1. Concussion

2. Dr. Joseph M. Childs Board Certified Chiropractic Neurologist

3. T Joseph Childs, DC, DACNB Board Certified Chiropractic Neurologist
Fellowship Trained in Functional Neurology
Fellowship Trained in Minor Traumatic Brain Injury & Concussion
Fellowship Trained in Vestibular Rehabilitation
Fellowship Trained in Childhood Neuro-development Disorders
Trained in Functional Nutrition and Blood Chemistry
Trained in Spinal Decompression & Biomechanics
Exercise Physiologist
Trained in Chiropractic Pediatrics T

4. Dr. Fred Carrick
(Father of Functional neurology)
The Carrick Institute for Graduate Studies (Functional Neurology)
Carrick Brain Center
Atlanta
Dallas
Harvard Medical School

5. Grand Rounds at the
Carrick Brain Center

7. What You Will Learn Today
The mechanism of concussion
What the leading Functional Neurologists are doing to diagnose and treat post concussion syndrome
What to do other than medications and rest if concussion symptoms are lasting beyond 1 month
What parts of the brain are most commonly involved
Why passing an IMPACT test may not = concussion healed. What is a complete baseline
Why eye movements and balance testing will be the gold standard in diagnosing areas of the brain damaged by concussion
Drug free approaches to treating the major areas of the brain affected by concussion

8. Concussion “GETTING YOUR BELL RUNG” = mTBI
Minor Traumatic Brain Injury
Concussion

9. 1. 7 Million people, including 475,000 children sustain a TBI in the U
1.7 Million people, including 475,000 children sustain a TBI in the U.S. each year. 3.1 million individuals live with life-long disability as a result of TBI

10. TBI’s are caused by caused by: Falls (35%) –Typically elderly
Car crashes (17%)
Workplace accidents (16%)
Assaults (10%)
Other- including athletics(21%)
About 75% of TBI’s that occur each year are concussions or other forms of minor traumatic brain injury

11. Head injuries do not have to result in a loss of consciousness to be serious.
The American Academy of Neurology:
Defines concussion as a "trauma- induced alteration in mental status that may or may not involve a loss of consciousness.
Studies show there are more than 300,000 sports related concussions per year.

12. concussion than those involved in leisure physical activities.”
“Children and adolescents involved in organized sports are nearly six times more likely to suffer a severe
concussion than those involved in
leisure physical activities.”
Keightley
We need a better approach to preventing, diagnosing and treating these young athletes

13. There is an unfortunate pattern developing among former athletes of contact sports; an Alzheimer’s-like neurodegenerative disease called Chronic Traumatic Encephalopathy (CTE). According to researchers, CTE has a clear environmental cause - repeated brain trauma.

14. What are the possible long-term effects of multiple concussions?
According to a 2005 study by the Center for the Study of Retired Athletes, former NFL players who suffered three or more concussions are five times more likely to have mild cognitive impairment and three times more likely to have significant memory problems than players who do not have a history of concussions. In addition, there appears to be a link between multiple concussions and the early onset of Alzheimer's. The study's disturbing conclusion: "Our findings suggest that the onset of dementia-related syndromes may be initiated by repetitive cerebral concussions in professional football players."

15. CTE: Chronic Traumatic Encephalopathy
Retired boxers and football players develop dementia at a higher rate and a younger age compared to the general population.
Brain autopsies of athletes who have multiple concussions demonstrate markers similar to Alzheimer’s disease:
Taui-immuno-reactive tangles
Beta –amyloid (ab) peptides

16. mTBI SYMPTOMS:
Headaches: Common and can be debilitating. (Autonomics – chemical)
Feelings of dizziness: Can create total dysfunction. (Vestibular cerebellar)
Poor Balance: (cerebellum, brain stem)
Nausea and/or vomiting: Can create electrolyte and hydration issues. Brain stem and Sensitization/Chemical) “

17. mTBI SYMPTOMS:
Sensitivity to noise: Mesencephalon, collicular and tectal issues. (Sensitization and chemical.)
Poor sleep: Mesencephalic GABA, Glutamate, (Sensitization and chemical).
Fatigue: Poor fuel and cortical function. (Mitochondrial and fuel utilization issues).
Irritable: Limbic function that has poor cortical gaiting function. (Cortical and limbic damage). “

18. mTBI SYMPTOMS:
Depressed or tearful: Limbic function that has poor cortical function. (Cortical and limbic damage)
Frustrated or impatient: Loss in frontal and cortical function. (Cortical and chemical)
Forgetful, poor memory: Hippocampal and cortical damage. (Cortical – chemical and cortisol).
Poor concentration: Poor cortical function. (Loss in cortical function and fuel) “

19. mTBI SYMPTOMS:
Taking longer to think: Poor cortical and cellular function. (Fuel and cellular function).
Blurred vision: Visual system or interpretation damage. (Autonomic – vergence – accomodation)
Upset by bright light: Mesencephalic and brainstem changes. (Fuel and cellular function) “

20. Double vision: Cortical or brainstem damage.
mTBI SYMPTOMS:
Double vision: Cortical or brainstem damage.
Restlessness: Basal ganglia, gaiting, transmitter and CIS issues. (Anatomical and chemical)
Altered sensation such as Numbness or tingling:
(parietal Lobe)
Abnormal or altered movement such as gait:
(frontal lobe, motor pathways, cerebellum, basal ganglia) “

21. RECOVERY?
Younger players (HS and younger) seemed to recover slower by 1 week compared to older college athletes.
Balance deficits and headaches should be dissipated in 3‐5 days.
Neurocognitive deficits should be dissipated in 5‐7 days.
What does it mean if these things do not resolve?

22. Post‐concussion symptoms usually dissipate after 7‐10 days.
However…
The Zurich Concussion Consensus paper states that 10-15% have persistent symptoms greater than 10 days.
Many sufferers continue to have symptoms for months to years.
What does that mean?

23. The Standard Return to Play Protocol:
Stage 1- No activity (complete physical and cognitive rest) remain in stage 1 until symptom free.
Before going to stage 2 athlete should attempt a period of reading and light cognitive activity that causes no symptoms
Stage 2-Light aerobic exercise
Stage 3- Sport specific exercise
Stage 4-Non-Contact Drills
Stage 5- Full-contact practice
Stage 6-Return to play
If any symptoms are incurred at any one of the stages, the athlete is to take the rest of the day off and return to the previous stage the following day. The athlete is to remain at that stage for at least 24hrs. If symptom free they may attempt the next stage again

24. My son or daughter passed the IMPACT test but still has chronic headaches, sensitivity to light, and poor balance. WHY?
Computerized neuropsychological tests do not test all areas of the brain that can be involved in a concussion
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

25. We do not treat emergency situations. We do not treat with medications
Where does the functional neurologist fit into the picture?
How are we different in our approach?
We do not treat emergency situations.
We do not treat with medications “

26. 3. We look at overall brain function
Where does the functional neurologist fit into the picture?
3. We look at overall brain function
4. We look at each specific brain region, specific functional capabilities and the neurochemical environment very well.
This is different than just passing a computerized test or vague, generalized batteries of tests that do not look at various things from a functional model. “

27. Where does the Functional Neurologist fit into the picture?
Example: IMPACT test is normal, you have math, recall and no other neurological symptoms
But your eye movements are still pathological and fatigue rapidly and you have transient mental fatigue issues “

28. We also look and treatment and recovery differently.
Where does the functional neurologist fit into the picture?
We also look and treatment and recovery differently.
More on that in a bit “

29. We treat patients Neurologically , Metabolically and Biomechanically.
What Makes the Functional Neurological approach different than every Other Doctor That You Have Seen?
We treat patients Neurologically , Metabolically and Biomechanically.

30. “As Functional Neurologists …
We see concussion patients who do not get better symptomatically by rest
It is important to understand the majority of concussion sufferers that do feel better with rest are not really better neurologically
If a player goes back less than 100% there is a high chance that they will get hurt again

31. Second Impact Syndrome
HS athletes are 3x more likely to experience a 2nd concussion after experiencing an initial concussion in a season. Especially if not fully recovered
Second Impact Syndrome
1. Sustaining a 2nd concussion WHILE still recovering from an initial concussion.
2. Severe Brain Swelling can cause death. Red flags – must be treated appropriately

32. There are two main things that happen to the brain with concussion.
First-there is the actual mechanical trauma where the brain bangs around inside the skull . Coup- Contrecoup
Second- there is a biochemical reaction that involves inflammation and swelling.

33. So there is a
MECHANICAL and NEUROLOGICAL consequence of a traumatic brain injury and also a resulting METABOLIC consequence.
Lets talk neurological first…

34. Cerebrum
Brainstem

35. Anatomy of the Brain Stem
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

36. “Concussion is due to an abrupt linear and/or rotational
acceleration or deceleration of the brain within the skull”

37. Concussion= mTBI

38. Coup - Contrecoup

39. “Like ringing out a wet towel”
The rotational forces of trauma torque and damage the midline structures of the soft brain
“Like ringing out a wet towel”
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

40. The midline structures of the brain such as the brain stem, cerebellum, limbic system and basal ganglia control:
Eye movements
Balance
Cardiac Function and Breathing
Emotion
Digestive Function
Coordinated Movement
Blood Flow To The Brain
Perception Of Body Position In Space
Not involved so much in executive function
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

41. Central Vestibulopathy?:
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

42. Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

43. Pupil Stays Wider
More Light Comes In

44. Head injuries that result in concussion often are associated with injury to the neck and spine
The associated resultant joint dysfunction may further impair brain function, due to the alteration and reduced afferent input from the cervical joint and muscle receptors in the neck.

45. Advanced Testing Of Brain Function:
We are expertly trained in the use of advanced neurological instrumentation that objectively evaluate your brain and are used to monitor progress
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

46. Advanced Testing Of Brain Function: Also a Better BASELINE
VIDEO-NYSTAGMOGRAPHY
SACCADOMETRY
CAPS- Balance / Posturography testing
IMPACT
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

47. That does not test all areas of the brain that may be affected
Typical Computerized neuropsychological tests such as IMPACT assess attention, working memory and executive functions
That does not test all areas of the brain that may be affected
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

48. WHY ARE EYE MOVEMENT SO IMPORTANT TO DIAGNOSING AND TREATING CONCUSSION?
Eye movements are the only human physiological function that involves every part of the brain
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

49. SACCADOMETRY
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

50. SACCADOMETRY Research
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

51. Sensitive computerized measurements of fast eye movements known as:
SACCADOMETRY
Sensitive computerized measurements of fast eye movements known as:
SACCADES
Latency
Velocity
Accuracy
Waveform
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

52. Saccadometry

53. Saccadometry

54. Saccadometry

55. Saccadometry

56. Why SACCADOMETRY?
Lets say a Quarterback has a concussion and after some rest he passes his IMPACT test and he gets back on the field But
If he had SACCADOMETRY it would reveal that his saccadic reaction time (latency) to the left is normal at
< 200d/s but his saccades to the right (his blind side) are pathologic at 500d/s. Do you think with that delay that he may miss the linebacker coming to tackle him from the right thus putting him at risk for another concussion?
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

57. VIDEO NYSTAGMOGRAPHY Gaze Stability (all planes)
Nystagmus (gaze in the dark)
Pursuits (horizontal/vertical)
Saccades (horizontal/vertical)
Optokinetics (horizontal/vertical)
Vestibular Ocular Reflex (VOR) “

58. VIDEO-NYSTAGMOGRAPHY
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

59. VIDEO-NYSTAGMOGRAPHY
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

60. VIDEO-NYSTAGMOGRAPHY
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

61. Balance / Posturography Testing
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

62. Balance / Posturography Testing
CAPS
Balance / Posturography Testing
Is an extremely sensitive force platform and specifically designed software. It is so sensitive that it can measure otherwise imperceptible, undetectable movements a patient is making when they are standing
CAPS can detect abnormal balance and instantly compares the results to normative data for a person age, height and gender
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

63. Balance / Posturography Testing
CAPS
Balance / Posturography Testing
After a concussion the brain’s perception of where the body is in space becomes distorted from what is normal and accurate. This is called a person’s Center of Pressure and it can be altered in various planes. This can be measured by the CAPS unit and compared with the eye movements to create specific therapeutic exercises to help a person recover from their concussion
Show pertinent parts: cerebellum, pontomedullary area and mesencephalon (mid-brain)

64. How Many Of You Have Had All Of These Tests Performed???
WHY NOT?

65. Treatment: Neuroplasticity
… “Of all the finds, though, one is rewriting the textbooks. It is the dawning realization that a brain older than three years old is not the rigid structure that scientists long thought, but a malleable, ‘plastic’ organ”... “But a flood of discoveries show that the brain continually reorganizes itself. It’s called ‘neuroplasticity.’ And it means that “you create your brain from the input you get”

66. Treating a brain that is malfunctioning after a TBI
The Brain REQUIRE 2 things in order to function properly:
Fuel: - Glucose
- Oxygen
Activation - “brain exercise”- stimulation

67. Therapies Used for Brain Activation
May Include Some of the Following:
Specific eye exercises based on the testing
SSEP
Vibration Therapy
Proprioceptive stimulation
Balance Therapy
Advanced muscle retraining
Vestibular stimulation therapy

68. Therapies Used for Brain Activation
Interactive metronome
EYELIGHTS
Optokinetics
HemiStim Programs
Many more…..

69. METABOLIC
From a metabolic perspective, there are several things that happen following a concussion.
1. Increased glutamate levels
2. Altered glucose utilization
3. Mitochondrial dysfunction
4. Reduced available Magnesium
5. Brain Inflammation

70. BRAIN INFLAMMATION
In the injured brain there is a slow build up of free radicals, prostaglandins, lipid peroxidation products, inflammatory cytokines and excitotoxins that damage the connections between brain cells, the synapses, axons and dendrites.
The process is mediated by cells called microglia. Once the microglial cells are activated, they tend to persist in this state and can actually create even greater neural inflammation over time

71. A diet heavily loaded with excitotoxins such as MSG or Aspartame
A person that prior to their brain injury already has an inflamed body and brain from poor metabolic health such as:
Blood sugar issues
A diet heavily loaded with excitotoxins such as MSG or Aspartame
Food sensitivities such as Gluten and Dairy
Intestinal permeability (leaky gut)
Adrenal dysfunction
Can compound the negative metabolic affects associated with concussion causing a poor recovery

72. Preliminary Blood Testing CBC Chem panel Liver panel Iron/ Ferritin Full Thyroid Panel Thyroid Antibodies Lipid Panel Inflammation markers Vitamin/ Minerals Simple Gluten Sensitivity Test

73. Special Panels/Testing Cyrex array 2: Intestinal Antigenic Permeability Screen (Leaky Gut Testing) Cyrex array3: Wheat/Gluten Proteome Reactivity & Autoimmunity Cyrex array4: Gluten Associated Cross-Reactive Foods and Food sensitivity Stool Microbial Ecology Adrenal Stress Index

74. Intestinal Permeability Test
LEAKY GUT SYNDROME
A) Normal absorption = healthy gut
B) Poor gut barrier : Common problem in celiac disease, autoimmune processes, food sensitivities, CHRONIC PAIN
C) Malabsorption =poor gut health 74

75. METABOLIC

76. (Spinal Biomechanics)
Metabolic
Structural
(Spinal Biomechanics)
Functional Neurology
Symptoms
Condition

77. Where to go from here? Post-Concussion Severity Evaluation
Neurological exam
Advanced testing
Complete Baseline Evaluation for Concussion 77