Download Dr Childs* PPT - Concussion Relief: Home

Dr. Joseph M. Childs
Board Certified Chiropractic Neurologist
Joseph Childs, DC, DACNB
– Board Certified Chiropractic Neurologist
– Fellowship Trained in Functional Neurology
– Fellowship Trained in Minor Traumatic Brain Injury &
Concussion
– Fellowship Trained in Vestibular Rehabilitation
– Fellowship Trained in Childhood Neuro-development
Disorders
– Trained in Functional Nutrition and Blood Chemistry
– Trained in Spinal Decompression & Biomechanics
– Exercise Physiologist
– Trained in Chiropractic Pediatrics
T
• Dr. Fred Carrick
•
(Father of Functional neurology)
• The Carrick Institute for Graduate
Studies (Functional Neurology)
• Carrick Brain Center
Atlanta
Dallas
• Harvard Medical School
Grand Rounds at the
Carrick Brain Center
What You Will Learn Today
• The mechanism of concussion
• What the leading Functional Neurologists are doing
to diagnose and treat post concussion syndrome
• What to do other than medications and rest if
concussion symptoms are lasting beyond 1 month
• What parts of the brain are most commonly involved
• Why passing an IMPACT test may not = concussion
healed. What is a complete baseline
• Why eye movements and balance testing will be the
gold standard in diagnosing areas of the brain
damaged by concussion
• Drug free approaches to treating the major areas of
the brain affected by concussion
“GETTING YOUR BELL RUNG”
=
mTBI
Minor Traumatic Brain Injury
=
Concussion
• 1.7 Million people,
including 475,000
children sustain a TBI in
the U.S. each year. 3.1
million individuals live
with life-long disability
as a result of TBI
TBI’s are caused by caused by:
• Falls (35%) –Typically elderly
• Car crashes (17%)
• Workplace accidents (16%)
• Assaults (10%)
• Other- including athletics(21%)
About 75% of TBI’s that occur each
year are concussions or other forms
of minor traumatic brain injury
Head injuries do not have to result in a loss of
consciousness to be serious.
The American Academy of Neurology:
Defines concussion as a "trauma- induced
alteration in mental status that may or may not
involve a loss of consciousness.
Studies show there are more than 300,000
sports related concussions per year.
Children and adolescents involved in
organized sports are nearly six times
more likely to suffer a severe
concussion than those involved in
leisure physical activities.”
Keightley
“
We need a better approach to
preventing, diagnosing and treating
these young athletes
There is an unfortunate pattern developing
among former athletes of contact sports; an
Alzheimer’s-like neurodegenerative disease
called Chronic Traumatic Encephalopathy
(CTE). According to researchers, CTE has a
clear environmental cause - repeated brain
trauma.
What are the possible long-term
effects of multiple concussions?
According to a 2005 study by the Center for the Study of
Retired Athletes, former NFL players who suffered three or
more concussions are five times more likely to have mild
cognitive impairment and three times more likely to have
significant memory problems than players who do not
have a history of concussions. In addition, there appears to
be a link between multiple concussions and the early
onset of Alzheimer's. The study's disturbing conclusion:
"Our findings suggest that the onset of dementia-related
syndromes may be initiated by repetitive cerebral
concussions in professional football players."
CTE: Chronic Traumatic Encephalopathy
Retired boxers and football players
develop dementia at a higher rate and a
younger age compared to the general
population.
Brain autopsies of athletes who have
multiple concussions demonstrate
markers similar to Alzheimer’s disease:
• Taui-immuno-reactive tangles
• Beta –amyloid (ab) peptides
“
mTBI SYMPTOMS:
Headaches: Common and can be
debilitating. (Autonomics – chemical)
Feelings of dizziness: Can create total
dysfunction. (Vestibular cerebellar)
Poor Balance: (cerebellum, brain stem)
Nausea and/or vomiting: Can create
electrolyte and hydration issues. Brain stem
and Sensitization/Chemical)
“
mTBI SYMPTOMS:
Sensitivity to noise: Mesencephalon, collicular
and tectal issues. (Sensitization and chemical.)
Poor sleep: Mesencephalic GABA, Glutamate,
(Sensitization and chemical).
Fatigue: Poor fuel and cortical function.
(Mitochondrial and fuel utilization issues).
Irritable: Limbic function that has poor cortical
gaiting function. (Cortical and limbic damage).
mTBI SYMPTOMS:
“
Depressed or tearful: Limbic function that
has poor cortical function. (Cortical and
limbic damage)
Frustrated or impatient: Loss in frontal
and cortical function. (Cortical and
chemical)
Forgetful, poor memory: Hippocampal
and cortical damage. (Cortical – chemical
and cortisol).
Poor concentration: Poor cortical
function. (Loss in cortical function and
fuel)
mTBI SYMPTOMS:
Taking longer to think: Poor cortical and
cellular function. (Fuel and cellular
function).
“
Blurred vision: Visual system or
interpretation damage. (Autonomic –
vergence – accomodation)
Upset by bright light: Mesencephalic and
brainstem changes. (Fuel and cellular
function)
mTBI SYMPTOMS:
Double vision: Cortical or brainstem damage.
Restlessness: Basal ganglia, gaiting, transmitter
and CIS issues. (Anatomical and chemical)
“
Altered sensation such as Numbness or
tingling:
(parietal Lobe)
Abnormal or altered movement such as gait:
(frontal lobe, motor pathways, cerebellum,
basal ganglia)
RECOVERY?
Younger players (HS and younger) seemed to
recover slower by 1 week compared to older
college athletes.
Balance deficits and headaches should be
dissipated in 3‐5 days.
Neurocognitive deficits should be dissipated in
5‐7 days.
What does it mean if these things do not
resolve?
Post‐concussion symptoms usually
dissipate after 7‐10 days.
However…
The Zurich Concussion Consensus
paper states that 10-15% have
persistent symptoms greater than
10 days.
Many sufferers continue to have
symptoms for months to years.
What does that mean?
The Standard Return to Play Protocol:
Stage 1- No activity (complete physical and
cognitive rest) remain in stage 1 until symptom free.
Before going to stage 2 athlete should attempt a period of
reading and light cognitive activity that causes no symptoms
Stage 2-Light aerobic exercise
Stage 3- Sport specific exercise
Stage 4-Non-Contact Drills
Stage 5- Full-contact practice
Stage 6-Return to play
If any symptoms are incurred at any one of the stages, the athlete
is to take the rest of the day off and return to the previous stage
the following day. The athlete is to remain at that stage for at
least 24hrs. If symptom free they may attempt the next stage
again
My son or daughter passed the IMPACT test
but still has chronic headaches, sensitivity to
light, and poor balance. WHY?
Computerized neuropsychological tests do not
test all areas of the brain that can be involved
in a concussion
Where does the functional
neurologist fit into the picture?
“
How are we different in our
approach?
1.
2.
We do not treat emergency
situations.
We do not treat with
medications
Where does the functional
neurologist fit into the picture?
“
3. We look at overall brain function
4. We look at each specific brain region, specific
functional capabilities and the neurochemical
environment very well.
This is different than just passing a computerized
test or vague, generalized batteries of tests that do
not look at various things from a functional model.
Where does the Functional
Neurologist fit into the picture?
“
Example: IMPACT test is normal, you
have math, recall and no other
neurological symptoms
But your eye movements are still
pathological and fatigue rapidly and
you have transient mental fatigue
issues
Where does the functional
neurologist fit into the picture?
“
We also look and treatment and
recovery differently.
More on that in a bit
What Makes the Functional
Neurological approach different than
every Other Doctor That You Have
Seen?
We treat patients
Neurologically ,
Metabolically and
Biomechanically.
“As Functional Neurologists …
• We see concussion patients who do not
get better symptomatically by rest
• It is important to understand the
majority of concussion sufferers that do
feel better with rest are not really better
neurologically
• If a player goes back less than 100%
there is a high chance that they will get
hurt again
HS athletes are 3x more likely to experience a 2nd
concussion after experiencing an initial
concussion in a season. Especially if not fully
recovered
Second Impact Syndrome
1. Sustaining a 2nd concussion WHILE still
recovering from an initial concussion.
2. Severe Brain Swelling can cause death. Red
flags – must be treated appropriately
There are two main things that happen to
the brain with concussion.
First-there is the actual mechanical trauma
where the brain bangs around inside the
skull . Coup- Contrecoup
Second- there is a biochemical reaction that
involves inflammation and swelling.
So there is a
MECHANICAL and
NEUROLOGICAL
consequence of a traumatic
brain injury and also a
resulting METABOLIC
consequence.
Lets talk neurological first…
Cerebrum
Brainstem
Anatomy of the Brain
Stem
“Concussion is due to an
abrupt linear and/or rotational
acceleration or deceleration of
the brain within the skull”
Concussion= mTBI
The rotational forces of
trauma torque and damage
the midline structures of the
soft brain
“Like ringing out a wet
towel”
The midline structures of the
brain such as the brain stem,
cerebellum, limbic system and
basal ganglia control:
• Eye movements
• Balance
• Cardiac Function and Breathing
• Emotion
• Digestive Function
• Coordinated Movement
• Blood Flow To The Brain
• Perception Of Body Position In Space
Central Vestibulopathy?:
Pupil Stays Wider
More Light Comes In
Head injuries that result in concussion often are
associated with injury to the neck and spine
The associated resultant joint dysfunction may
further impair brain function, due to the
alteration and reduced afferent input from the
cervical joint and muscle receptors in the neck.
Advanced Testing Of Brain Function:
We are expertly trained in
the use of advanced
neurological
instrumentation that
objectively evaluate your
brain and are used to
monitor progress
Advanced Testing Of Brain Function:
Also a Better BASELINE
• VIDEO-NYSTAGMOGRAPHY
• SACCADOMETRY
• CAPS- Balance / Posturography
testing
• IMPACT
Typical Computerized
neuropsychological tests
such as IMPACT assess
attention, working memory
and executive functions
That does not test all areas of
the brain that may be affected
WHY ARE EYE MOVEMENT SO
IMPORTANT TO DIAGNOSING AND
TREATING CONCUSSION?
Eye movements are the only
human physiological function that
involves every part of the brain
SACCADOMETRY
SACCADOMETRY Research
SACCADOMETRY
Sensitive computerized measurements
of fast eye movements known as:
SACCADES
1.
2.
3.
4.
Latency
Velocity
Accuracy
Waveform
Why SACCADOMETRY?
Lets say a Quarterback has a concussion and after
some rest he passes his IMPACT test and he gets back
on the field But
If he had SACCADOMETRY it would reveal that his
saccadic reaction time (latency) to the left is normal at
< 200d/s but his saccades to the right (his blind side)
are pathologic at 500d/s. Do you think with that delay
that he may miss the linebacker coming to tackle him
from the right thus putting him at risk for another
concussion?
“
VIDEO NYSTAGMOGRAPHY
•
•
•
•
•
•
Gaze Stability (all planes)
Nystagmus (gaze in the dark)
Pursuits (horizontal/vertical)
Saccades (horizontal/vertical)
Optokinetics (horizontal/vertical)
Vestibular Ocular Reflex (VOR)
VIDEO-NYSTAGMOGRAPHY
VIDEO-NYSTAGMOGRAPHY
VIDEO-NYSTAGMOGRAPHY
Balance / Posturography
Testing
CAPS
Balance / Posturography Testing
Is an extremely sensitive force
platform and specifically designed
software. It is so sensitive that it can
measure otherwise imperceptible,
undetectable movements a patient is
making when they are standing
CAPS can detect abnormal balance and
instantly compares the results to
normative data for a person age,
CAPS
Balance / Posturography Testing
After a concussion the brain’s
perception of where the body is in
space becomes distorted from what is
normal and accurate. This is called a
person’s Center of Pressure and it can
be altered in various planes. This can
be measured by the CAPS unit and
compared with the eye movements to
create specific therapeutic exercises
to help a person recover from their
How Many Of You
Have Had All Of
These Tests
Performed???
WHY NOT?
Treatment: Neuroplasticity
… “Of all the finds, though,
one is rewriting the textbooks.
It is the dawning realization
that a brain older than three
years old is not the rigid
structure that scientists long
thought, but a malleable,
‘plastic’ organ”... “But a flood
of discoveries show that the
brain continually reorganizes
itself. It’s called
‘neuroplasticity.’ And it means
that “you create your brain
from the input you get”
Treating a brain that is malfunctioning after a TBI
The Brain REQUIRE 2 things in order to
function properly:
Fuel: - Glucose
- Oxygen
Activation - “brain
exercise”- stimulation
Therapies Used for Brain Activation
May Include Some of the Following:
• Specific eye exercises based on the
•
•
•
•
•
•
testing
SSEP
Vibration Therapy
Proprioceptive stimulation
Balance Therapy
Advanced muscle retraining
Vestibular stimulation therapy
Therapies Used for Brain Activation
•
•
•
•
•
Interactive
metronome
EYELIGHTS
Optokinetics
HemiStim Programs
Many more…..
METABOLIC
From a metabolic perspective, there are
several things that happen following a
concussion.
1. Increased glutamate levels
2. Altered glucose utilization
3. Mitochondrial dysfunction
4. Reduced available Magnesium
5. Brain Inflammation
BRAIN INFLAMMATION
In the injured brain there is a slow build up of free radicals,
prostaglandins, lipid peroxidation products, inflammatory
cytokines and excitotoxins that damage the connections
between brain cells, the synapses, axons and dendrites.
The process is mediated by cells called microglia.
Once the microglial cells are activated, they tend to
persist in this state and can actually create even
greater neural inflammation over time
A person that prior to their brain injury
already has an inflamed body and brain from
poor metabolic health such as:
• Blood sugar issues
• A diet heavily loaded with excitotoxins such
as MSG or Aspartame
• Food sensitivities such as Gluten and Dairy
• Intestinal permeability (leaky gut)
• Adrenal dysfunction
Can compound the negative metabolic affects
associated with concussion causing a poor recovery
Preliminary Blood Testing
CBC
Chem panel
Liver panel
Iron/ Ferritin
Full Thyroid Panel
Thyroid Antibodies
Lipid Panel
Inflammation markers
Vitamin/ Minerals
Simple Gluten Sensitivity Test
Special Panels/Testing
Cyrex array 2: Intestinal Antigenic Permeability Screen
(Leaky Gut Testing)
Cyrex array3: Wheat/Gluten Proteome Reactivity &
Autoimmunity
Cyrex array4: Gluten Associated Cross-Reactive Foods
and Food sensitivity
Stool Microbial Ecology
Adrenal Stress Index
Intestinal Permeability Test
LEAKY GUT SYNDROME
A) Normal absorption = healthy gut
• B) Poor gut barrier : Common
problem in celiac disease,
autoimmune processes, food
sensitivities, CHRONIC PAIN
• C) Malabsorption =poor gut health
METABOLIC
Metabolic
Symptoms
Condition
Functional
Neurology
Structural
(Spinal
Biomechanics)
Where to go from here?
Post-Concussion Severity
Evaluation
• Neurological exam
• Advanced testing
Complete Baseline Evaluation for
Concussion
• Advanced testing