Chronic traumatic encephalopathy, better known as CTE, has received a lot of coverage in recent years, largely due to its relationship with sports concussions. As we learn more about that relationship, we also learn more about the treatment of concussions to the extent that a new standard of treatment is emerging that is targeted to the individual and appears to be producing better long term results. In the latest Short Talks from The Hill, RJ Elbin, associate professor of exercise science and director of the office for Sports Concussion Research, joins host Hardin Young to discuss his research in concussion treatment.
Hardin Young: How have concussions been traditionally treated?”
RJ Elbin: It’s evolved. In 2005, when I first started learning about concussion, usually it was like ‘Hold up two fingers back into the game’. We used to grade concussions way back when you would have, similar to an ankle sprain, which is kind of still used today, but a grade one, a grade two or grade three. And it was a recipe that a healthcare provider could use if they could figure out the severity and grade of the injury, then they could tell and predict when an athlete could go back to play. So if you had a grade one, you were maybe out a couple of days, a grade two, you were out maybe a couple of days to a week, and grade three is longer. So the higher the grade, the longer the sit out time. Now, we weren't assessing. We were just how are you feeling? Tell us your symptoms. Really had no idea really, how concussion behaved in the everyday lives of patients, in contrast to what we're learning now. And those grading scales were based on, like, the length of time that someone was unconscious. That happens in less than ten percent of all these injuries. So if you think about that for a second, most concussions don't have that hallmark sign. It's pretty rare, although we see it a lot on TV because the gruesome images, unfortunately, and the sensationalized kind attracts viewers. But most concussions, I mean, it's called the hidden injury for a reason. It's also called the last one to show up at the party for that reason. Like, whereas symptoms of concussion can be a little bit delayed, concussion looks a lot like a migraine, a lot like dehydration, a lot like fatigue. And I'm glad I'm not an athletic trainer on the sidelines. I work with them. They have a really, really hard and important job. Critically important to identify, is this concussion? And when in doubt, sit them out, especially with younger kids. But the clinical care of this injury has evolved. We're no longer how many fingers am I holding up? Just checking symptoms. How are you feeling? We're not grading concussions anymore. In the clinical setting. There's lots of little taglines, and one of them is once you've seen one concussion, you've seen one concussion, and everyone's different. We have a lot of different personality characteristics, different health history characteristics, and those play a role in the treatment of this injury. It also plays a role in the length of recovery and the diagnosis of this injury. So we've come a long way from grading concussions to now taking all of this information about the individual. Number one. So a doctor, that is what I would call up to date because concussion care has become very, very specialized. There's a few centers of excellence around the country that are training medical professionals, and that's all they do. They only see individuals with concussion, young and old. So these folks will take what the individual brings to the table. Their health history also details the injury, whether or not maybe there was on field dizziness, whether or not there was loss of consciousness, what were the acute symptoms that were presented? They pack that all together and then they do a very comprehensive test, more than just impact or that cognitive test that I talked about. We're now assessing dizziness. We're assessing vision, balance, mood, and emotional changes. And then along with that we want to know what environmental triggers make those show up. Some kids can go to school fine. Some kids can't be in busy environments. Those are telltale signs that they help doctors to understand what's below the surface. Right? If we can figure out what's below the surface, then we can be targeted and we can attack and treat that impairment, even rehab it. And that's where concussion care has gone now. We call that a clinical profiles approach. So we think that there are distinct subtypes of this injury. And these subtypes for example cognitive, this can be a predominant cognitive subtype. There can be a predominant mood subtype or a vestibular subtype. People with vestibular subtypes have problems in busy environments. So there's all these subtypes and they can be matched to treatments.
Hardin Young: You use the word vestibular. Can you explain to people what you mean by that, who may not know?
RJ Elbin: Everyone has a vestibular system. It's part of the brain that gives us information from the environment and makes sense of it. In other words, when we're in cars, when we're maybe on boats, our balance. It's a complex system in the brain that helps us know where we are in time and space.
Hardin Young: And that's a specific test that can be an indicator of a concussion?
RJ Elbin: There are a few tests that we've developed that we're currently using in clinical care. And when patients are provoked on these screening measures, they're often referred to specialists. And that's that targeted care. These specialists can really attack and rehab that vestibular system if that's the predominant problem going on, that's a distinct subtype that has a very well match. And really there's more and more research coming out on the efficacy of vestibular rehabilitation. It's a specialty area of physical therapy. So people are getting physical therapy for their concussion.
Hardin Young: As I mentioned in the introduction, you recently co-authored a paper with Dr. Womble (Ph.D) out in Virginia. So explain what the study was and what you found.
RJ Elbin: Dr. Melissa Womble (Ph.D) is the clinical director at the Anova Sports Medicine Concussion program. And back in 2017 I'm her research right arm, and she sees the patients and I write the papers. She said back in 2017, ‘Hey, why don't we get approval to follow my patients and see how they're doing?’ There's quite a bit of science out there on the long term effects of these injuries, but many of that research doesn't really consider the type of care, or lack thereof, of the participants in those studies. And so back in 2017, we started consenting patients to say, like, ‘Hey, we're going to contact you a little bit later on, years later, and we're going to see how you're doing’. So it's been a long time coming. Our idea was to measure what's called health related quality of life. It's a commonly used measure. Anyone can take it and it assesses how someone is doing in various domains like their sleep, their physical well-being, whether or not they experience daily pain, their cognitive well-being, mood, emotion. It's widely accepted and used in a lot of different studies and a lot of different medical disciplines. It's a good picture on how someone is, quote, doing. So we sent out that survey to one hundred or so patients, ranging one to, I believe, six years following medical clearance. So all of these patients had a stamp of clearance from Dr. Womble. They were treated by the same physician, and they all received this new clinical care approach that I alluded to earlier. And we just wanted to say like, you know, how are these patients doing? So we gave them a battery of health related quality of life questionnaires, and we compared their responses to normative data. These are, as I said before, well-established. And there are norms. So we know what a fifty year old male should, you know, what the average is above or below average. And what we found was, I want to say nearly ninety percent. The overwhelming majority of patients were doing fine. One to six years after concussion, these patients had health related quality of life scores at or above normal, which is in contrast to what you see in some of the other papers that are really detailing, some really not so good long term effects from concussion in various populations, former professional athletes, military personnel, military individuals. But those individuals are not like these patients. These patients that we published on were everyday patients. They were either in a car accident. Some were sports. They underwent treatment like treatment, like they weren't just monitored, they were all treated. And I will say this was not a randomized controlled trial. We didn't compare to other approaches. This was just a descriptive paper saying like, ‘Hey, we got this cohort of patients and let's see where they're at.’
That was RJ Elbin, an associate professor of exercise science at the University of Arkansas and director of the office for Sports Concussion Research. He was speaking with Hardin Young. You can hear their full conversation about targeted concussion treatment by searching for Short Talks from The Hill in your podcast app.
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