An Update on the Physiology of Mild Traumatic … Barry...2017/11/03 · An Update on the...
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An Update on the Physiology of Mild Traumatic Brain Injury
Barry Willer PhDGrand Rounds
Psychiatry 2017
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Disclosures
The Buffalo Sabres Foundation Robert Rich Family Foundation
PUCCS FoundationNFL Charities
Ralph and Mary Wilson FundNIH (1 R01 NS094444-01A1)
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Change in Perspective of Concussion (and mTBI)
• Concussion has generally been perceived of as a problem of cognition– Hence the emphasis on
neuropsychological testing (e.g. ImPACT)
– And an emphasis on symptoms (self report)
– Until recently the Treatment as Usual (TAU) has been rest and isolation
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Purpose
• To present information on concussion as a problem with physiology (with psychosocial implications)– Concussion is perceived as a “medical” condition
with psychological and social factors– Physical signs are emphasized (in addition to
symptoms)– Physiologic research translates to assessment,
diagnosis and treatment– Treatment is proactive and evidence based
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Consensus guidelines for return to play
• Based largely on the observation of exercise intolerance
• We developed the Buffalo Concussion Treadmill Test to systematically assess exercise intolerance
• Exercise intolerance is a problem of ANS disruption
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Animal research described the Metabolic Cascade and Physiologic Changes
2 6 12 20 30 6 24 3 6 10minutes hours days
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0
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% o
f nor
mal K+
Glutamate
Glucose
Cerebral Blood Flow
Calcium
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Concussion produces alterations in the ANS
• Dysregulation of CBF – Decreased at rest– Increased during exercise
• Higher resting HR at rest• Decreased HRV at rest• Decreased HR during
exercise– Sympathetic at rest
(Difficulty attaining a parasympathetic state)
– Parasympathetic influence during exercise
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Cardiovascular Dysfunction during Exercise in Adolescents
5 days after SRC (Acute) and at 14 days (Recovered), (N=27) Hinds A et al. J Neurol Neurophysiol 2016, 7:4.
For both HR and RPE, time and group were significant (p<0.05) and a group-time interaction effect was significant for RPE (p<0.05)
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UB Data on ANS function in College athletes within 1 week of SRC
10 concussed v. 10 HC after Cold Water Immersion- Blair Johnson PhD
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Patients with Concussion
• At rest, higher than normal HR, decreased HRV, decreased CBF, evidence of orthostatic imbalance
• Unable to achieve a true sympathetic response during exercise (e.g. inadequate HR, reduced cardiac output, poor regulation of CBF)
• Unable to achieve a true parasympathetic response during rest (increased HRV)
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Autonomic Nervous SystemSYMPATHETIC PARASYMPATHETIC
Flight or Fight
Rest andDigest
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Sympathetic
Fight or flight
• Quick response system (not intended for long periods)
• Characterized by increased HR and decreased HRV
• Pupil dilation
Experienced by the individual
• Disconcerting• Anxious (over time
anxiety morphs into depression)
• Light and sound sensitivity
• Dizziness• Exercise intolerance
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Parasympathetic
Rest and Digest• Increased blood flow to
internal organs• Contraction of ciliary
muscles facilitating accommodation
• Modulation of vital functions to achieve homeostasis
How patient feels• Difficulty achieving a
restful state• Difficulty going to and
staying asleep• Nausea• Irritable bowel • Loss of appetite• Difficulty with close
vision
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Other conditions that have ANS dysfunction
• Parkinson’s disease• Multiple system atrophy• Postural orthostatic
tachycardia syndrome• Multiple Sclerosis• Jet Lag and Space flight
JON MCBRIDE
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CBF Regulation
• Assessed using Transcranial Doppler (TCD)
• Tilt table raises feet 6” (6 degrees)
• Initially there is increased profusion but the ANS adjusts in seconds…in controls.
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Imaging of CBF Regulation
• Had to build a table that could be tilted 6” while the subject was in the imager. Can’t included any metal. Head must remain motionless.
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Implications for Assessment
Physical Exam:• Neck• Eyes• Vestibular function• Orthostasis
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Physical Examination within first week after Concussion (% with abnormal physical signs, n=54)
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29 28
33
7
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18
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0
18 18
54
27
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Neck spasm Necktenderness
Neck ROM Smoothpursuits
Convergence Nystagmus Saccades VOR VOR dizziness Tandem gait Romberg
Perc
enta
ge w
ith a
bnor
mal
sign
s
Physical exam signs
Initial Physical Exam
Recovered Not Recovered
Visit #1
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Physical Exam
• Excellent for diagnosis• Not predictive of
recovery time• Excellent for
determination of recovery
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Exercise (In)Tolerance
• Buffalo Concussion Treadmill Test
• Also have a protocol for an exercise bike
• Key outcome: Heart Rate when patient is unable to continue due to symptoms
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Physiological Model improves differential diagnosis
• Physical exam derived from research on physiological changes– Exercise intolerance– Orthostatic imbalance– ANS disturbance
• Patients who are exercise tolerant may have related condition– Cervicogenic– Oculomotor– Vestibular
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Differential Diagnosis of Post Concussion Disorders
PCS (22)20%
Resolved (19)15%
CVO (22)55%
Anxiety (20)5%
Migraine (15)5%
Diagnoses
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Physiological Approach improves Prognostication
9813
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RCT of Exercise versus Stretching
0
5
10
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25
TAU (Rest) Stretching Aerobic Exercise
Days to Recovery
Days to Recovery
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ANS Recovery
• In case of concussion ANS expect spontaneous recovery in 85% of cases
• Exercise speeds recovery for those that would recovery spontaneously
• Exercise reduces number of patients with protracted recovery
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A Complete Approach to Treatment• Sub-Threshold exercise
– Other interventions that address ANS imbalance
• Treating COV deficits– Vestibular– Oculomotor– Cervicogenic
COV issues recover faster if there is coincident ANS recovery
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Exercise Script Must Be Individualized and Must Be Sub-Threshold
• 10% below threshold• 20 minutes a day• Don’t exercise on “bad”
days• Stop if you feel
symptoms
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Why (How) Does Exercise Do Its Magic?
• Most of what we know is from Animal studies:– Increases available BDNF, HGF, general endocrine
function, wakefulness/sleep cycle, energy metabolism
– Inhibits apoptosis– Promotes angiogenisis particularly in the
hippocampus– Improves CBF in response to cognitive demands– Improves inflammatory response– Improves white matter integrity
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When and How Much Exercise
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Is Exercise the Only Answer?
• Anything that improves an individual’s control of the ANS should be beneficial:– Yoga; Meditation; Good
sleep/wake cycle, bio-feedback
– Especially useful for older patients or patients who do not want to exercise
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What About Cognitive Interventions
• Absolutely Essential– For Patients With Pre-
existing cognitive deficits
• For patients with pro-longed recovery– Generally struggle with
cognitive intolerance (fatigue)
– Assisting with adjustment issues
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Definition of Recovery
• Asymptomatic• Negative physical
exam• Exercise tolerant
(BCTT)• Cognitive tolerant?
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Questions