S03_E08 - Getting our Brains Around TBI and Concussions

Speaker 1: 0:01

Welcome to the Healthy Matters podcast with Dr. David Hilden , primary care physician and acute care hospitalist at Hennepin Healthcare in downtown Minneapolis, where we cover the latest in health healthcare and what matters to you. And now here's our host, Dr. David Hilden.

Speaker 2: 0:19

Hey everybody, it's David Hilden , back with another episode of the Healthy Matters podcast. Today on episode eight, we're gonna be talking about traumatic brain injuries and concussions. Joining me today is a colleague of mine from Hennepin Healthcare, doctor Matt Erba . He is a physical medicine and rehabilitation doctor. And yes, I'll ask him to describe what that is. He's also a veteran of the Air Force. So Matt, first of all, thanks for being on the show.

Speaker 3: 0:43

Thank you. It's a absolute pleasure to be here.

Speaker 2: 0:45

Tell us how you got here. Start off with your, your military career. You were, you're a veteran. A

Speaker 3: 0:49

Absolutely. So I got a scholarship to medical school through the United States Air Force. So after completing my internship, I spent five years on active duty as an Air Force flight surgeon. I spent a couple years in Ohio and three years in Germany, and I was able to travel around Europe and the Middle East and Africa and being able to treat a lot of our active duty service members. And then when I came back here to do residency, I was a member of the International Guard for four years. It was a great experience. Well,

Speaker 2: 1:15

Thank you for that service. My father was in the Air Force, so that's a , uh, uh, I have some connection to that branch of the service. I appreciate that. What is a physical medicine and rehab

Speaker 3: 1:24

Doctor? So, a pm and r doctor is , uh, also called a physiatrist or a phy . What we are is we're specialists in the restoration of function for people who have had severe injuries or illnesses. So today

Speaker 2: 1:37

We're gonna talk about TBI and concussion. And here at Hennepin Healthcare, we're in downtown Minneapolis. Um, we care for a lot of people in our TBI clinic. So if you could start us out with some basics, what is the definition of a traumatic brain injury ? So

Speaker 3: 1:53

The way the CDC defines us is some sort of disturbance of brain function that is due to a bump jolt or penetrating injury to the brain. That

Speaker 2: 2:03

Sounds bad. Is that a concussion?

Speaker 3: 2:04

So a concussion is a type of traumatic brain injury. It's often referred to as a mild traumatic brain injury. Oftentimes we'll use the word concussion when referring to an injury that occurs in just sport, but you can apply that definition in things like a car accident or falls .

Speaker 2: 2:19

Talk to me if you could, about how common this is because at, at our hospital, I get the impression it's kind of , kind of common 'cause we see a lot of people with TBI. But in the general population, how, how common is traumatic brain injury? Well, you'd

Speaker 3: 2:31

Be surprised almost 50% of Americans have sustained a concussive event or a brain injury within their lifetimes half. Yes sir. And

Speaker 2: 2:39

What is the most common reason they're getting that?

Speaker 3: 2:42

So the most common one overall is going to be due to sports injuries. The most common cause of presenting to a hospital is going to be due to a fall.

Speaker 2: 2:51

A fall from a building or what do you mean <laugh> or you mean just walking around falls ,

Speaker 3: 2:57

Uh , walking around. We commonly get these, especially here in Minnesota during the winter months.

Speaker 2: 3:01

Can you get a concussion, for instance, just walking down the sidewalk and falling down?

Speaker 3: 3:05

Yes. Unfortunately, I've seen a lot of people who have had that exact same scenario.

Speaker 2: 3:09

So explain to me then if you could, the various levels of severity. You used the word mild and you used concussion. How do you classify how bad it

Speaker 3: 3:20

Is ? That's a great question. And oftentimes there's a lot of discrepancy behind this. We classify them by mild, moderate, and severe traumatic brain injuries. This is based off of several different factors. One is, did you lose consciousness? And for how long was that, were you dazed or confused? How long did that last for? Did you have any memory loss from this? Also, just the overall impairment of your neurological functioning. We commonly will use the Glasgow Coma Scale. It's a score that emergency rooms will commonly use to grade how well your brain is doing. And based off of that, we can also assess how severe it is .

Speaker 2: 3:57

Are we seeing more of it currently because it's actually in the public consciousness a lot. I think largely 'cause of sports and everybody knows about the concussion protocol. And we're gonna get more into concussion specifically. But my question is this, has this been going on roughly for decades and decades and nobody just ever looked into it? Or is it truly on the rise?

Speaker 3: 4:16

That's a really likely case. The number of cases that have occurred are still kind of underestimated. We still think that there's a lot more concussions, especially in sports that are not getting the appropriate attention. And that's been great because we've seen the number of diagnosed concussions increase because of that awareness. Overall, though, we have seen an increase in hospitalization and deaths related to traumatic brain injury. So we know the incidence is on the rise overall.

Speaker 2: 4:45

So let's shift to concussion specifically , um, or mild traumatic brain injury. You said it happens a lot in sports or from a fall. What is actually happening in the brain in a concussion?

Speaker 3: 4:56

That's a great question. So we tend to think that there's two main pathological forces that are going on. One is that when you do strike the head, you'll get a bruise to the brain. A focal contusion as we'll commonly say a

Speaker 2: 5:08

Brain bruise.

Speaker 3: 5:08

Exactly. Exactly. The other part is, is that there's oftentimes some sort of force that twists or stretches the brain a little bit, and that causes a diffuse injury that often causes us to feel this overwhelming sense of the brain not moving right. Not performing the way it wants to.

Speaker 2: 5:26

Your , your brain is inside your skull. Your skull's got this important job of protecting your brain. So could you help flesh that out for me a little bit more if you could? Does your brain slosh around in there? Is it moving? Or how do you get a brain bruise when you've got this skull over it?

Speaker 3: 5:42

Yeah, so your brain is about the consistency of jello, surprisingly, but it's

Speaker 2: 5:46

Surrounding by and some of us us functions about at the level of jello too. Huh? <laugh> <laugh> . I couldn't resist. I couldn't resist that.

Speaker 3: 5:54

No . So the brains, you know , this gelatin ish kind of substance and it's surrounded by fluid, our cerebral spinal fluid, which is then, then , uh, shielded by a bunch of layers of tissue, including our skull. But when you have a lot of rotational forces or axial forces as well, that causes a lot of stretch. So great example for common things. A sneeze can produce something like 3.8 G forces. You know, that's a meters per second squared. Plopping in your chair can be about 10 of those kind of forces. An average NFL concussion is 98 Gs. So you need to have a significant force that goes on. A lot of times I'll use the reference a uh , hook punch in boxing that will cause both a rotational force as your jaw struck and kind of an axial up and down force that can cause that stretching sensation inside your brain that

Speaker 2: 6:49

Cannot be good for you. Boxing.

Speaker 3: 6:51

Yes, we refer to those things as bad.

Speaker 2: 6:54

Yeah , <laugh>. So Matt, how would you know the difference between a bump in your head, a harmless bump to your head and an actual concussion? In other words, how would a person in the general public know the difference and when to seek help?

Speaker 3: 7:06

Yeah, and that can be difficult at times for a lot of individuals. You know , we talk about it needing to be a significant mechanism of injury. You know, a high speed car crash, getting the airbags deployed to your face, that's going to be a different type of force than let's say just hanging your head on a cabinet sink or something like that. So what I'm really asking patients to pay attention for is did you lose consciousness? Did you lose memory of the event? Did you see stars or feel dazed for what seemed to be a longer period than what you would've

Speaker 2: 7:40

Expected? That's interesting that you said. Did you , did you lose consciousness? Did you see stars? That's kinda what we see 'em like in cartoons and you know, the road runner and all the stars above their head. But people really do get those things. They can, you see lights and stuff.

Speaker 3: 7:52

Absolutely. I do have a lot of patients who said, yeah, I just wasn't there for a while. It felt very strange sometimes I've heard people describe it as an outof body experience. Do

Speaker 2: 8:02

We know what is happening in the brain when you're losing consciousness? I mean, you bumped your head or you got a concussion, why do you lose consciousness?

Speaker 3: 8:11

We don't really know exactly why that occurs. We know what kinds of injuries are associated with it. That stretching force is associated with the loss of consciousness. I kind of use a reference of a record player. You know, if you hit the record player hard enough, the needle's going to pop off the record. And that can be a relative easy analogy for people to kind of grasp onto . I

Speaker 2: 8:35

Really like that. I have not heard that one before. 'cause I struggle sometimes to describe that for patients. So what other symptoms , uh, of concussion are there?

Speaker 3: 8:44

The most common one, approximately 90% of the time, 96% of the time, my apologies, is headache. Uh , this is followed by vestibular dysfunctions, which can be about 80% that sensation, feeling dizziness or that vertigo sensation. Oftentimes people describe feeling fatigued, having slowed processing, like their brain's just not moving the way it wants to memory deficits. Uh, and oftentimes some people will describe some mood difficulties as well.

Speaker 2: 9:13

What short-term consequences are there of a concussion and what are the long-term effects?

Speaker 3: 9:18

That's a great question. So short-term, we tend to kind of think that for most mild traumatic brain injuries and concussions, they'll resolve relatively quickly. Most return to play guidance that the CDC and the International Committee of Sport have put out are generally resolving their, their protocol within seven to eight days. Generally

Speaker 2: 9:38

Resolving their protocol means you're better.

Speaker 3: 9:40

Oh yes. Or meaning returning back to full play. Okay. But for some people they still have persistent symptoms that can last for months to years afterwards, and it's hard to predict who might be in that category.

Speaker 2: 9:52

Does that risk increase with multiple concussions?

Speaker 3: 9:56

Well, the joke in our field is, is once you've seen one concussion, you've seen one concussion. Mm . Every concussion is different based off of the types of forces that occur into the event and also what you're bringing to the table. If you've already had a damaged brain, it's very likely that the next injury is going to worsen that damage. Yeah.

Speaker 2: 10:15

It can't be good to repeatedly have concussions. At least it doesn't make common sense that it would be, it would be worse.

Speaker 3: 10:21

Correct. A concussion is kind of like a brain sprain, you know, with an ankle sprain, you're , yeah, you can get hurt, you can brace it, but every time you sprain it, it might worsen that injury and it might make it worse later on in life. So

Speaker 2: 10:35

Matt, you also work with professional athletes. I think you've told me that you actually work with professional football players on , on concussion protocols. So that leads me to ask, how do you diagnose a concussion? Or in other words, what are those NFL players doing when they go into that blue tent? So

Speaker 3: 10:50

The diagnosis actually was just recently updated by the American Congress of Rehabilitation Medicine in 2023. The first thing is you need to have that appropriate mechanism, like I said, along with some sort of clinical sign being the loss of consciousness, the alteration of consciousness, stumbling, ataxia. Once those have been identified, then the player or the patient is understood, basically that meets the definition of concussion. From there, we do a more formal assessment on the sideline. The current assessment is something called the sport Concussion Assessment Tool, scat . Clinically, we're usually assessing in the emergency room or oftentimes in our family practice or primary care office to determine what kind of symptoms and persistence of problems are still going on. When

Speaker 2: 11:37

Someone is in a sport related concussion, they're often told not to go back in and play, but they used to. That used to be a thing they just get back in there. Shake it off. Yeah, shake it off. You got your bell rung <laugh> , uh, um, talk about if you could, the importance of seeking medical attention and what you ought to do after you get a concussion.

Speaker 3: 11:55

So one of the largest concerns that we have is an entity in that's been reported called Second Impact syndrome. This is a catastrophic brain injury that occurs when your brain gets injured again while recovering from the first injury. This is extremely horrible because what ends up happening is that the brain loses its ability to control the blood flow inside the skull. And when you get a second injury, all of a sudden you have risk of getting increase of blood pressure, which can unfortunately cause your brain to herniate, which is a severe neurological problem.

Speaker 2: 12:31

We are talking with Dr. Matthew Erba . He is a physical medicine and rehabilitation doctor. Here at Hennepin Healthcare , we're talking about traumatic brain injury, and when we come back from the break, we're gonna talk about the importance of treatment and rehabilitation after traumatic brain injury. And we're also gonna touch on the relationship between TBI and mental health. Stay with us. We'll be right back

Speaker 4: 12:55

When Hennepin Healthcare says we are here for life. They mean here for you, your life, and all that it brings. Hennepin Healthcare has a hospital HCMC and a network of clinics both downtown and across the West Metro. They provide all the primary care and specialty care you would expect to find, but did you know they also have services like acupuncture and chiropractic care available at many of their primary care clinics and at their integrative health clinic in downtown Minneapolis? Learn more@hennepinhealthcare.org. Hennepin Healthcare is here for you and here for life.

Speaker 2: 13:33

And we're back talking about traumatic brain injury. Before we get into rehabilitation and treatments, Matt, could you help dispel a few misconceptions about, about TBIs or, or are these real people talk about don't fall asleep or stay in a dark room? Could you comment on those? Yeah,

Speaker 3: 13:48

Absolutely. And I still get questions about those on a regular basis. So the first one is the don't fall asleep, you know, stay awake the entire time. Then we have proved that long ago that you do not need to do that. So that is still a vast misconception out there. What

Speaker 2: 14:03

Was the thought that you would never wake up?

Speaker 3: 14:04

Well, there was this idea that if your brain did undergo a , you know, severe injury and would end up herniation, then you would lose consciousness and you'd fall asleep. Uh, that is by far not the case. The vast majority of concussive events are not that kind of case. And for the most part, once a person is out of kind of a watch area for a few hours, then they're probably safe. Now again, it should be mindful to keep checking on people every so often. You know, I do sometimes still say, just check on them, make sure that they're okay in the middle of the night. But sleep is good, sleep is important for the brain, so we don't wanna deprive the brain of that precious resource. Uh , I've also heard of people , uh, quote unquote cocooning themselves, meaning that they lock themselves into a dark room. They avoid all screen time whatsoever, and no, that's not recommended either. We do recommend after a head injury in a concussion to have relative physical rest and cognitive rest for between one to two days afterwards. This means reducing screen time, making sure you're not doing any activities that provoke things like headache and fatigue and getting adequate rest.

Speaker 2: 15:13

What about long-term treatments?

Speaker 3: 15:15

So, as I had alluded to earlier, the vast majority of concussions do improve within that first two week period. So they should be continued to be followed by the appropriate medical personnel, whether that's through their athletic trainer, their primary care provider, et cetera . For people that still have persistent symptoms, beyond that two weeks or month, they should be elevated to A TBI clinic or a TBI specialist to help ensure that there isn't other issues that are at play and to make sure that the patient gets the adequate treatment that they need. So

Speaker 2: 15:45

At Henneman Healthcare, we, we care for a great number of people with TBI in our system. Could you just briefly tell us what that professional team looks like? It's doctors like you, but there's a whole group of people.

Speaker 3: 15:57

So while our physician team may be at the center of this , uh, in our TBI clinic, it is composed of a vast array of great professionals. This can include physical therapists, occupational therapists, speech language pathologists who help us work on thinking, retraining for patients. We also have a developmental optometrist who is a specialist in eye injuries or eye dysfunction after traumatic brain injury. We also work with our psychology teams, including our neuropsychology teams and , um, our audiology teams to make sure we're providing the appropriate care for patients.

Speaker 2: 16:32

So Matt, when a patient comes to your team or you in the TBI clinic, what does that treatment look like?

Speaker 3: 16:38

The first part is, is that we spend time learning more about the patient and what kind of symptoms that they're having, and we're doing assessments to looking for things of balance disorders, how well they're thinking and how well their eyes are moving from there, then we're referring on to other members of our team to kind of address those areas. So for a patient that has persistent dizziness or vertigo afterwards, they may be getting their balance centers assessed by our audiology team. They may be going to the physical therapist to work on balance exercises to ensure that they don't fall. Again. For patients that have vision difficulties, their eyes have problems tracking objects or they gain worsen blurry vision, we'll work with our developmental optometrist and our occupational therapist to work on vision rehabilitation so that their eyes can get realigned.

Speaker 2: 17:27

So in a nutshell, summarize what ought to be done after a concussion.

Speaker 3: 17:31

So in any suspected concussive events, the patient needs to be assessed by the appropriate personnel, whether that's sideline going to their primary care or to the emergency room, physical and cognitive rest for one to two days, and then following the appropriate return to play and return to activity guidelines. And if they still have symptoms or you're still kind of not doing well, that's when they need to be escalated in their care.

Speaker 2: 17:53

Super helpful. I wanna talk about something that you alluded to a few minutes ago about mental health and cognitive health in its relation to concussion.

Speaker 3: 18:03

Absolutely. And this is a great intersection between two fields that people think are separate, but they're actually very similar. The brain handles our emotions, we can all agree on that, and when we do have brain injury, that can cause our emotions to be kind of not working the way that they need to be. Oftentimes people describe this as what's called emotional ability . You know, they feel like they go from zero to 60 and you know, zero seconds flat, so they just don't have that bandwidth, that cognitive reserve to allow their emotions to be appropriately processed.

Speaker 2: 18:34

How do you address that , uh, in your, in your team?

Speaker 3: 18:37

So oftentimes these are worsened because they have headache, dizziness, they can't sleep well. So the first goal is to try and work on getting their sleep, their headache under control, trying to improve that ability of their brain to have that reserve so that they can handle things a little bit better for those people who are still having significant mood symptoms. We often bring in our TBI psychology team. One of the other factors is we're talking about traumatic brain injury, which can often be a traumatic event. And so sometimes people will have post-traumatic stress disorder or post-traumatic stress, which can also influence them . So our TBI psychology team is fantastic at helping these individuals work through some of these things and trying to help to work on reprocessing their emotions so that they feel more in the driver's seat

Speaker 2: 19:25

Sort of giving coping strategies.

Speaker 3: 19:27

Absolutely.

Speaker 2: 19:28

Yeah, that, that, that's a key point I think is the intersection between your mental health and TBI. What about cognitive functioning , uh, um, in the long term ? Uh , do people lose some executive functioning or is that not very common?

Speaker 3: 19:41

There can be. There has been a lot of literature that's been looked at in terms of people's ability to kind of use their cognitive energy , uh, in brain injury. We commonly think of our cognitive areas of our brain as being the frontal lobes, and those are one of the lobes that are commonly affected with injury.

Speaker 2: 20:00

So for people or their family members or loved ones who have experienced A TBI, and maybe we're getting even more now into the more moderate to severe TBIs, what resources are available to support them either online or in person or through your clinic? Where do you suggest people go for support

Speaker 3: 20:18

While we are one component of that, you know, we're the medical treatment team. There are definitely lots of community support out there. One of the largest ones is the Minnesota Brain Injury Alliance, which holds a lot of community events and raises a lot of community awareness about traumatic brain injury. That's

Speaker 2: 20:36

Terrific. We can try to get a link to that , uh, that site in our show notes. So listeners, if you want to get more , uh, information, you can certainly access that. Let's close off Dr. Peter BA by talking about some preventive strategies. What , what few things would you advise for prevention?

Speaker 3: 20:52

Uh, don't do silly things. Okay. Okay . That's a good advice. <laugh> ,

Speaker 2: 20:56

I think that about sums it up. Yeah.

Speaker 3: 20:58

Uh , um, but largely things that I really do hammer on is one is that there is a huge intersection between alcohol misuse and traumatic brain injury. Up to 70% of traumatic brain injuries have alcohol as a factor involved.

Speaker 2: 21:12

That's a lot.

Speaker 3: 21:13

Yeah. And it could be as simple as the person being intoxicated and driving, or an intoxicated driver hitting another person and causing them to have traumatic brain injury. So really responsible alcohol use is one of the things I really do pay attention for. And I talk about often don't get behind the wheel when you're intoxicated. We have Uber, Lyft, you have so many different ways to get rides, so please no drinking and driving and avoidance of alcohol when you're doing activities that may put you at risk such as sports or rock climbing or other things like that.

Speaker 2: 21:45

That's such an important point. So I'm really glad you said that. What

Speaker 3: 21:49

Else? Wearing a helmet when appropriate, so things like cycling, there's oftentimes we see a lot of bicycle accidents, especially with our younger patients. So encouraging good helmet use will oftentimes be a great preventative source to reduce the severity and potential incidents of traumatic brain injury. Do

Speaker 2: 22:07

You have tips for parents? So like, when my teenagers would ride their bikes away from the home, they would have their helmet on, and I am fully aware that when they got a block away from our house, the helmet was , uh, strapped around the

Speaker 3: 22:19

House . Yeah. I mean, I guess you can always put an Apple tag on it and see what happens. <laugh> uh , <laugh> ,

Speaker 2: 22:25

High tech monitoring That's right . Of your children's behavior. It is hard to get kids to, I'm , I'm being facetious, but not really. It is hard to get kids to wear their helmets sometimes.

Speaker 3: 22:33

No, absolutely. I have five children and that is one of the key things, anytime they get onto the bike, they know that they have to have their helmet on.

Speaker 2: 22:39

Yeah. So prevention is what you're getting at here.

Speaker 3: 22:42

Absolutely. You know, it's in terms of traumatic brain injury, once the injuries occurred, there is some treatment options, but that injury is there to stay. So if we can prevent it, that's better for your brain. Smart

Speaker 2: 22:54

Use of alcohol. Number one, wear your helmet in the, in many situations,

Speaker 3: 22:59

And if you do have an event where you do think you had concussion, seek medical attention early on. These

Speaker 2: 23:05

Are great tips. Dr. Matthew Erba , thank you for being on this show today.

Speaker 3: 23:10

Absolutely. It was my pleasure. We've

Speaker 2: 23:12

Been talking with Dr. Matthew pba . He is a physical medicine and rehabilitation doctor here at Hennepin Healthcare in downtown Minneapolis. He's also a flight surgeon for the United States Air Force, and he also works with professional athletes for the National Football League. So he has a wealth of information and I thank him so much for sharing it with us today. If you wanna learn more about traumatic brain injury, please go to the show notes where we have links to more resources for you. And if you wanna learn more about medicine, join us in two weeks for our next episode. In the meantime, be healthy and be well.

Speaker 1: 23:44

Thanks for listening to the Healthy Matters podcast with Dr. David Hilden . To find out more about the Healthy Matters podcast or browse the archive, visit healthy matters.org. Got a question or a comment for the show, email us at Healthy matters@hcme.org or call 6 1 2 8 7 3 talk . There's also a link in the show notes. The Healthy Matters Podcast is made possible by Hennepin Healthcare in Minneapolis, Minnesota, and engineered and produced by John Lucas At Highball Executive producers are Jonathan, CTO and Christine Hill . Please remember, we can only give general medical advice during this program, and every case is unique. We urge you to consult with your physician if you have a more serious or pressing health concern. Until next time, be healthy and be well .