Heads Up! Let’s Talk Concussion with Dr. Richard Figler

Podcast Transcript

Cassandra H:     Hi, thanks for joining us. I'm your host, Cassandra Holloway, and today you're listening to Health Essentials podcast by Cleveland Clinic. We're broadcasting from Cleveland Clinic's main campus in Cleveland, Ohio, and we're here with Dr. Richard Figler. Thanks for being here.

Richard Figler:   Thanks for having us.

Cassandra H:     Dr. Figler is the director of the Concussion Center at Cleveland Clinic and today we're going to be talking about concussions. Before we begin, we want to remind our listeners that this is for informational purposes only and should not replace your own doctor's advice. Concussions are a hot topic lately. Everywhere you look, there's controversy over professional sports and concern over young kids playing in these competitive leagues. And concussions are a big deal for good reason. Let's start off with the very basics. Can you explain when someone gets a concussion, what's going on? What's happening to their brain?

Richard Figler:   By definition, a concussion is a transient or a traumatically induced transient disturbance of brain function and it involves a very complicated pathophysiological process and that pathophysiological process happens when the brain gets altered. If you think about the brain sitting in the skull, it's twisted or knocked or the mechanical forces from the blow to the head get transmitted into the brain and the brain responds with these neurons and these axons kind of getting stretched or irritated. It sets off this chemical process of the brain trying to heal itself. And during that process, and depending on what part of the brain it actually affects because of where the force occurs, it can affect different functions like balance or memory or concentration or focus or even visual disturbance as well.

Richard Figler:   And there's also usually a neck component to this as well. You think about your head sitting on your neck and when the head gets hit, the neck has to kind of take on some of that force as well. We see a lot of concomitant neck issues going on with concussion as well. But it's a very complex process. And the brain is obviously a very complex organ and it does a great job of healing itself. But sometimes when a concussion occurs, we get in the way of the healing process.

Cassandra H:     Is the brain actually moving in the skull when it hits the impact?

Richard Figler:   We think that there's a very little, little, very minimal movement of the brain, especially when it comes to minor injuries, more traumatic injuries, obviously more damage, more damage, more symptoms as well. And more severity of symptoms too. We talk about a lot of sports related concussions which are relatively low velocity injuries. A fall from a ladder, a motor vehicle accident, much higher injuries can cause a lot more damage. This, the fine movements of the brain that cause these stretching of the neurons I think what we think happens in these more lower velocity injuries versus something that would be like a fall that could potentially cause a brain bleed and not just a concussion.

Cassandra H:     Got you. You mentioned sports, falls, what are some other common causes of concussions?

Richard Figler:   Yeah. By far and away falls is the most common. Takes up over about 50% of the concussions that are seen, that present to the emergency room. Out of falls, roughly about 80% of those falls occur in the elderly. You could think loss of balance. They fall, they slip on the ice as they become less active over the course of time, they can lose that bounce a little bit more readily. Motor vehicle accidents are a little bit less common, about 13% and then sporting injuries or traumatic injuries make up about anything that, whether it's a bookshelf or whether it's a football helmet, account for about 17% of those injuries.

Cassandra H:     Interesting. 80% is because of falls.

Richard Figler:   80% in the elderly population, but overall about 50% of the injuries that occur from concussions are from falls.

Cassandra H:     Interesting.

Richard Figler:   And that could be falls slipping on the ice. That could be falls off of a bike. That could be falls off a trampoline. That could be falls off a lot of different things. It's really hard to be able to get people to admit to exactly what they're doing and collect that data from the emergency department. When they say falls, they kind of loop them all together. It's not necessarily going to be the jungle gym or the monkey bars cause 2% of the falls versus the bikes cause a lot more falls. But you could imagine with bike injuries, if they whittle it down, a lot of those injuries can be prevented and that's where the helmet laws came in years and years and years ago.

Cassandra H:     Makes sense. Let's talk about symptoms. When someone is experiencing a concussion or has experienced it, what are some of the symptoms that might be happening?

Richard Figler:   The symptoms vary and there's a lot of symptoms that happen. The brain is obviously a very complex organism as well, or organ as well. And headache is probably by far and away the most common. Dizziness, lightheadedness, difficulty with focus, concentration, inability to think. Sometimes those symptoms aren't noticeable until after somebody gets into more complex activities like going back into class. They have a harder time processing information, light disturbance, where they're a lot more light sensitivity, noise sensitivity, neck discomfort. Sometimes they'll have balance issues as well. There's a lot of different symptoms that kind of correlate with each other initially when that happens and sometimes those symptoms are a little bit later onset like sleep disturbance.

Richard Figler:   Some people will feel more sleepy than normal. They'll have to need more rest to recover. Some people have difficulty falling asleep, some people have trouble staying asleep, some people notice that their energy level is extremely low or they get fatigued a lot easier during the course of the day. There's some people that will develop anxiety or irritability or anxiousness after their injury as well. There's a list of symptoms that we usually check off, about 27 symptoms every time someone comes in to evaluate them for a concussion so we could see exactly where they fall in this, what we call a graded symptom checklist. To see what we can do to help them out based on which individual symptoms they present with.

Cassandra H:     What about loss of consciousness? How often does that typically happen?

Richard Figler:   The numbers are variable. You can look at the literature and it's roughly about five to 10% of people that develop loss of consciousness for a concussion. Loss of consciousness does equal concussion, but not having loss of consciousness does not mean you didn't have a concussion. Think about 90% of people that are going to come in, do not have loss of consciousness as a presenting sign for a concussion.

Cassandra H:     Sure. And then how do you know when a concussion is truly dangerous? What are those warning signs? You know you've mentioned a lot of symptoms, but how do you know when it's really truthfully a dangerous situation?

Richard Figler:   We have over the course of the years developed these red flags that we talk about and the red flags are kind of at the point of care, but also a little bit afterwards as well. Somebody that has a prolonged loss of consciousness, that's a concern. Think longer than a minute, that's somebody that should probably be evaluated. Somebody that has inability to recognize people, places or things that doesn't go away very quickly. Five minutes after their concussion and they're still asking the same questions and they're asking who their teammates are and where they are. That's not a good sign. Repetitive vomiting, headaches that get bad, but then getting more severe and get worse over the course of time. An inability for somebody to be aroused or awakened. They're talking to you and they just start to fall asleep, not a good sign. If they lose consciousness and then regain consciousness and lose consciousness again, again not a good sign. Significant clumsiness where they can't walk around and they're falling over because they can't keep on their feet.

Richard Figler:   Numbness, tingling in their arms, legs or severe neck pain. All those things are. Loss of vision, unequal pupils, those are all concerns that we would want them to get immediate attention to the emergency room. It's harder obviously in younger people and sometimes harder and older people to discern their mental status. And the best person to ask the question to is, the person that's right next to them or close to them to see if they're acting normally or not. But most people when they're that severe, a trip to the emergency room is warranted.

Cassandra H:     Is there ever a point where you don't need to go to the emergency room? Or do you recommend anytime there's a bonk on the head that you go straight to the doctor?

Richard Figler:   Those, those red flags are reasons to go the emergency room. Otherwise the emergency room would be inundated with every knock or bump to the head. Again, and just to be clear, if you are ever concerned about it then you should go. And just for nothing else, peace of mind. But the symptoms that are mild symptoms that are following an expectant course, symptoms that have been checked out by somebody, whether it's a primary care physician, sports medicine physician, pediatrician and they think that it's relatively mild in the office setting versus somebody who's acutely getting worse over the course of that right after the injury wouldn't necessarily warrant a trip to the emergency room. We base it on severity and if there's ever a concern though, the best thing to do is to be safe and be evaluated.

Richard Figler:   In the sports realm of things, laws have been passed over the course of many years that are to protect the athlete. And in essence what we use as a mantra on the sidelines is we evaluate them to make sure those red flags aren't there so we can make sure that it's safe enough for them to stay there and not go transport to the emergency room. And we reevaluate them serially to make sure that they're not decompensating. Again, make sure they don't need to go to the emergency room for an evaluation. But in essence, what the laws have dictated is that when in doubt, if they show signs and symptoms of a concussion, we sit them out. If they come off and they've looked confused or they come off and they're holding their head or they have a headache, protecting that young brain is extremely important. We'll pull them out so that we can evaluate them and get them back on the field as quickly as we can safely.

Cassandra H:     Makes sense. Absolutely. Seek medical attention if you think this might have happened and if any of these warning signs are manifesting. First and foremost, see the doctor. Okay. Say we went to the doctor, we're someone who has a concussion. What are some of the tests to see and to diagnose someone with a concussion? What do you look for?

Richard Figler:   It's a great question. We're still working on that. There is not one validated objective test that we can do to evaluate and monitor and diagnose a concussion. There's such a constellation of different symptoms that we typically use a battery of tests when they come in. The graded symptom checklists that we alluded to, those signs and symptoms that we need to discuss with them. And then we can do anything from checking their balance, to their reaction time, to some more in depth neurocognitive tests. But in the basic evaluation, it should be the graded symptom checklist and then a good exam to make sure that there's none of those things that may be kind of lurking, but we don't outwardly see. And that could be something, an ocular exam that could manifest symptoms, a good cervical spine exam and a thorough neuro exam to make sure there's nothing underlying that might warrant further imaging or further testing down the road.

Richard Figler:   We do a lot of monitoring over the course of someone's recovery from a concussion to make sure that they're not getting worse, and so we compare those symptom checklists from point A to point B to see if there's different nooks that we can look into and say, "Listen, your vision is off, or your memory is off, or you're having more headaches. Can we kind of delve into that and make sure that we're treating that appropriately?" Because it's really amazing when some of these symptoms, people come in with all these myriad of symptoms that are all over the place from depression, anxiety, and sleep issues, but then they come in the second visit, they're really only having sleep issues. And that's what we focus on. Trying to dovetail that and to make sure that we're getting the right treatment is really important.

Cassandra H:     Let's talk a little bit about the treatment then. Let's start really basic. If someone comes in and you're pretty sure they've had a concussion, obviously rest, time off, kind of what are the basic treatment options that you would follow?

Richard Figler:   Initially we want everybody to rest for that first kind of 24 to 48 hours and kind of really lay low. The idea is based on a very simple mantra that we use, which is recognize the activities that are triggering the symptoms that you're having and then slow down or stop that activity, rest the appropriate amount of time, and then you can return to that activity. I know that sounds very simplistic, but it works. And what we have found is that we don't, back in the day, we would say we can't go to school for four days. And then what we found was if they didn't go to school for four days, they didn't have that social interaction. They could've gone to school the four days. And the next thing you know, they're four days behind in school and then they're trying to catch up. And that elevates their stress, which elevates their symptoms, which causes a prolonged recovery.

Richard Figler:   What we try to do is get them to do as much as they possibly can without aggravating their symptoms. We call it sub symptomatic activities. If they sit down and they start to read a paper and they notice after 10 minutes they have symptoms and then they slow down and they back off and they rest and their symptoms go away, then they can go back. And those symptoms can be anything from, eye pain to headaches, to reading the paper and seeing the words kind of jumble. Looking at the paper and reading the paragraph and then reading the paragraph again and then reading a paragraph again, and not really getting it. To listening to somebody in class and saying, the teacher's talking and then they can't understand what the teacher is saying. Whereas before they could process that information a lot quicker.

Richard Figler:   Those changes are what we're looking for from what they were before to what they're going back into school for. After the first 24 to 48 hours, then we start to do this kind of light activity and that's mental activity, so cognitive activity. We tell them try to limit their electronics because sometimes the glare from the screen or the small font can make their symptoms a little bit worse because of the increased focus and concentration. We tell them to make sure that they can, they do what they can do to keep up with their school work as well. We don't advocate for people to go back to school, especially the student athletes for half days or full days. We tell them to go to as much as they can handle, take appropriate breaks and that goes through with everything. Whether it's going back to work for people that are in the workforce or just going back to daily activities such as balancing and checkbook or watching TV.

Richard Figler:   They can watch TV for a half hour, but they have symptoms at 45 minutes, half hour's probably their max. The next day maybe they go to 45 minutes. We try to get them to be as active as possible, as early as possible, but again, without provoking any symptoms. We ask them to start to do a little bit of light activities. Research has shown that the inactive brain becomes kind of more stagnant and that takes a little bit longer to recover and the the right amount of activity is a little bit harder to find, but we base it on symptoms. We'll get them on a stationary bike and start to get them to get their heart rate up. They have symptoms, they slow down, no symptoms, they exercise at that lower level. And we think that that elevated blood flow helps heal the brain a little bit quicker than doing nothing from a physical activity standpoint. And especially with a lot of these people that are active, playing sports or even inactive when they're not playing sports and they have an injury, that exercise does help them get better a little bit faster.

Cassandra H:     Interesting. On average, how long does it take a concussion to heal?

Richard Figler:   The majority, about 90% of concussions will get better in about two weeks or so. 80 to 90%. usually the younger patient population, the pedes, zero to five or so. In the older population take a little bit longer to get better. We found that the younger kids maybe under 14 take maybe closer to four weeks, but the high school takes about two to three weeks and we've actually found that the collegiate athlete and the professional athlete take a little bit even less time to recover. But in general it's just from a gestalt for all people considered, it's roughly about two weeks or so.

Cassandra H:     I'm curious, why does it take longer for younger people? Why is age a risk factor in them?

Richard Figler:   We think that there's things that are going on in the brain that are what we call plasticity and the ability for the brain to kind of recover during that time. That it takes a little bit more time for it to recover based on the insult, but also on the gains that it can make as well to kind of, or to heal itself overall. And as the more mature brain is more mature, being the 80 year old, takes a little longer to recover because unfortunately we start to lose some of our mental capacity as we get a little bit older. And that middle age brain, that high school and that collegiate brain, we think that the high school brain is still developing. And when you really think about the collegiate brain is still developing until about 20 to 25 years old or so, where, we think that those pathways can kind of help heal themselves a little bit more readily.

Cassandra H:     Absolutely.

Richard Figler:   It's a complicated process.

Cassandra H:     Can't even imagine. I guess is it true that if someone gets a concussion or takes a blow to the head, do they need to be woken up every hour? I feel like you've always heard that wives tales. Is there any truth to that?

Richard Figler:   It is a wives tale and I don't know which wife told us that, but there is no evidence to support that that's needed. However, and if my child had a concussion, checking on them every couple hours, not necessarily poking them with a stick to see if they're okay, but making sure that their breathing pattern is normal. Totally okay. What we think helps the concussion immediately is an appropriate amount of rest. The person that needs X number of hours of sleep, it needs X plus a little bit more number of hours of sleep. And we think that the brain is telling that concussed person that they need to sleep a little bit more and that sleep is when it's longterm, you go eight hours straight, is going to be more beneficial than if somebody is waking them up at two hours and saying, "Are you okay? Are you okay? Are you okay?"

Richard Figler:   Things that we worry about when people are sleeping, if they have an abnormal breathing pattern, that'd be something that would be a concern. Yes, probably wake them up, but there is no evidence to suggest that if we wake them up every two hours or every one hour, that they're going to get better faster. And we actually think that is probably counterproductive as far as your healing process goes. I would advocate against that.

Cassandra H:     Good to know. We want to go back to treatment really quick and touch on medications. If someone just had a concussion, what medicines should they be taking and what's off limits?

Richard Figler:   Yeah. We prefer them to not take any medications. And I know that sounds kind of counterproductive to what we have in our medicine cabinets, but one of the things that we try to do is monitor their symptoms so they're able to monitor their symptoms so they're not making their symptoms worse and prolonging their recovery. If they take medicine and they go do an activity, in that four to six hour window when it's working, they can do a lot of stuff and probably not have too many symptoms. When that medicine wears off, typically they have much worse symptoms and then what do they do? They go to reach for more medication. That kind of, it's relatively counterproductive for their recovery process.

Richard Figler:   We do however, advocate them taking medication at night before they go to bed, if they're having a headache so they can go to sleep a little bit easier and they don't have pain effecting their ability to get a good night's sleep. What we try to tell them is to take Tylenol as opposed to Advil, Motrin or Aleve in that initial phase because we think that there's a theoretical risk with taking aspirin or some of the anti-inflammatories, like ibuprofen or naproxen sodium that may actually increase their risk of bleeding after the injury as well. Which especially with somebody who is, has a head trauma, we don't want to induce any more bleeding.

Cassandra H:     Sure. Makes sense. If you have one concussion, are you more at risk for getting additional concussions in the future?

Richard Figler:   Yeah, that's true. And we think that that is, and it's actually been borne out in data that we have back from 1990s, 1980s that if somebody went back to play too soon, they had a much higher risk for a concussion within the first 10 days. It was something like 90% and then as time went by, after they recover from their concussion, their risk went down. But it was still there. We use a number of about two to five times increased risk after you get a first concussion. But we don't know exactly when the brain completely heals. We know that symptom wise we can say that the brain is completely healed, but we don't know when that threshold goes down back down to zero and it might be months, it might be years after the initial injury where it actually does go back down to zero.

Richard Figler:   What we're trying to do is protect the brain and we want the brain to heal completely so the brain can do what it needs to do to heal itself and then it gives them the best chance of not having any kind of potential longterm issues down the road. Making sure that they're very much aware of their symptoms and they're being honest with their symptoms. They're getting the appropriate treatments to make sure that they have a complete recovery before they go back to potentially increasing their risk of another injury is very, very important.

Cassandra H:     Makes sense. Is there any truth around getting, how getting these repetitive concussions can alter the brain? I feel like we keep seeing a lot of stuff about professional sports players and just the risk of them getting these concussions over and over again and having to take themselves out. Can you talk a little bit about that?

Richard Figler:   Yeah, that's a very complicated issue. But if I broke it down into simple things and said, "If I were to keep punching you in the arm repetitively every day that arm's probably going to hurt. And even though your tissue is trying to heal itself in between every punch that you get, it is still has to go through the process of healing. And that takes time." And so what we think happens with the brain is the brain heals itself in between those episodes. And we think that there's a lot of different variables that go into this. A lot. And we don't know why some people develop these chronic traumatic encephalopathic changes, which are these little tau proteins that develop in different parts of the brain. We don't know if that's a byproduct of the healing process or if that's a problem with the healing process to start off with.

Richard Figler:   We don't know if there's probably some genetic predisposition to it. There's some behavioral predisposition to it. There's probably more increased load or mechanical forces like you mentioned that can go along with somebody who's played football all their life, that could potentially cause some of those changes. What we don't know is why some people get it. Now if you look at different studies, you take a group of people that played high school football and you take their age matched counterparts that played other sports, there's no significant increased risk of depression or anxiety associated with them. If you look at NFL football players and you look at age matched controls, the risk of them having suicide is actually lower in the NFL football players despite what you would hear in the media because the general population has a higher risk of suicide than the NFL football players.

Richard Figler:   There's a lot of reasons for that and we don't necessarily know why, but we don't know what happens to the brain and why some people don't have this after they played football for majority of their life and why some people do. It could be these, what we call sub-concussive impacts where the trauma is induced, trauma is induced, trauma is induced, but they continue to play. I think that part of it is due to the lack of reporting and a lack of reporting that was there and the lack of awareness about concussions that really hasn't hit until the past 10, 15 years or so. People were out there playing, they were getting concussed, they didn't heal, they got concussed again, they didn't heal. They got concussed again and then they developed issues later on down the road that may have been mentally depressed or anxious or developed Parkinson's disease that may or may not been associated with that or may have had a predisposition for that based on their genetics in the first place.

Richard Figler:   Which is interesting because one of the things that we have found in our own patient cohort, and that's being shown in some of the literature as well, is if somebody gets a concussion and they have a family history or personal history of depression or anxiety, their recovery goes from a very short period of time without those to an extremely long period of time if they have those incidents. We do think that there's some kind of neurotransmitter or genetic predisposition for people to have a longer period of recovery from their concussion as well, which is again, something that from a pathophysiological process, we don't know exactly why, but we know that if we treat that a little bit earlier, they tend to get better a little bit faster.

Cassandra H:     That's fascinating.

Richard Figler:   It is, it really it is.

Cassandra H:     So complex, so many issues go into it.

Richard Figler:   And it's amazing when you have 27 different symptoms that you could potentially treat. It's not like when you come in and say, "Hey, my throat's sore." And so we're trying to, we're still trying to figure out, what is the best treatment option for each person. But one of the sayings that we use in concussion treatment is if you've seen one concussion, you've seen one concussion, you have to treat each one of them individually to make sure that you're not missing what you can do to make sure that person gets the best outcome possible.

Cassandra H:     Absolutely. And okay, so the last question I want to ask you here is about prevention. Our listeners could be the average person or they could be the young competitive athlete or collegiate athlete. What are some tips or advice that you have about preventing concussions very high level?

Richard Figler:   Simple things, being safe. Sports that require you to wear a helmet, activities that require you to wear a helmet, wear a helmet. There's a reason why there's helmets out there that for to protect people from falls. Exercise is an extremely important component of this. When we talk about the elderly having falls, accounting for 80% of the concussions that are presented in emergency room. If their balance was just a little bit better by them doing some kind of exercise, whether it's walking, whether it's yoga, whether it's Tai Chi, whether it's strengthening, whatever it is, just doing something to help keep that system in check is going to help reduce the risk of falls. Wearing a seatbelt. Even though motor vehicle accidents don't account for a ton of them, but they do account for some of them, and obviously the severity can be decreased significantly by wearing a seatbelt when you're in the car.

Richard Figler:   Not taking undue risk. And that's one of the reasons why we think there's such a high proportion of injuries that happen in that younger age population is because they're more risk takers. And so the younger kids are going to fall, they're going to climb on cabinets and they're going to potentially fall, but that four to 17, 25 year old age group, that is the higher risk population. The skateboarders, the jumpers and playing sports as well. Overall that age group accounts for about a third of the overall concussions. Which kind of makes sense, and especially from an activity related standpoint. It's not taking undue risks, and playing with within themselves. Another part of it is making sure that they recognize that if they do have signs and symptoms of a concussion, to pull themselves out. Not to rely on somebody else to do it, but for them to report their own symptoms.

Richard Figler:   If they're playing a sport and they don't feel right, their head is bothering them, they're a little bit confused, they did get hit in the head, but they don't remember exactly how they got hit in the head. And it wasn't one big blow where everyone went, "Oh my gosh." But it's one of those maybe potentially cumulative things where they're just not feeling right. They’re pulling themselves off typically means that they're going to get better faster. Instead of them playing with that injury and getting more blows to their head, they can get better a little bit faster. One of the things that we've done as sports medicine physicians has been able to detail what their risks are when they're playing sport as well. If we, from the NFL changing the rules to the collegiate NCAA changing the rules has decreased the number of concussions overall.

Richard Figler:   Some latest data has shown that in football there's actually been an increase in the incidence of high school related concussion reporting and over the past five or 10 years. And the reason why I think that is because of awareness and education, which is huge. And that's what we wanted to see. Now the other component of that is that same study showed that concussion incidence in practice went down in football. And the reason why that happened is because of rules changes. They're not hitting as much, they're not engaged in hitting activities as much so that decreases their overall risk of concussion as well. And so the awareness and the education are a huge component of this prevention program that we're preaching. Those are the things that we need to do.

Richard Figler:   Cheerleading is the second most common risk of injury behind football in practice. Cheerleading. And it's because they're practicing typically unsupervised or doing stunts that they're trying to perfect to do in front of a crowd or in the competition. And they may not be practicing on the safest of surfaces. In order for them to change that, we have to look at that and say, "What can we do for cheerleaders to decrease their risk of injury?" And those are the, that's how we get to these prevention questions is by being smart and making sure that the trends that we see, we can kind of reverse and decrease the incidence.

Cassandra H:     I love that awareness message. Just kind of keep talking about it. We've seen the decrease happening starting to happen at least and to keep being mindful about if you do have a concussion, be smart about it. Take yourself out like you said, of the game.

Richard Figler:   One brain, that's it. That's all you got. Got to protect it.

Cassandra H:     That's great advice. Unfortunately that's all the time we have today. Thank you, Dr. Figler, for being here.

Richard Figler:   My pleasure.

Cassandra H:     To learn more about concussion treatment and minimizing your risk, visit clevelandclinic.org/concussion. If you want to listen to more Health Essentials podcast by Cleveland Clinic experts, subscribe on iTunes or visit clevelandclinic.org/hepodcast. And don't forget, follow us on Facebook, Twitter, and Instagram to stay up to date on the latest health tips, news, and information. Thanks again for listening. We hope you enjoyed the podcast.