How to Treat Concussion & Traumatic Brain Injury | Dr. Mark D'Esposito & Dr. Andrew Huberman
00:00:00.000 | - One subject that we haven't talked about
00:00:04.120 | on this podcast previously,
00:00:06.600 | but is of tremendous interest to people
00:00:09.080 | is traumatic brain injury or concussion,
00:00:12.160 | even mild concussion.
00:00:13.920 | And before we were recording today,
00:00:16.520 | we were talking about football,
00:00:18.000 | but just wanna remind people that football
00:00:20.840 | is just one instance of an opportunity
00:00:24.760 | to get a concussion or traumatic brain injury.
00:00:26.480 | Most traumatic brain injury and concussion
00:00:28.180 | is not due to football.
00:00:29.880 | It just gets a lot of the attention,
00:00:31.920 | but you've got bicycle accidents, car accidents,
00:00:34.540 | playground accidents.
00:00:35.900 | Maybe you could list off a few more,
00:00:40.300 | but how common is TBI in concussion?
00:00:43.860 | And maybe you could just perhaps list out
00:00:46.700 | some of the other situations where you see a lot of this,
00:00:49.780 | that it's a bit more cryptic
00:00:50.920 | that people wouldn't necessarily think that sport
00:00:52.900 | or that population gets TBI, but they do.
00:00:56.260 | - Yeah, I think concussion is much more prevalent
00:00:59.500 | than we realize, and the numbers have gone up and up,
00:01:02.860 | not because it's becoming more common,
00:01:05.620 | it's just that it's becoming more recognized.
00:01:07.500 | And I think we underestimated and trivialized
00:01:10.820 | sort of what a concussion is,
00:01:12.280 | that it's just something that is,
00:01:16.140 | you're gonna recover from it.
00:01:18.480 | I mean, still the old school thinking
00:01:20.760 | by a lot of neurologists is that everyone gets better
00:01:23.980 | within a couple of months.
00:01:25.580 | Just wait it out and you'll get better.
00:01:28.140 | That's just the normal time course of concussion.
00:01:31.340 | But as we've studied it more,
00:01:33.060 | we realized that there's actually quite a large percentage
00:01:35.260 | of people who a year out, they're still suffering problems.
00:01:38.780 | They still feel like they're not mentally clear
00:01:41.900 | and they still are sensitive to light
00:01:44.020 | and they still feel a little dizzy.
00:01:46.440 | And just a host of symptoms that just one year later,
00:01:51.160 | after a concussion where they didn't even lose
00:01:53.300 | consciousness, that's something that they may not
00:01:56.400 | have even talked to their doctor about is lingering.
00:02:00.980 | And so it's a real,
00:02:02.500 | we call this persistent post-concussion syndrome
00:02:04.740 | and that's the most worrisome to me
00:02:06.580 | because it is true that most concussions will recover.
00:02:09.940 | Luckily the brain is incredibly resilient,
00:02:12.020 | incredibly plastic and it will heal itself.
00:02:15.380 | But there are a lot of patients where it just persists
00:02:18.180 | and those are the most worrisome to me
00:02:19.700 | because we don't have very good interventions
00:02:22.580 | to try and help that.
00:02:24.060 | And I don't think we take these patients very seriously
00:02:27.120 | when they're complaining of something that seems very vague
00:02:30.640 | and not very specific to most doctors.
00:02:33.960 | - What do you tell a patient who comes in
00:02:37.000 | and clearly had a concussion, mild or severe concussion,
00:02:42.000 | maybe car accident, maybe a sports injury,
00:02:44.520 | maybe they were knocked out cold, maybe not,
00:02:46.600 | but they're having some headaches, some photophobia,
00:02:49.480 | sensitivity to light, just feeling not right.
00:02:51.840 | I've had a couple of these, unfortunately,
00:02:55.540 | and you just feel off, you don't feel quite right.
00:02:58.140 | And some of that manifests as focus issues.
00:03:02.300 | This was some years ago, I like to think I'm through it.
00:03:05.200 | I've had scans and I'm good, so thank goodness.
00:03:08.440 | But what do you tell them besides don't get another one?
00:03:13.940 | - Yeah, well, first of all, I explain what a concussion is.
00:03:17.700 | What I found in neurology,
00:03:18.900 | a lot of what patients wanna know is just,
00:03:21.180 | they just wanna understand their problem,
00:03:22.600 | not walking in expecting a cure,
00:03:25.180 | just understanding what it is,
00:03:27.260 | having someone understand what happened to them
00:03:29.460 | is very helpful and comforting.
00:03:31.800 | So what we mean by concussion,
00:03:34.500 | and in the clinical world, we use mild traumatic brain injury
00:03:37.580 | kind of synonymously with concussion.
00:03:39.640 | It basically is a tearing of axons.
00:03:44.540 | The brain cells have these long fibers
00:03:47.020 | that communicate with each other and they're called axons.
00:03:49.900 | And when the brain violently moves forward and backwards,
00:03:53.460 | if you're in a car accident and you have your seatbelt on
00:03:55.900 | and you suddenly hit, you go from 50 to zero,
00:03:58.820 | your head violently goes forward
00:04:00.220 | and violently goes backwards.
00:04:01.480 | And that angular force actually tears
00:04:04.380 | and stretches axons in the brain.
00:04:06.980 | So if you've had a concussion, you have torn some axons.
00:04:10.660 | I mean, luckily we have billions of them.
00:04:13.300 | And so if you tear a couple of thousand,
00:04:15.420 | you will recover, but you have torn axons.
00:04:19.620 | It's a real neurological, it's a real brain injury,
00:04:23.860 | even if you haven't lost consciousness
00:04:27.380 | and you've only had symptoms for a couple of days.
00:04:30.420 | But there's a correlation.
00:04:31.740 | The longer you've lost consciousness
00:04:33.700 | and the longer your symptoms last,
00:04:35.300 | the more axons you've torn.
00:04:37.220 | There's kind of a direct relationship between the two.
00:04:39.740 | So the mechanism is these torn axons.
00:04:43.860 | So now, nerves don't communicate with each other
00:04:46.460 | and the brain, different brain regions
00:04:49.060 | are not communicating with each other.
00:04:51.140 | So, and it turns out the most common place
00:04:53.900 | for axons to tear is in the frontal lobes.
00:04:56.220 | And so now we talked about all these things
00:04:58.420 | that the frontal lobes do to orchestrate
00:05:00.260 | the rest of the brain.
00:05:01.100 | Well, it doesn't, it has some injured pathways.
00:05:04.580 | And that's why a lot of the symptoms that patients have
00:05:07.820 | are these kind of mild executive symptoms.
00:05:10.780 | This mental fogginess that they're describing
00:05:13.100 | is this ability, just this inability to get things done.
00:05:17.900 | They don't lose knowledge of who they,
00:05:20.060 | they don't forget their name or forget where they live
00:05:22.860 | or lose memories from the past or anything like that.
00:05:24.980 | But they just, they don't officially get things done
00:05:27.780 | as well as they used to.
00:05:28.820 | And it only takes a little bit of a drop, right?
00:05:31.660 | People think you have to have a big drop in performance
00:05:34.660 | to have it have a real life impact.
00:05:36.460 | Just a 1% drop and you're having a hard time
00:05:39.300 | doing your podcast or teaching a lecture
00:05:42.580 | or whatever you might do.
00:05:44.460 | - A 1% drop sounds like a frighteningly small change
00:05:49.460 | required to negatively impact life.
00:05:55.220 | So how about a poor night's sleep?
00:05:57.660 | I mean, what kind of drop in prefrontal cortical function
00:06:00.340 | are we looking at from, let's say,
00:06:02.700 | I normally get seven or eight hours or six to eight hours
00:06:06.660 | and I suddenly only get three or four.
00:06:08.780 | Are we talking a significant detriment?
00:06:11.260 | - I do think so.
00:06:12.620 | I do think that, yeah, that it is significant,
00:06:16.620 | this poor night's sleep.
00:06:18.340 | And we all notice that.
00:06:20.300 | I mean, it's very obvious.
00:06:22.020 | I mean, and you know, it's hard to sort of quantify.
00:06:26.500 | I'm a baseball fan, so I can quantify it.
00:06:28.740 | Like if you think about it in a pitcher
00:06:31.220 | and how fast they throw, you know, a small drop for them,
00:06:35.980 | someone who's throwing a hundred miles an hour,
00:06:37.540 | just a small drop turns them, you know,
00:06:39.620 | from really elite to someone mediocre.
00:06:42.540 | Maybe it's more of a 10% drop,
00:06:44.180 | but it's still relatively small drop can have a huge impact.
00:06:48.060 | I think people think that just because
00:06:49.700 | you're a little bit off, that's not gonna,
00:06:51.580 | that's not a big deal.
00:06:52.540 | You kind of work through it.
00:06:54.500 | And that's what most doctors say.
00:06:55.740 | You just plow through it, just work your way through it.
00:06:59.300 | You're gonna get better.
00:07:00.380 | And as opposed to saying,
00:07:02.900 | yeah, you really had a brain injury.
00:07:05.780 | This is what happened.
00:07:07.020 | We need to rehabilitate you.
00:07:09.580 | Just like we would do
00:07:10.620 | if you tore your anterior cruciate ligament.
00:07:12.340 | I don't know why tearing your cruciate ligament
00:07:15.420 | or your Achilles tendon gets more interest
00:07:18.740 | than tearing axons in your brain.
00:07:21.140 | It's amazing to me that there's more emphasis
00:07:24.900 | on orthopedic injuries than brain injuries.
00:07:27.900 | - Yeah, I don't know why that is either.
00:07:29.100 | I think the brain is mysterious enough
00:07:31.460 | that most people and many clinicians
00:07:36.420 | just kind of back away with hands raised.
00:07:38.500 | But if you are in the field of neurology or psychiatry,
00:07:41.940 | I suppose that then one has officially signed on
00:07:44.220 | to try and resolve these matters.
00:07:46.660 | So for somebody that has a traumatic brain injury
00:07:49.620 | or low-level concussion, excuse me,
00:07:52.500 | would part of the primary advice
00:07:57.020 | be to try and get one's sleep as good as possible?
00:08:01.780 | Given that sleep deprivation can compound
00:08:05.300 | traumatic brain injury-induced deficits in working memory.
00:08:08.460 | And who knows?
00:08:09.300 | Maybe a good portion of the deficits in working memory
00:08:11.820 | due to traumatic brain injury and concussion
00:08:15.140 | is because of the sleep deprivation that it can cause.
00:08:17.500 | So it can get circular.
00:08:19.620 | - Not only that, but one of the most common symptoms
00:08:22.540 | that my patients with concussion have
00:08:24.420 | is their sleep is disruptive.
00:08:27.100 | And that's true in neurology.
00:08:28.300 | It's fascinating.
00:08:29.260 | Almost every neurological disorder,
00:08:31.460 | my patients complain of their sleep.
00:08:33.060 | And I started asking, not a lot of neurologists
00:08:35.780 | ask you how you sleep.
00:08:38.140 | But I remember back from my residency,
00:08:40.020 | one of the first things my attending would do
00:08:42.260 | when we got to the ward is, "How'd you sleep last night?"
00:08:44.380 | And it's just across the board.
00:08:46.980 | Patients are not falling asleep.
00:08:48.940 | They're not staying asleep.
00:08:50.380 | We still don't understand why just brain injury does that.
00:08:54.460 | So almost every concussion patient says,
00:08:56.380 | "I'm not sleeping well,"
00:08:57.580 | which then compounds the problem.
00:09:01.100 | So optimizing sleep, obviously, optimizing nutrition.
00:09:04.180 | There's a question about activity.
00:09:07.220 | It used to be that we used to recommend,
00:09:09.740 | you had a concussion, you should don't go to work,
00:09:14.060 | just take it easy for a while.
00:09:17.780 | Don't exercise.
00:09:18.620 | - Keep the blood strong.
00:09:20.100 | - But now it's the idea
00:09:21.940 | is that you should really get up and moving.
00:09:24.780 | You gotta do what you can tolerate.
00:09:26.340 | You don't wanna give yourself more of a headache
00:09:29.660 | or more light sensitivity.
00:09:30.980 | But as much as you can tolerate
00:09:32.580 | is the thought these days about sort of promoting recovery
00:09:37.580 | and then really getting your brain back working.
00:09:40.460 | I think a lot of my patients,
00:09:42.100 | they're off from work for a couple of weeks
00:09:43.500 | and they feel fine
00:09:44.580 | and they think they're pretty much normal.
00:09:46.140 | And then the first day of work is a complete disaster
00:09:48.900 | because until you actually test it in real life,
00:09:51.940 | you don't know what kind of troubles you have.
00:09:54.180 | So I don't recommend going back full steam,
00:09:55.900 | but I do recommend going back,
00:09:58.220 | trying to build up these skills again.
00:10:02.140 | And then I think we need to develop therapies
00:10:05.100 | that people will use.
00:10:06.860 | Things like goal management training,
00:10:09.580 | which involves a therapist
00:10:11.220 | and health insurance doesn't pay for this.
00:10:13.900 | So 99% of my patients don't get any help
00:10:18.900 | by any kind of intervention, unfortunately.
00:10:21.940 | But now we talked about technology,
00:10:24.540 | things like Brain HQ.
00:10:27.780 | Do you know about Brain HQ?
00:10:29.300 | So Mike Merzenich,
00:10:31.020 | which I know you've talked about with Eddie,
00:10:33.300 | developed a company called Posit Science
00:10:38.620 | where it developed these brain training games
00:10:41.660 | that can help improve specific cognitive functions.
00:10:46.220 | And they're very easy to do because they're online
00:10:48.900 | and there's science behind them and you can do them.
00:10:53.220 | So in that way,
00:10:54.660 | you don't have a therapist in your room,
00:10:55.940 | but you can online sort of do these sort of things
00:10:59.300 | that are targeting specific mechanisms
00:11:01.900 | to try to improve the kind of things
00:11:03.580 | that we think are impaired by concussion.
00:11:05.740 | And I'd like to see more patients get started
00:11:08.180 | on some of those things.
00:11:09.380 | Importantly, if you go on the web
00:11:10.740 | and just say I'll do brain training,
00:11:12.580 | you'll be overwhelmed with things
00:11:14.380 | and you don't know what works and what doesn't work.
00:11:16.060 | - Yeah, I think the work that Merzenich
00:11:18.260 | and colleagues have done,
00:11:19.180 | and we'll provide a link to that.
00:11:20.380 | I don't have any financial stake in his work
00:11:23.020 | or products trainings that is,
00:11:26.380 | but I will say I think Mike's work has been tremendous.
00:11:29.620 | I mean, he is so far ahead of the curve.
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