#263 ‒ Concussions and head trauma: symptoms, treatment, and recovery | Micky Collins, Ph.D.
Dr. Michael "Mickey" Collins, a leading expert in sports-related concussions and director of UPMC's Concussion Program, discusses the definition, diagnosis, and six types of concussions. He emphasizes the critical importance of prompt, targeted treatment and active rehabilitation over rest, offering an optimistic outlook for recovery even in chronic cases.
Deep Dive Analysis
14 Topic Outline
Dr. Collins' Background and Concussion Specialty Genesis
Defining Concussion: Pathophysiology and Diagnosis Challenges
Concussion Symptoms, Predictors of Severity, and Early Treatment Impact
The Six Distinct Types of Concussion and Their Management
Age and Gender Differences in Concussion Recovery
Impact of Misinformation and Importance of Specialist Care
Case Study: Chronic Vestibular Concussion in a Racecar Driver
Understanding the Vicious Cycle of Vestibular, Anxiety, and Migraine
Active Rehabilitation vs. Rest for Concussion Recovery
Exploring Hyperbaric Oxygen and Synthetic Ketones for Concussion
Concussion's Natural History and Link to Neurodegenerative Disease
Advice for Parents: When and Where to Seek Concussion Care
Concussion Risk in Older Adults and a Geriatric Case Study
Concussion Research Funding and Training for Specialists
5 Key Concepts
Concussion Pathophysiology
A concussion occurs when the brain shifts inside the skull, stretching neuron membranes. This causes potassium to leak out and calcium to leak into cells, leading to an increased demand for glucose (energy) while simultaneously decreasing cerebral blood flow. This creates an energy crisis or metabolic mismatch, where cells struggle to operate efficiently without structural damage or cell death.
Concussion Types
Concussion is not a singular injury but manifests in six distinct clinical profiles: cognitive fatigue, vestibular, ocular, migraine, anxiety, and neck. Patients may experience one or multiple types, each with unique symptoms, risk factors, and requiring targeted therapeutic techniques for effective treatment and recovery.
Metabolic Mismatch
This refers to the energy crisis within brain cells following a concussion. The stretched neuron membranes lead to an efflux of potassium, demanding more glucose for active pumping, while an influx of calcium causes vasoconstriction, reducing the blood supply and thus the energy available. This supply-demand imbalance impairs cellular function.
Vestibular Ocular Motor Screening (VOMS)
VOMS is a physical exam used to evaluate the vestibular and ocular motor systems after a concussion. It helps clinicians identify specific problems related to balance, eye movements, and motion interpretation, which are crucial for diagnosing and targeting treatment for vestibular and ocular concussion types.
IMPACT Testing
IMPACT (Immediate Post-Concussion Assessment and Cognitive Testing) is an FDA-approved, computer-based neurocognitive test. It provides an objective way to quantify and assess concussion by evaluating cognitive functions, helping clinicians identify neurocognitive correlates associated with different concussion types.
10 Questions Answered
A concussion is a metabolic mismatch where the brain's movement inside the skull stretches neuron membranes, causing potassium to leak out and calcium to leak in. This creates an energy crisis where the brain demands more glucose but experiences decreased blood flow, impairing cellular efficiency without causing cell death.
On-field dizziness is six times more predictive of a longer recovery (a month or more) than any other symptom, including loss of consciousness. Fogginess, or feeling detached/one step behind, is the second-best predictor.
Yes, research shows that patients who continue to play for just 15 minutes after sustaining a concussion have an average recovery time of 44 days, compared to 18 days for those immediately removed from play. Every minute played through an injury can add 7-8 days to recovery.
There are six distinct types of concussions: cognitive fatigue, vestibular, ocular, migraine, anxiety, and neck. Patients can present with one or a combination of these, and each type requires a targeted treatment approach.
Currently, there is no blood test, serum marker, or imaging study (MRI, PET, functional MRI, MEG, EEG) that definitively helps with concussion diagnosis. The injury is at a cellular, energy crisis level, without structural changes visible on current imaging.
Seeking specialty care within seven days of a concussion is the best predictor of a quicker and more effective recovery. While earlier intervention is ideal, it is never too late to seek help, even for chronic symptoms.
No, complete rest can actually worsen outcomes. An active, targeted, and exposure-based model involving specific physical therapy, exercise, and regulated sleep is the recommended approach, tailored to the specific type of concussion.
There is no compelling empirical data to suggest that hyperbaric oxygen treatments are effective for concussion. While synthetic ketones present an interesting theoretical argument for addressing the energy crisis, there is currently no research to support their use in concussion treatment.
Well-controlled research, including ongoing studies, has not definitively shown a proclivity towards dementia, Lewy body disease, or other neurodegenerative illnesses from concussions. Anecdotal evidence suggests some patients mistakenly attribute chronic symptoms to CTE when they may be treatable concussive issues.
Parents should immediately remove a child from play if they show any signs or symptoms of concussion. They should then seek specialty care at a concussion clinic, which are now available in most major geographic areas, ideally within a week of the injury for the best outcomes.
13 Actionable Insights
1. Immediate Concussion Removal
If a head injury occurs with concussion symptoms (like dizziness or fogginess), immediately remove the individual from play or activity, as continuing to play for even 15 minutes can significantly prolong recovery.
2. Seek Early Specialist Care
For any suspected concussion, seek evaluation from a concussion specialist within seven days of the injury, as early intervention is the best predictor of quicker recovery and prevents secondary problems.
3. Embrace Active Rehabilitation
Contrary to common belief, active and targeted rehabilitation, including exertion therapy and specific physical therapy, is crucial for concussion recovery, rather than prolonged rest which can worsen symptoms.
4. Follow Targeted Exercise Program
Engage in specific vestibular exercises (e.g., Russian twists, planks with head turns, lateral shuffles, burpees) and a daily exercise program, such as a 45-minute morning walk and a 45-60 minute rigorous afternoon workout, to retrain affected brain systems and increase parasympathetic nervous system arousal.
5. Regulate Sleep Schedule
Establish and maintain a consistent sleep schedule by going to bed and waking up at the same time daily, and avoid napping, to support nervous system regulation and recovery from concussion.
6. Engage in Environmental Exposure
Actively expose yourself to busy environments like grocery stores, restaurants, and parties, and engage in external activities to challenge and retrain the brain, avoiding rumination and social isolation which can worsen symptoms.
7. Treat Chronic Concussion Symptoms
Even if concussion symptoms have persisted for years, seeking specialist care can lead to significant improvement and recovery, as the injury is treatable and not irreversible.
8. Prioritize Behavioral Treatment
Initially focus on behavioral interventions, such as exercise, sleep regulation, and exposure therapy, before considering medication, as these often address the root cause of concussion symptoms.
9. Avoid Hyperbaric Oxygen Therapy
Do not pursue hyperbaric oxygen treatment for concussion, as there is no compelling data to support its effectiveness, and it may lead to unproductive searching for solutions and increased anxiety.
10. Educate on Concussion Symptoms
Parents and individuals should be aware of subtle concussion symptoms like dizziness and fogginess, which are strong predictors of longer recovery, and understand the importance of reporting them immediately.
11. Avoid Re-Injury During Recovery
Be vigilant to prevent another head injury while recovering from a concussion, as subsequent impacts during this vulnerable period can lead to more severe outcomes and prolong recovery.
12. Seek Concussion Specialists
When seeking medical attention for a concussion, prioritize clinics or specialists with specific expertise in concussion management, as general neurologists or neurosurgeons may not be up-to-date on the latest science and treatment protocols.
13. Consider Neck Strengthening
Recognize that neck strength can play a role in concussion susceptibility, implying that strengthening the neck may be a proactive measure, especially for athletes, to potentially reduce risk.
5 Key Quotes
Concussion fights dirty. Like whatever you bring to the table that's weak seems to be affected more generally in patients.
Dr. Mickey Collins
I firmly believe 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.
Dr. Mickey Collins
Too much awareness without a solution is called hysteria.
Dr. Mickey Collins
The patients that come see me from out of town, almost all of them, because they haven't been treated.
Dr. Mickey Collins
Rest. You're exactly right, and you're absolutely wrong in how we approach this injury.
Dr. Mickey Collins
1 Protocols
Chronic Vestibular Concussion Rehabilitation Protocol
Dr. Mickey Collins- Complete a detailed set of vestibular exercises every morning and evening.
- Engage in a rigorous afternoon workout program (45 minutes to an hour) that specifically trains the vestibular system and increases parasympathetic nervous system arousal.
- Maintain a regulated sleep schedule, waking and going to bed at the same time daily, with no napping.
- Perform daily exposures to busy environments such as grocery stores, restaurants, and parties to challenge the vestibular system and reduce environmental sensitivity.
- Engage in external activities to prevent rumination and internal focus on symptoms.
- Follow up with a specialist every three to four weeks (in-person or via telemedicine) for adjustments and monitoring, with medication considered only if behavioral treatments are insufficient.