Concussion: The Hidden Injury
R.J. Elbin: Thank you.
HY: So first of all, I’m curious about how people arrived at their area of expertise. What is your background and how did you decide to make the study of concussions the focus of your research?
RJE: It’s a great question. I was a college athlete. I played college baseball at the University of New Orleans, and I’ve always been involved in sports. I also played high school football, and knowing now what I maybe should have known then, I’m sure that I’ve had a few concussions. However, I’ve had none diagnosed to my knowledge. But, I was a graduate student at the University of New Orleans. I originally wanted to be in more of the sports performance side, like bigger, faster, stronger. I got my masters in exercise physiology.
Mentors are so important to us, as we develop as students and professionals. I had a professor, Dr. Anthony Kontos, who was a professor at U.N.O. at the time, and I was doing a master’s thesis. He stopped me in the hall one day and he goes, “Hey, have you come up with your topic for your master’s project?” I’m like, “no, you know, I haven’t.” And he goes, “Well, I’m working on this project with a colleague of mine,” who ended up being a pioneer in the field, actually, Dr. Mickey Collins, and they were developing a new computerized cognitive test specifically for concussion. I was one of the first students to do a project with that. We had this prototype, so to speak, or this test on a floppy disk. And I went out to high schools and started to do it, just really fell in love with research. I was really fascinated by the brain and just piqued my interest as a student moving forward. Now that test is worldwide. It’s delivered on the internet, and I had the old floppy disk in my hand. So it’s kind of cool to be on the grassroots of a really cool thing, and it’s turned into a great career and a fulfilling career.
HY: And can you tell us what was that test? What were you measuring?
RJE: The short name is called ImPACT. It’s been around for, oh, I don’t know, 10, 15, maybe even 20 years. It’s a cognitive function test. So the idea with this test is that you would get a baseline. So people take this test in the preseason, if you use football or soccer for example. We would bring kids in and they would get a 20-minute test. It’s like video games, like putting shapes in order, reaction time, memory, visual span, learning, those types of cognitive functions. So, you get kind of like a baseline of where you’re at. Just a rough gauge on how well your brain performs those functions, your cognitive performance. And then after a suspected head injury, we can track cognitive performance throughout recovery. So, we see decrements in memory, reaction time and speed in those areas. And it should be no surprise that after a high school kid gets a concussion, yeah, they probably will struggle with their fifth period physics test when they can’t even remember a few numbers or a few shapes.
HY: Can you tell us a little bit about what the Office of Concussion Research does? You don’t treat them, but you research it. So can you talk about the shape that research takes?
RJE: Yeah, and full disclosure, I branded my research lab when I first got here to Arkansas in 2013 as an office. As a young professor, I thought it would be really cool to have a center, and I realized really quick that a center involves a donor, someone to invest in that. So kind of the first step to becoming a center of excellence or a center for research is to establish an office, which is a fancy name for a community outreach program that I’ve been conducting. My first couple years here at Arkansas, I was following anywhere from 2,000 to 3,000 athletes in the area, partnering with high schools and various clinics, working side by side, doing research alongside athletic trainers, sports medicine physicians here at Arkansas and meanwhile, still keeping colleagues around the country. I did my postdoctoral training at the University of Pittsburgh, ironically with that guy, Dr. Anthony Kontos from New Orleans, who’s now at Pittsburgh with that pioneer in the field, Dr. Mickey Collins. They’re a clinical and research team up there. So I’ve been collaborating with those folks for a long time. And then even for my other collaboration halfway across the country in Fairfax, Virginia, at Inova Health Care. I have a foot in community research here in Arkansas, and then also I have my other foot in clinical research at Inova Health Care System in Fairfax, Virginia, at the Sports Concussion Program there, led by Dr. Melissa Womble.
HY: How have concussions been traditionally treated?
RJE: It’s evolved. In 2005, when I first started learning about concussions, usually, it was like, hold up two fingers and 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 a grade three. And it was a recipe that a health care provider could use. If they could figure out the severity, and the 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’re 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 concussions behaved in the everyday lives of patients. In contrast to what we’re learning now.
Those grading scales were based on, like, the length of time that someone was unconscious. That happens in less than 10% of all of 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, are sensationalized and that kind of 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 a reason. 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 sideline. I work with them. They have a really, really hard and important job, critically important, to identify is this a 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.” 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. And 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 concussions, young and old. So these folks will take what the individual brings to the table, their health history, and also details on 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, 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 help doctors understand what’s below the surface, right? And if we could 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, which 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.
HY: You used the word vestibular. Can you explain to people what you mean by that who may not know?
RJE: Everyone has a vestibular system. It’s a 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 on boats, our balance. It’s a complex system in the brain that helps us know where we are in time and space.”
HY: And that’s a specific test that can be an indicator of a concussion?
RJE: 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 matched, 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 like people are getting physical therapy for their concussions.
HY: As I mentioned in the introduction, you recently coauthored a paper with Dr. Womble out in Virginia. So explain what the study was and what you found.
RJE: Dr. Melissa Womble is the clinical director at the Inova 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 this injury, 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, other 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—in a lot of different medical disciplines. It’s a good picture on how someone is quote doing. So we sent out that survey to 100 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 50 year-old male should, you know, what the average is, above or below average. And what we found was, I want to say nearly 90%–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. Now, I will say, this was a not a randomized control 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.
HY: I know you’re not a doctor, but in your experience, what are the dangers of not treating concussions or ignoring the symptoms?
RJE: It can be really deleterious. It can be bad for just well-being. There’s different consequences, I think, with different ages. Youth, for example, an undiagnosed concussion can really result in poor sleep, poor mood, poor cognitive performance. Just poor overall health. For lack of a better term, it can suck, for youth, but especially for those that have brains that are developing. We don’t want those kids to get another concussion on top of one that may be hidden or not reported, maybe not recognized. We have a real problem in youth sports where there’s not a lot of medical staff. Like every Saturday there’s folks playing soccer, hockey, lacrosse, football, and there’s just a lot of parents out there, which is great, but who’s medically in charge of some of these recreational leagues? So there’s a lot of grassroots efforts to educate, but there can be dire consequences. For a youth, it can be really problematic. Hospitalization, I mean, it’s pretty rare. Second impact syndrome is pretty rare, but it can even lead to death in rare cases. I mean, if someone is just keep getting a head injury on top of another head injury on top of another head injury, is not good. And we’ve done a really, really good job of mitigating that. Coaches get training, parents get training, kids get training, in terms of what a concussion looks like. If you have these symptoms, say something.
Now for older adults, maybe you get in a car accident. They’re struggling going to work. They’re struggling at home. They’re not punched in as a parent. They’re not punched in as a spouse, as a family member, as an employee. They’re just not being able to focus. Performance goes down. Sleep is garbage. I mean, these are all the things that can happen. My colleagues see chronic patients all the time that come in and like, man, it’s been years and I’ve bounced around doctors and everyone just tells me to rest. Rest is the worst thing we can do for concussions.
HY: In light of these new, improved outcomes for concussion treatments, do you have any advice for parents whose kids might be participating in a sport that could lead to a concussion, like the ones you named earlier?
RJE: Sports have never been safer. If you think about the available resources, the available trainings, the advances in equipment, and the advances in clinical care. Sports done right is a really, really good thing. It’s good for social development, etc., we could go on and on about how good sports participation is. All parents should weigh the benefits and the risks. So as far as, like, what to look out for. Obviously signs of symptoms that are associated with a head impact is really important that parents pay attention to that. But I will say this, whiplash is also a mechanism of concussion. An individual does not necessarily have to get hit in the head to have a concussion. Their head can be shaken very, very rapidly and come to an abrupt stop, or the brain kind of shifts abruptly inside the skull and have these concussion symptoms. So symptoms, changes in behavior, changes in sleep patterns, just feeling off. Like they may have a very hyperactive child or an individual and they just sleep all afternoon, like what’s going on here. Having open lines of communication with the league, the recreational league, and making sure in the league that someone participates in does have some sort of concussion training. The three big areas are heat, heart and head. Those are all the three areas that I know the Arkansas Activities Association really emphasizes, in terms of coaches being trained and recognizing—especially if there’s no medical person present at practices and games—making sure there’s some sort of process for identifying suspected concussions. When in doubt, sit them out. It’s always better to be safe than sorry. But those would be some steps to kind of identify this injury.
HY: All righty then. Sounds good. Thank you. RJ Elbin, thanks for coming in.
RJE: Thanks so much.
HY: “Short Talks from the Hill is available wherever you get your podcasts. For more information and additional podcasts, visit ArkansasResearch.uark.edu, the home of science and research news at the University of Arkansas. Music for Short Talks from the Hill was written and performed by local musician Ben Harris.”
