point, depending on the effects of the concussion the brain does swell and unfortunately the brain has nowhere to go but down because the cranium doesn’t expand. Everywhere else in our body the swelling can expand, and we all know that swelling can get big and boggy at times. So, the problem with staying on the field or continuing your activity when you have an immediate and fresh concussion taking place, if you were to get hit or sustain another significant whiplash type of injury that is when the swelling really doubles down. Again, there is nowhere to go that brain and the swelling of the brain, but down. When I say down, I mean it starts hitting a lower part of your brain, the mid brain the medulla oblongata, these are all where your cranial nerves live. It is responsible for your heart rate, your blood pressure and vital systems that keep you alive. When that pressure works its way down it is very serious. If someone isn’t transported to the hospital for immediate emergent care, it is unfortunately almost always a guarantee of death.
[16:38] Cassy Price: Oh wow. Now, if you’ve had previous concussions does that increase your likelihood of developing things like Second Impact Syndrome or CTE or any other, I guess, long term effects?
[16:53] Dr. Mindy Mar: Yeah. So, as far as if you have had a concussion before, Second Impact Syndrome happens when it is back to back concussions. If someone has sustained a concussion today and six months later, they go on the soccer or baseball field again and sustain another concussion it doesn’t necessarily put them at risk for Second Impact Syndrome. It does though, I have known athletes who have had anywhere from three to six concussions within a period of a few years and that is not good. You don’t want to keep injuring the brain. The more you injure the brain or anything else in your body for that matter, the weaker it becomes and the more susceptible it becomes to injury and the harder it will be for it be able to return back to full functioning. Going back to your CTE, it is hard to know. We do have a lot of information coming out on CTE, Chronic Traumatic Encephalopathy these days. I don’t know if sustaining one concussion makes you immediately prone to CTE. There is so much more research that we need to do. CTE, the cause of CTE is there are hundreds of millions of neurons of brain cells in your brain so very tiny structures. The axon, that is the skinny part of the neuron, that is the weakest link of the brain cell. So, anytime there is blunt force trauma, whiplash or shaking, the axons they shear, and they tear. That is it. What keeps surrounding the axons, I don’t want to get too involved in my description here, but you’ve got structures that surround the axons and they are microtubules. These tubes help carry cellular waste, oxygen, blood flow etc from one end of the neuron to the other.
[18:55] So, when the axon breaks these microtubules, they break pretty easily too. The axon can sometimes withstand, when I say axon that is the skinny part of the nerve in your brain, there can be some movements or shaking that doesn’t necessarily shear or tear the axon’s each and every time but these tubes that are extremely tiny surrounding the axons, they break and damage a lot easier. It doesn’t take a lot to break them on a regular basis. These little tubes are held together by a protein called taw. Every time there is some damage or some injury to these microtubules, the protein taw separates. It is no longer holding these tubes together and over time they start to band and clump together and over time these clumps of taw start to build up in certain areas of the brain hence effecting the brain with the cognitive symptoms which a lot of the times mimic Alzheimer’s and we see the build up of the taw in the brain upon autopsy. As of right now there is no blood test or imaging right now to determine build up of taw in the brain while one is still alive. We are trying to figure out how to do that but as of right now it is autopsying the brain to determine if there is a significant build up of taw to see if that is what contributed to CTE and ultimately death. That is the big thing. It is one of the big things that is being worked on in the field of concussion, it is how do we determine if someone has a significant build up of taw, how can we keep it at a minimum? There is really no way, once the damage has been done to the axons and the microtubules, the damage is done.
[20:50] Cassy Price: Does that go for any neurological damage that is sustained from a concussion or can some of it be reversed?
[21:00] Dr. Mindy Mar: Once nerve cells die, they die. We have a fair amount of them in the brain but once you start to lose too many, they don’t necessarily regenerate the way bone does. You can break your bones and that regenerates. Your fingernails and your hair, it grows, and it regenerates. Once there is cell death in the brain the neurons die and they don’t grow back.
[21:23] Cassy Price: Okay. So, if you had previously experienced a concussion or had a concussion occur, what are some of the physical and mental symptoms that should be red flags if that persist for an excessive amount of time or crop up again after you’ve ‘recovered’?
[21:42] Dr. Mindy Mar: So, if you mean two or three months as far as a long time since one has sustained a concussion?
[21:52] Cassy Price: Yeah.
[21:53] Dr. Mindy Mar: Yeah. Okay. So, right going back to what I said the seven to ten days for adults or three to four weeks with children. So, with these symptoms, whether it is your first concussion or your third concussion down the road if it is still ongoing two/three/four months later that is something known as Post Concussive Syndrome. Then it is important to follow up with your doctor or neurologist. There are different examinations that we do on the field immediately, like memory recall for example cognitive exams or different balancing tests that we do or a cranial nerve exam. So, if these symptoms are ongoing, more often or not someone is experiencing dizziness or headaches, those are two of the most common post concussive symptoms that one will experience. That is when we need to start thinking that the vestibular system has not recovered. The vestibular system is part of our inner ear. There are quite a few structures in our inner ear that make up the vestibular system and that’s involved with how we keep our balance, our sense of spatial orientation. So, a lot of the times, again whether it is blunt force trauma, violent shaking or significant whiplash, there can be some damage to inner ear that is nor resolving quickly on its own. Vestibular rehab we know has very effective for someone suffering from post concussive signs and symptoms. A lot of physical therapists actually specialize purely in vestibular rehab. Outside of the dizziness and headache if someone is still having more of the emotional signs and symptoms or personality wise it is not what it used to be, so to speak, then that would warrant a follow up with both a neurologist and perhaps even a psychologist or a sports psychologist.
[23:56] Cassy price: Fantastic. I think this is such a fascinating topic. I think this is something that obviously there is still a ton of research that is going into it and is regularly developing but I think especially because so many of us do enjoy different activities or partake in different sports that this is a reality for many people. Obviously throughout North America it is something that is really great to discuss further and learn more about the brain itself because it is so fascinating so injuries to it can be very fascinating as well.
[24:31] Dr. Mindy Mar: Yeah. It is fascinating. I think for a lot of people it can be scary and we want to take it seriously. I know a lot of parents in the last decade or so have had concerns, “should I put my child in football? Would you put your child in football?” like everything else it is risk verses reward. My own personal take is that I don’t think keeping kids out of sports 100% in fear of a head trauma or a concussion. The other side of that is when your child is losing out on all of the benefits of sports like gaining confidence, working with a team, the physical activity, learning how to be a good sportsman, cooperation, there are so many benefits to being involved in sports and playing sports. Everything is a risk. I would say to anyone concerned with kids or teenagers at home that are weighing the risk verses reward that is when you want to get to know your coach, get to know the athletic trainer, the sports chiropractor working on the side lines. Understand if there is a protocol. Should someone go down on the field? Where is the nearest hospital? What is the plan? There should always be a plan worst case scenario. I would say for any parent or person that has these concerns then have that open dialogue before the season starts. If you are a weekend warrior and you’re going to go to the park and pick up a game, then be responsible for yourself if it is not an organized event. Have a game plan or some first aid. Just knowing the basic signs and symptoms. You don’t have to be a doctor or someone who specializes in concussion or rehab to know the basic mechanism of injury or the basic signs and symptoms and when in doubt rule it out.
[26:31] Cassy Price: Fantastic. So, if any of our listeners wanted to continue to learn from you on this subject or work with you, what would be the best way for them to get a hold of you?
[26:39] Dr. Mindy Mar: My website, if that would be helpful, is sdcentreforhealth.com. That is a good way to look me up and learn more about me. I do believe my contact information is there as well.
[26:54] Cassy price: Fantastic. This has been a great conversation and I really appreciate you taking the time to enlighten us all with your boundless knowledge on this topic.
[27:02] Dr. Mindy Mar: I really enjoyed speaking with you and hopefully I was able to share some information that was helpful to your listeners. Thank you so much.
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