In conjunction with National Concussion Awareness Day and National Traumatic Brain Injury Awareness Month, the ANA talks with Ramon R. Diaz-Arrastia, MD, PhD, Director of the Traumatic Brain Injury Clinical Research Center at Penn Medicine in Philadelphia, Pennsylvania. He discusses the massive shift in public understanding of concussions, the changes in treatment for concussions, and more.
What does the public need to understand about concussions that it often doesn’t?
There has been a large shift in public understanding of concussions over the past 10 to 15 years. In the past concussions were mostly ignored. Whenever I gave a talk to a school or community group on TBI, I always included a few slides on concussion and mentioned that they can be serious and should not be blown off. Now, the pendulum has swung too far in the other direction, and there is excessive fear of the consequences of concussion. When I give a talk now to a school or community group, the message is “a concussion is not quite as bad as you think.”
What the public needs to know is that concussions and mild TBIs are very common, and that the vast majority of the time people recover fully from them. But not 100% of the time—there is a small fraction of individuals who experience persistent disability for months (or permanently) after a single concussion. And the effects of concussion are cumulative. Recover from a second, third, or fifth concussion is usually slower and less complete than recovery from the first concussion. Multiple concussions are not rare, particularly for those who participate in contact sports at a highly competitive level.
The public also needs to understand that the clinical symptoms of concussion (loss or alteration of consciousness, amnesia, confusion, and headaches) are only the tip of the iceberg, and subconcussive impacts (that do not result in any clinical symptoms) can also be dangerous when they are very numerous. There is such a thing as “silent concussion,” just like there are silent strokes and silent MS lesions.
How are treatment options for concussions different today from 10 years ago?
Unfortunately, not really very different. We do not (yet) have any effective therapies or treatment modalities.
We did go through a period of over-reaction where “cocooning” therapy was recommended by some—prescribing absolute bedrest in a quiet dark room without any stimulation—for concussed patients. We now know that approach is counterproductive in that it delays recovery from concussion. Fortunately, that therapy has fallen out of favor.
There are some suggestive studies that indicate that counseling and education as to appropriate expectations, even when conducted over the telephone, can be effective.
What promising research is poised to change the standard of treatment for concussions?
The most important research going on in this area is related to the identification of biomarkers that can identify the small fraction of concussed patients who are at risk of long-term symptoms and disability. This would be a game-changer and would allow targeted counseling and appropriate referral to rehabilitation services. And such biomarkers are absolutely critical to the design of future clinical trials designed to test neuroprotective or neurorestorative therapies that could accelerate recovery and reduce long-term disability.
What work is your lab undertaking to move understanding or treatment for concussions forward?
We are very involved in research regarding biomarkers, both molecular biomarkers (molecules such as brain-derived proteins or microRNAs) as well as imaging biomarkers (using novel MRI techniques). The goal is to go beyond diagnostic biomarkers to find prognostic biomarkers (those that provide information about the expected natural history of recovery) and predictive biomarkers (which would identify patients who are likely to benefit from a drug, nutraceutical, or non-pharmacologic therapy).
We are particularly interested in identifying imaging and molecular biomarkers of traumatic microvascular injury. These biomarkers will be essential to inform the design of early phase clinical trials of therapies targeted at supporting the resilience and promoting repair of the microvasculature after TBI.
How has the ANA supported your career and/or work in this area?
Over the last several years the ANA has supported educational and scientific programs in TBI across the spectrum from concussion to coma. Historically this was an area of neurology that had been ceded to neurosurgeons and physiatrists. It is great to see that a new generation of neurologists are becoming interested in this important and very common cause of neurologic disability.