Peter Attia MD263 ‒ Concussions and head trauma: symptoms, treatment, and recovery | Micky Collins, Ph.D.
EVERY SPOKEN WORD
85 min read · 16,725 words- 0:00 – 1:15
Intro
- MCMicky Collins
There's a lot of misinformation out there about concussion, and I think it actually hurts outcomes a lot of times. Clinicians that aren't aware of the recent advances in knowing how to treat this, clinicians that don't know w- how to f- do the right evaluation, and there's a lot of mismanagement and mistreatment of this injury that leads to very poor outcomes. Again, and you're gonna hear it from me over and over again, if you bring me a patient with concussion, I, I can pretty much tell you I can treat that and get 'em, get that patient better and get 'em back to the sports they love. There are highly effective treatments with this injury. [upbeat music]
- PAPeter Attia
Hey, everyone. Welcome to the Drive Podcast. I'm your host, Peter Attia. Well, Micky, thanks so much for, uh, for making time to sit down. I know you're particularly busy today, so I really appreciate it. Um, this is a conversation I've wanted to have for quite a while. Um, it's a topic that comes up over and over again in, uh, my life personally, and even professionally, whether it be patients or, uh, children of patients, things like that, and, and that's basically th- that have head trauma, and particularly, uh, you know, what, uh, what, you know, what happens when someone has a concussion? What are their options? And, um,
- 1:15 – 8:28
Micky’s interest in concussion and how he started the first concussion clinic
- PAPeter Attia
so I think before we get to that, I'd, I'd kinda like to give folks a bit of a sense of your background. How, how did you, how did you come to do this?
- MCMicky Collins
[sighs] It's a really interesting question, and it's kind of a long-winded response, but, um, I went to college and didn't really know what I wanted to do in life. I had a bunch of family members that were physicians and in the medical field. Um, I was... I also went to college to play baseball as much as I did to be a student. And I was playing baseball my junior year, and my coach came up to me and said, "Micky, if you don't declare a major today, you're gonna be ineligible." [laughs] So-
- PAPeter Attia
[laughs]
- MCMicky Collins
... I was like, "Okay." Um, and I was taking a neuroscience course at that time, like a biopsychology course, and it kinda hit my buttons when they needed to be hit, and I was very intrigued by it, so I just kinda dove in, in studying biology and psychology and, and really the neurosciences, and graduated college, went to s- went to s- graduate school, uh, and knew, and knew I wanted to do brain behavior studies. And I got involved in a, a, a program at Michigan State University. I got my PhD from there and, and studied in clinical psychology with a, a emphasis in neuros- clinical neuropsychology, which is the study of brain behavior, and took some of the medical classes there through Michigan State, but also did a lot of, you know, psychology, clinical psych, and neuroscience courses and combined that into my PhD. Um, and maybe two or three years into studying that at Michigan State, I said to myself, "I really miss sports," and I wanted, and I somehow wanted to combine traumatic brain injury and sports into something, and no one had really done that before, really. I mean, there wasn't, there was no concussion specialty when I went to school, uh, period. Uh, uh, and in fact, the whole conc-
- PAPeter Attia
S- sorry, just, just to make sure I understand that, Micky.
- MCMicky Collins
Yeah.
- PAPeter Attia
You're, you're meaning that even a patient that has a concussion in a sport, w- if they saw a neurologist, that neurologist wouldn't really have any particular insight on it?
- MCMicky Collins
This field did not exist in two, in 1998 or '99, '97 when I was in school. This field simply did not exist.
- PAPeter Attia
Hm.
- MCMicky Collins
Honestly, when I arrived here at UPMC in 2000, um, I, I, I really didn't know how I was gonna make a living doing this. I didn't know if I was-
- PAPeter Attia
[laughs]
- MCMicky Collins
... gonna be able to see patients. I didn't... No one would care on my research. I mean, it was a very, there was very little traction in anyone studying this topic, like literally nobody.
- PAPeter Attia
[laughs]
- MCMicky Collins
We were, we had the first clinic in the world here at UPMC, and that was developed... That ca- I came here in 2000. That's when we started the clinic. But long story short, back when I was getting into this, I, I, I wanted to study concussion or mild traumatic brain injury, and I somehow wanted to involve sports, and at, right now, if you think back, I mean, that sounds kind of intuitive 'cause everyone, it's a hot topic now. At the time, no one could care about it. But that was around the time that Troy Aikman and Steve Young and, um, Paul Kariya, if every- remembers that name-
- PAPeter Attia
Yep. Yep
- MCMicky Collins
... uh, Ricky Craven, a racecar driver, um, and, and others started to talk about this topic of concussion. And I remember watching Al Michaels on Monday Night Football talking about Steve Young's concussion in 1997 or '96, whenever it was, and he basically said, "No one knows anything about this injury, this topic, and there's a lot, there's just a lot of speculation, but no one really understands about the injury." And I said to myself at that moment, and not to be too dramatic here, but I said to myself at that moment, "That's what I can do," 'cause it was the perfect sort of marriage of brain trauma and sports, which is what I wanna do for a living. And long story short, I ended up having a mentor, a guy named Mark Lovell, and a guy named Joe Maroon, who's a neurosurgeon.
- PAPeter Attia
Yep.
- MCMicky Collins
Um, they were my mentors, and I was at Henry Ford Hospital in Detroit at the time doing my fellowship, and Mark Lovell came into me and said, "Hey, Micky, do you wanna move to Pittsburgh?" And I'm like, "Not really, but why?" And he said, "Well, they're s- they're starting an orthopedic, big orthopedic sports medicine center there. They want us to do a concussion program there." And I'm like, you know, "Let's go check it out." So we came here to Pittsburgh, and long story short, I came here with my mentor, Mark Lovell, and Joe Maroon is here, who's a neurosurgeon, and the three of us started this program in 2000. And that was at a time when [laughs] when, I mean, we had no patients. No one Could care about concussion, literally. We started researching it. Slowly but surely, we published many papers on it. Published a big paper in JAMA in 1999, actually. I was the lead author on that paper, where we looked at college football and concussion. And it was at Michigan State University, and we did some baseline testing with guys. And I tell the, always tell this story. It's kind of a funny story. [lip smack] Like, I wanted to do research on college football players. Um, and I was like, "Okay, we're gonna baseline test these guys. If they have a concussion, repeat the testing to see what we can find." And I naively thought, "I'm just gonna go to the, uh, medical staff of Michigan State and say, 'Hey, I wanna work with your football team.'" I did do that, but they said, "Well, we're interested, but you have to meet with the head coach to get approval." So, I went into the head coach's office, and that coach was Nick Saban. And that was the first coach I ever br- broached this to, and he said, "You know what? I think that's a great idea." And we researched this at Michigan State. We then started work in the University of Florida. We worked at University of Utah. K- uh, ironically, came to Pittsburgh and worked with them. All that data we collected, we published, and that was published in JAMA in 1999, which was one of the first groundbreaking studies of looking at concussion in sports. [lip smack] Um, and that ended up getting us here to Pittsburgh, and then we started growing this Pit- this program in Pittsburgh. And, uh, uh, when I-- The first five years, I, I swear I worked in a cubicle [chuckles] and I would see maybe two or three patients a week, if that. And I was doing-
- PAPeter Attia
Hmm
- MCMicky Collins
... research, et cetera. And now fast-forward 23 years later, we have 20,000 patient visits a year to our program. We've published over 450, 500 papers. We've written books. We've given talks around the world, and it's probably the hottest topic in sports medicine. So it's been quite a ride. Uh, a- and I'd like to think that we've learned a hell of a lot about this injury over that 23 years, and hopefully we can share some of that, uh, wisdom today.
- PAPeter Attia
Well, that's an awesome overview, and I think it speaks to, uh, you know, a, a, a f- an interesting and familiar sort of path in medicine. A lot of times people, you know, what looks completely unappealing and uninteresting becomes the most, uh, remarkable, you know, direction and, you know, to pursue. I mean, whether it's, you know, immunotherapy in cancer that, you know, in the '80s looked like a total no man's land, a graveyard for research, is now clearly the most promising therapeutic in oncology. [lip smack] So
- 8:28 – 20:16
Concussion: definition, pathophysiology, and risk factors making someone more susceptible
- PAPeter Attia
let's, let's get to some of the semantics. I mean, I think everybody's heard the word concussion, but what actually is it? What is the diagnosis? How subjective versus objective is it? What are the criteria?
- MCMicky Collins
[lip smack] So the word concussus literally translates from Latin to English to mean to shake violently. And if you think about your brain as like an egg yolk inside an eggshell, you know, the brain is, is, is inside this hard, you know, cavity, and if you have acceleration, deceleration, or translational forces that are hard enough, the brain's gonna shift inside the skull, and that shifting of the skull is actually what causes concussion. Uh, when the brain moves inside the skull, the membrane to the neuron will stretch, and when that membrane stretches, this little p- little chemical called potassium, which is supposed to be inside the neuron, will leak into the extracellular space. And when that does, there's an increased demand for glucose or energy that occurs due to the release of potassium. At the same time, there's an influx of calcium. So calcium leaks across that same stretched membrane, goes into the cell, and when calcium goes into the cell, we get vasoconstriction and decreased cerebral blood flow. So at the very ti- time the brain's demanding more energy due to the hyperglycemia lysis, we get an influx of calcium vasoconstriction and decreased cerebral blood flow and decreased energy supply. And so what concussion is is a mismatch between demand and supply of energy to the cell.
- PAPeter Attia
Hmm.
- MCMicky Collins
Now, this is not enough to cause cell death, Wallerian degeneration. There's no structural changes to the neuron. There's no death of the neuron. But the cells struggle to operate at their normal efficiency. And we've now learned that when that energy problem happens, different systems in the brain can be de- decompensated, and that decompensation of certain systems, we've now learned there's different types of concussions. There's actually six different types of problems we see following concussion. And that, those different types of concussions help to determine how we treat the problem. So as a clinician, my job is to find out where the aberrant signal's coming from and what system is decompensated, and then we have to apply the right treatment to the right problem. None of anything I just told you we knew in 2000. None of it. And so we've now really learned a lot about how this injury occurs. We, we understand the pathophysiology fairly well, not completely well. There's animal model work that's been looked at with that. [lip smack] And we, more importantly, we now clinically know how to evaluate this injury in a way where we can kinda figure out what's happening and then apply a, a more targeted treatment to its tre- to its treatment. Now, one thing is, Peter, is, is that we don't have a biomarker right now for this injury.
- PAPeter Attia
Hmm.
- MCMicky Collins
We don't. There's no blood test that's ready for prime time. There's no serum, serum marker. There's no imaging. This is not seen on MRI. It's not seen on PET scan. It's not seen on functional MRI. It's not seen on MRI. It's not seen on MEG. Uh, it's not seen on EEG. Um, there's no imaging studies right now that definitively help us with this diagnosis. And, um-
- PAPeter Attia
Even CSF fluid if you could access it?
- MCMicky Collins
No. And we're doing that. But no. All those things are looked at. People are re- very smart people are looking into those things and researching it, but I do not have a biomarker to measure this injury. It's, it's at the cellular level. It's an energy crisis. There's no structural changes in the brain that we see following concussion, and everyone is, like, searching for that biomarker, but right now we just don't have it, and I don't see that happening in the foreseeable future. I mean, there's a lot of good work being done on it. There might be a panel of biomarkers that we look at, you know, but-- and there's discussion of certain, certain markers may help us. But no, at this point in time, there's nothing I would tell you that's ready for primetime.
- PAPeter Attia
Just to go back to the beginning of this, so make sure I understand this.
- MCMicky Collins
Yeah.
- PAPeter Attia
Um, you, you have this, uh, m-movement of the brain relative to its, its, its, um, protection in the skull. The membrane of the neuron stretches, so presumably it's you have a passive effusion of potassium out of the neuron-
- MCMicky Collins
Correct
- PAPeter Attia
... as a result of that. [coughs] Is the demand for glycolysis so that you can actively pump potassium back in against a gr- unfavorable gradient?
- MCMicky Collins
Correct.
- PAPeter Attia
Okay, so that's why you need glucose, more ATP, force potassium back into where it doesn't wanna go. And then tell me about the calcium. Why is the calcium, uh, is the calcium just following a gradient across the stretch, stretched membrane at that moment?
- MCMicky Collins
Yeah. I don't know if we have an answer to that, but yes, that's my understanding of it. And when that pals- p- when that calcium goes into the cell, you know, we get a vasoconstriction and decreased cerebral blood flow, and this is very clearly an energy crisis or what we call a metabolic mismatch that occurs to the cell. The important thing at this point is we don't feel the cells die from this. Um, it-- they're just operating at a different level of efficiency. And what we literally see happen with this is different systems in the brain that require a lot of energy don't work as efficiently, and they will literally decompensate from that energy problem. And that's given us some good understanding of how to kind of approach this injury, actually. It's, it's, uh... We can get into the different problems we see from concussion, but yeah, it's, it's basically these systems that aren't working as efficiently as they should.
- PAPeter Attia
How global versus focal is this type of injury? So if you have two injury-- if you have two athletes, uh-- And by the way, I think we're gonna talk a lot about athletes, but the reality of it is you can get into a car accident and have the same injuries. [chuckles] So it-
- MCMicky Collins
This happens a lot more in non-athletes than it does athletes. Uh-
- PAPeter Attia
Yeah
- MCMicky Collins
... but, you know, we use sports as a laboratory. It's a great petri dish to study this injury.
- PAPeter Attia
Yeah.
- MCMicky Collins
Um, but this applies to slip and falls, car accidents, all kinds of older people fall, and boy, that's a real problem that no one's really addressing. So keep going. I'm sorry.
- PAPeter Attia
Yeah. So, so, so let's just say we took two individuals who, at the macro level, appear to have a very similar insult.
- MCMicky Collins
Yep.
- PAPeter Attia
Is this process occurring across the entire spectrum of neurons, or could two people say, "No, no, actually this is occurring far more in the temporal lobe in you, and it's occurring more in the frontal lobe in you," and, and i- is it-- Uh, uh, clearly, there's gonna be a clinical diagnosis that's gonna be required to differentiate that. But again, just at the pathophysiologic level, what's the, what's the diffusity of this?
- MCMicky Collins
It's an interesting question. I wouldn't look at this as more like this affects the hippocampus or this affects the prefrontal gyrus or whatever. I wouldn't look at it that way. I'd look at this as it more affects systems in the brain and pathways-
- PAPeter Attia
Mm
- MCMicky Collins
... in the brain. And so there's really no known, like, you get hit in the head here, you have this symptom. That's-
- PAPeter Attia
Mm-hmm
- MCMicky Collins
... that's antiquated in terms of how we think about this. It's more systematically looking at how the brain's functioning, okay? So now with that said, interestingly, we do see the posterior-- When people hit the back of their head-
- 20:16 – 26:55
Symptoms of concussion, predictors of severity, and the importance of early and effective treatment
- MCMicky Collins
effectively. Now, the key here, though, Peter, is to manage it effectively when you have one, and you don't wanna stack these things up, and people that do can get in trouble with it. And y- this is becoming a very specialist kind of thing to see. You wanna go to someone that knows what they're doing to manage this injury effectively when you have one. You wanna make sure you're getting the right assessment done, the right tools, 'cause there's really, there's, there's definite morbidity when this isn't managed properly, for sure.
- PAPeter Attia
Let's go back to the, the, the, the person, the athlete, the non-athlete, whatever, who has the, who has the head injury. So we've already established we have no biomarker, right? So-
- MCMicky Collins
Correct
- PAPeter Attia
... this person gets their bell rung, be it in a car accident or on the football field, and it's a clinical diagnosis. So tell me if you're at the sidelines or if you're in the clinic when the person shows up the next day, what are they typically complaining of, and what are you doing to make that diagnosis?
- MCMicky Collins
So there's approximately 21 different symptoms on the field that you can see following concussion, and it depends on what type of concussion you have.
- PAPeter Attia
Mm.
- MCMicky Collins
Um, there are signs and there are symptoms of injury. Signs are what you o- outwardly observe. Symptoms are what the patient reports. Signs of concussion include loss of consciousness. It includes confusion. It includes, uh, balance issues. Uh, includes vomiting. Uh, those are all signs of injury. Symptoms of injury are dizziness, fogginess or feeling detached, feeling one step behind, light sensitive, noise sensitive, nauseous, fatigued, blurred vision, double vision, fuzzy vision, um-
- PAPeter Attia
Headache
- MCMicky Collins
... headache, of course. Yeah. Thank you for that one. Um, uh, another s- uh, is, you know, post-traumatic amnesia, retrograde amnesia, loss of memory before the injury, loss of memory after the injury. Any-- We've done a lot of research looking at these different signs and symptoms and their, their relative ability to predict outcomes. I'll give you 20 bucks, Peter, if you tell me the, the one, the on-field symptom that best predicts a longer recovery from concussion.
- PAPeter Attia
I mean, I would have guessed loss of consciousness, but that seems too obvious.
- MCMicky Collins
Yeah, you're gonna, you... Yeah, that, that would be, uh, that would be obvious, and it's incorrect, actually.
- PAPeter Attia
Mm-hmm.
- MCMicky Collins
On-field dizziness is six times more predictive than any other symptom of predicting a longer out from concussion.
- PAPeter Attia
Wow.
- MCMicky Collins
And the s- the second symptom that best predicts outcome is fogginess.
- PAPeter Attia
Hmm.
- MCMicky Collins
Kind of feeling one step behind, detached, removed. Dizziness is six times more likely to cause a long, uh, longer being w- a month or longer of recovery-
- PAPeter Attia
Hmm
- MCMicky Collins
... than it, than is losing consciousness. Um-
- PAPeter Attia
Wow.
- MCMicky Collins
Yeah, right? Um, and you know what's interesting about that is this, i- is this, it's really interesting, is that the symptoms of injury way better predict poor outcome than the signs of injury, and the reason for that is because if you lose consciousness, it's very unlikely you're gonna go back to play. You know, like, you're not gonna get put back to play if you lose consciousness, unless you're in [chuckles] some archaic sport, you know? Uh, and, or in some geographical area that hasn't been exposed to this information, right? So when you lose consciousness, you get taken out of play, and you're not gonna get put back to play. That may be why these symptoms predict worse outcomes, because a lot of patients tend to play through their injury.
- PAPeter Attia
Hmm.
- MCMicky Collins
You know, we just published a paper in-- We've published a series of papers in Pediatrics, JAMA, and other journals where we looked at... We, we, we asked the question, if patients have a head injury and they have symptoms of concussion, what happens if we take them out of play immediately, w- or what happens if they continue to play, and what do their outcomes look like? And so we did this very cool study-
- PAPeter Attia
Sorry, this is not done prospectively. This is done retrospectively?
- MCMicky Collins
Retrospectively, right, because it's hard to do prospectively 'cause it's-
- PAPeter Attia
Yeah, of course
- MCMicky Collins
... right.
- PAPeter Attia
Yeah.
- MCMicky Collins
But retrospectively, we looked at a very large database. We had about, I think, 300 kids in the sample- 150 of them had symptoms of or signs of concussion, and they came out of play immediately. And then 150 of them continued to play after having those signs and symptoms, okay? The people that got taken out of play immediately, their average recovery time was 18 days. And patients who returned to play and played for just 15 minutes bepoint of the, b-beyond the point of their injury or p-point of having symptoms, their average recovery time was 44 days. So just playing 15 minutes through this event added almost, you know, close to a month onto the recovery.
- PAPeter Attia
And now, how were you, how were you able to control for the severity of the initial event? Presumably, there's a bias there, right? Which is that the kids who came out right away, [lip smack] I don't know, you know, they, uh, maybe they, uh, were more in tune with something. You know, I mean, it, it, it, it's hard to do that without randomization, right?
- 26:55 – 31:51
The six types of concussion, the effectiveness of treatment, and factors that impact recovery
- PAPeter Attia
p- uh, you know, kinda ears all perk up. But let's go back again to these different types. I think you mentioned-
- MCMicky Collins
Yeah
- PAPeter Attia
... that there are sort of six different types.
- MCMicky Collins
Yeah.
- PAPeter Attia
Is that... So basically based on presentation, um, and based on subsequent testing that you might do, you would then elucidate these, these six different types. Is that how it works?
- MCMicky Collins
Yeah. So we do an evaluation where we ask about symptoms, obviously do a very good clinical interview. We have a physical exam that we do called the VOMS, stands for Vestibular Oculomotor Screening. Um, we do impact testing. I don't know if you're familiar with the neurocognitive test. It's a-
- PAPeter Attia
Okay
- MCMicky Collins
... computer-based neurocognitive test that has been FDA approved that allows us to quantify and look at the, the concussion in a more objective way, looking at their cognition. There's different neurocognitive correlates that we see with these different types of concussions, et cetera. But you put all this information together, and yeah, and we're doing research now looking at these different, you know, phenotypes and different problems we see from concussion. But each of these different types of concussions are gonna have different symptoms. They're gonna have different pro- different risk factors, um, different therapeutic, you know, techniques to treat it, and different outcomes, and different return to play sort of situations. So, um, the different... Do you wanna... I mean, getting into it a little bit-
- PAPeter Attia
I'd love to hear them. Yeah.
- MCMicky Collins
Yeah.
- PAPeter Attia
Let, let's hear what they are. Yeah.
- MCMicky Collins
So there's, there's six different types of concussions. Cognitive. We actually call it cognitive fatigue. The second is vestibular, which is not the ear. It's more the central pathways in the brain. The, you know, the vestibular system is, is a very significant system in the brain that starts in the inner ear and then kinda goes to the deep parts of the brain. We're talking about more centrally derived problems from the, from the central part of the vestibular system or the brain part. The third type of concussion is ocular, which is your eyes working together as a team. It's not your vision as much as oculomotor. Um, the fourth type is migraine, which is what it sounds like, headache with nausea and/or light or noise sensitivity, and other symptoms as well. And then the fifth type, um, is anxiety. The sixth subtype is neck. You can have some of these symptoms coming from the neck. Um, not very common, but you can. So those are the six different problems we will see from concussion. Now, patients may have one of those problems, or they may have all six. They're not mutually exclusive. Um, and the more you have, the more difficult it is to treat. But you are gonna treat each of those different, each of those problems in a, in a distinct way or in a targeted way. And that's... You know, if there's 30 different types of knee injuries, why do we think there's one type of concussion, you know? And, but-
- PAPeter Attia
Yeah
- MCMicky Collins
... it, it's, we're starting to really be able to better identify kinda where the signal's coming from with this injury.
- PAPeter Attia
And is there, um, b- an age and/or, um, gender difference between these?
- MCMicky Collins
Yeah. Um, well, first of all, you may not be aware, but we've published a lot of, uh, data on this. The adolescent brain, if we looked at high school kids versus college athletes, and then college athletes versus professional athletes, the high school kids take the longest to recover from concussion. The college athletes take the second longest. The professional athletes recover more quickly than the other two. Um, there's a lot of sort of vulnerabilities of the adolescent brain to this injury you gotta be careful of, and, but there is an age relationship that we've published extensively on.
- PAPeter Attia
What do you think that's, uh, a result of? Do you think that the younger brain has a different hormonal milieu? Do you think that it-
- MCMicky Collins
I do.
- PAPeter Attia
Yeah. Do you think that that's the biggest driver of that, uh, distinction?
- MCMicky Collins
I, I don't know, and we're doing research on that now. We're actually doing a really cool women's study on concussion, looking at some hormonal influences, and we've found that menstruation can change after a head injury, and-
- PAPeter Attia
That was the first question that was gonna come to my mind is it would be so interesting to understand how a woman's menstrual cycle, and therefore, you know, not just menstrual cycle, but also, like, where is she ovulating? Where is she in the follicular and luteal phase? Because the estrogen-progesterone swings in those phases are enormous. Of course, it begs the question, are those hormones protective, right?
- MCMicky Collins
Yeah, and we actually are ... We- we're just about ready to embark the first women's study on this injury. Uh, we're collaborating with, uh, Magee Hospital here at UPMC, uh, with our clinic, and it's exciting work. Uh, we just got a grant to look at that. But we have published a paper already in JAMA Neurology, I believe, where we showed that, uh, menstr- the menstrual cycle does change, uh, relative to patients that don't have head injuries. So [sighs] this ... There's a lot to learn, and that's a cool thing is, is again, and we started doing this work and when no one cared about it. Now there's too much work to be done, and everyone cares about it. It's, it's fascinating and-
- 31:51 – 34:33
The importance of seeing a specialist and the prognosis for recovery
- PAPeter Attia
What, what do you attribute that to, by the way? How much of that do you think, um, is, is an indirect or even a direct consequence of the attention that's been brought to brain injury through the light of CTE, uh, vis-a-vis the NFL?
- MCMicky Collins
Yeah, it's an interesting question. I mean, clearly the spotlight in this injury is iridescent, you know? And clearly the NFL is a very powerful enterprise, and there's a lot of eyes on it, and there's a lot of discussion, open discussion on this topic, which is a good thing in a lot of ways. It drives science, and it drives awareness, but too much awareness without a solution is called hysteria, and we see that happen with this injury. Um, when the reality is, is that there's a lot of misinformation out there about concussion, and I think it actually hurts outcomes a lot of times. Clinicians that aren't aware of the recent advances in knowing how to treat this, clinicians that don't know w- how to do the right evaluation, and there's a lot of mismanagement and mistreatment of this injury that leads to very poor outcomes. Again, and you're gonna hear it from me over and over again, if you bring me a patient with concussion, I, I can pretty much tell you I can treat that and get 'em, get that patient better and get 'em back to the sports they love. There are highly effective treatments with this injury.
- PAPeter Attia
Is this the sort of thing where there's a relatively finite window in which you or the physician treating has to be able to access the patient, and the further a patient is from that window, absent the natural history resolution, the more difficult that gets?
- MCMicky Collins
Okay, so I'll answer that with data. Um, we just did a study again published in, I, I think it was in JAMA Neurology as well, where we looked at what factors best predict outcomes from concussion. Um, you know, migraine is a huge factor of predicting outcome, history of migraine. There's certain symptoms that predict outcomes. Uh, but we looked at all those things. The, the, the one factor that best predicted outcome was how quickly they get into our clinic. If they-
- PAPeter Attia
Yeah
- MCMicky Collins
... were seen by us within seven days, that was the best predictor of someone who got better from their injury. 'Cause we can apply our treatments quickly, and if you do wait, it's harder to treat. And but I, I still will argue, even if you're a year out, two years out, three years out from this injury, we can treat it effectively the great majority of the time. It's not irreversible. You can get patients better even if they have been living with it chronically. Peter, today, I, I mean, I saw patients all morning. I had 20 patients on my schedule before our podcast. Um,
- 34:33 – 46:23
Case study of a racecar driver who suffered a vestibular concussion
- MCMicky Collins
I just saw a, a racecar driver from, I don't know, Phoenix or someplace, and they've been going through this for two years and miserable. We will get that patient better. They will be normal when we finish treating them. There's nothing I'm seeing that worries me about them.
- PAPeter Attia
W- w- if you can, without giving any information that would identify this individual, can you give a bit of a sense of this as a case study? So presumably two years ago, this guy was involved in an accident?
- MCMicky Collins
Yeah, was involved in an accident. Um, didn't real- Had, had the, all the hallmark symptoms of vestibular problems. D-
- PAPeter Attia
What type of accident, by the way? Was this one where it was just a coup contrecoup injury where he whiplashed? I mean, you know, we wear a HANS in a car-
- MCMicky Collins
Yeah
- PAPeter Attia
... which limits our recoil now in our heads, but presumably-
- MCMicky Collins
I looked at the video on it, and this isn't-
- PAPeter Attia
Yeah
- MCMicky Collins
... at the highest levels of racing, so I'm not-
- PAPeter Attia
Sure, sure. Yeah.
- MCMicky Collins
So, you know-
- PAPeter Attia
Yeah
- MCMicky Collins
... you know, and we do work a lot with those patients, but this is a, this is a small track event or something where the patient got, somehow got hit in a way their car rotated and went backwards into the wall.
- PAPeter Attia
Okay.
- MCMicky Collins
In this video, I actually saw the video of the hit, and their head, you know, hit the back of the headrest. And there was no loss of consciousness, but the person immediately felt foggy, the slow wavy dizzy. They had a headache. Uh, they felt fatigued. Uh, they had bilateral blurred vision early on, but no loss of consciousness, no memory loss, no confusion. They, obviously the car was totaled, so they didn't race, but they didn't also get medically evaluated after this. They kind of went-
- PAPeter Attia
Mm-hmm
- MCMicky Collins
... about their lives and continued to have those symptoms and went back to racing two weeks later and got in another accident and had the same problem occur, same mechanism even, and that's when everything obviously got worse and when they sought medical attention. But- They've been living with that for two years. They've not improved. Th- they came to me today. They're having everyday headaches that can get up to an eight out of 10, light sensitive, noise sensitive, foggy. They don't like busy environments. They c- they don't like exercising 'cause they get really dizzy. They get headache. They get sick to their stomach. They've got a lot of car sickness. They have a lot of sympathetic nervous-
- PAPeter Attia
So th- this, this sounds debilitating.
- MCMicky Collins
Oh, it's totally debilitating
- PAPeter Attia
I mean, this is, this is, this, this is destroys your life.
- MCMicky Collins
It destroys your life, and this is a person who is not racing anymore. They're not working because of it. Um-
- PAPeter Attia
Oh, God
- MCMicky Collins
... they have massive sympathetic nervous system arousal where they can't sleep at night. They're very foggy, um, very, very worked up. Um, and they very much are isolative. They, they don't want to be around other people 'cause that triggers the vestibular problems, and so they become more reclusive. You know, they find themself exercising minimally. They're socially very inactive. They're not preoccupied with their mind, so there's a lot... Their thoughts are going so fast 'cause the nervous system is racing, so they're in their head all day long, and it cro- you know, m- migraines. And so you... I mean-
- PAPeter Attia
Hmm
- MCMicky Collins
... that's what I just saw this morning, Peter, and I do it all day long, and this is an injury that is... This causes so many problems in patients.
- PAPeter Attia
So notwithstanding the fact that this poor guy has been needlessly suffering ho- you know, for a couple years, tell me in broad strokes, what are, what are you gonna do to help this person? And, um, and, and, and what's a time course that you would give him for a, a reasonable expectation of recovery? So...
- MCMicky Collins
Um, okay, so we saw the patient today, and we have a very good evaluation we do. And the cool thing is we're s- we're very used to seeing out-of-town patients here. A lot of my patients are out of town, so they have five appointments in one day. I'm the point guard of it, but we also have a vestibular therapist here. We have what's called exertion therapy here. We have a psychiatrist here. We have a behavioral optometrist that we can use. Um-
- PAPeter Attia
Wow
- MCMicky Collins
... we have neck people we can use. So it's all under one roof, so people have appointment-
- PAPeter Attia
Yep
- 46:23 – 49:51
Why vestibular concussions are particularly problematic
- PAPeter Attia
It seems that of those six phenotypes you described, this vestibular one is very problematic because it seems to amplify the other ones. But again-
- MCMicky Collins
Yeah
- PAPeter Attia
... am I interpreting that correct?
- MCMicky Collins
Yeah, you kind of are. I mean, uh, it- we actually have done research on that. If you looked at the most common types of concussion, we published a study on this as well, the, the most common problem we see after concussion is post-traumatic headache and migraine. That's the number one profile that we see. This-- Oh, no, I'm sorry. I apologize. Let me retract that. The number one profile that we see is anxiety.
- PAPeter Attia
Hmm.
- MCMicky Collins
And then migraine, and then vestibular, and then ocular, and then fatigue, cognitive fatigue. So we actually have done work on that. So anxiety is ubiquitous across this injury, and that is what is the most common clinical profile that we'll see is that nervous system issue.
- PAPeter Attia
It's, it's interesting though because, uh, you also said, if I recall, that no, uh, symptom predicts a worse outcome more than dizziness.
- MCMicky Collins
Yeah.
- PAPeter Attia
And that, of course, makes me think, well, dizziness is so tied to vestibular.
- MCMicky Collins
Yeah. Right.
- PAPeter Attia
And-
- MCMicky Collins
I agree with that
- PAPeter Attia
... so, so there, there is something about this vestibular problem that, by the way, would also amplify anxiety.
- MCMicky Collins
So you know how we-
- PAPeter Attia
Because-
- MCMicky Collins
You know how we do research, and we look at the numbers, and you publish that. My gut is the vestibular stuff carries the day with this injury the great majority of the time, or at least it kicks it off, Peter. Uh, you know, like a lot of times I'll see patients that-
- PAPeter Attia
Right. It's a vicious cycle that spins out of control from that.
- MCMicky Collins
Exactly. Uh, I would agree with that. I'm, I'm not gonna overgeneralize to every human being 'cause there really is-
- PAPeter Attia
Yep
- MCMicky Collins
... it's a very different presentation in a lot of different people. Like I'll see people that come in here that have a oculomotor problem that no one's identified and have no vestibular issues. They have no migraine. They're completely normal except they can't focus when they look at their math homework, and they get headaches in the front of their head, and they're tired. Um, that's a oculomotor problem that we can fix pretty easily.
- PAPeter Attia
And that's just a PT program?
- MCMicky Collins
Yeah, we have to retrain the ocular system. Um-
- PAPeter Attia
Okay
- MCMicky Collins
... and we have exercises that we've, you know, that can do that very effectively. Um, and so we see those patients. But yeah, the vestibular stuff is, is ubiquitous. And but there's patients I see where the vestibular problems clearly kicked this off, but that's not present anymore. It's all migraine and anxiety, but it came from that, that beginning, if that makes sense.
- PAPeter Attia
Yeah.
- MCMicky Collins
And it sounds like your friend there that got that horrific bike accident, that sounds terrible, by the way. Um, like it sounds like he's gone down that profile. Yeah, right? I mean, the, the vestibular stuff and-
- PAPeter Attia
Yeah, and here's what's amazing. [clears throat] After two, two and a half, three years maybe-
- MCMicky Collins
Yeah
- PAPeter Attia
... he just kinda got better.
- MCMicky Collins
That's good.
- 49:51 – 56:43
A treatment plan for the racecar driver, possible use of medications, and how to address the root cause
- MCMicky Collins
Yeah.
- PAPeter Attia
So this, this gentleman today that you saw, he's gonna go back to Phoenix or wherever he's from-
- MCMicky Collins
Yep
- PAPeter Attia
... after he's had this amazing eval. Um, what's his homework assignment, meaning what are the actual types of PTs and activities he's gonna do, and when do you see him again?
- MCMicky Collins
So I'll see him back, um, in, uh, four weeks. They'll come back and see me. Um, and he has been given a very detailed set of vestibular exercises to complete every morning and evening. Um, he has been given an exercise program. Uh, we pretty much kicked him around the gym a little bit and got him moving. When this vestibular system breaks down, you have to move in certain ways to treat it, and we're very good at doing that. We're in sports medicine, so we know how to move people, and we've given him very specific workout that will treat over... that will train that vestibular system. And while we're doing that, we're also increasing the parasympathetic nervous system by doing exercise, so it's killing two birds, if that makes sense. And exercise also treats migraines, so that's three birds we're killing by doing the exercise stuff. He'll do that workout program every day.
- PAPeter Attia
How long will that be? How many, how many minutes a day will he spend exercising?
- MCMicky Collins
I have-- I'm gonna have him walk in the morning for 45 minutes, and then he does that very rigorous workout in the afternoon, and it takes about 45 minutes to an hour. And he's to do that every day until I see him back.
- PAPeter Attia
Wow.
- MCMicky Collins
Mm-hmm.
- PAPeter Attia
Can you give me an example of some of the exercises he'll do in the afternoon?
- MCMicky Collins
There's... For this patient, he had a horizontal vestibulo-ocular reflex problem. So this is your vestibulo-ocular reflex, and when he moves his head side to side-
- PAPeter Attia
He can't stay tracking when he does this?
- MCMicky Collins
Correct. And he also-- it will stir him up with dizziness and fogginess and headaches. Um, so we have him doing, like, a Russian twist where actually he's got a ball and he throws it against the wall, so we have him sort of really kinda train that vestibular system. We have him doing planks with head turns. We have him doing lateral shuffles.
- PAPeter Attia
Wow.
- MCMicky Collins
You know, that kinda stuff. And when you have a more of a vertical plane thing, we're doing a lot of burpees. You know, we're doing a lot of different things like that where it's more linear or, you know, you know, vertical rather than horizontal movements. This system will break down in distinct ways. Um, and given he's a racecar driver, that vestibulo-ocular reflex, when he's looking over his sho- looking side to side, like, that affects his racing. That's his moneymaker. He's better at that than I am. That's why he's such a good racer, right? You know, so that injury affected the very system that makes him who he is, right? So but we can retrain that by giving the right ex- So what this looks like, he goes home, does the vestibular exercises morning, night, does our worker pr- workout program night. I want a regulated sleep schedule. Gets up same time, goes to bed same time, no napping. Um, I want him to do exposures to busy environments, grocery stores, restaurants, parties, whatever. Um, I want him doing a lot of external activities. I don't want him internal. I don't want him, like, thinking about his symptoms. I don't want him ruminating, 'cause the nervous system is so fired up, you... Downtime makes this all worse, so we're gonna challenge him. There's three different types of exposures I want him to do every day in terms of busy environments and exercise and different ocular things. It's a very detailed program that's all written down, and they go home and do it, and I don't wanna talk to him for a month. Uh, and then he'll come back and see me. Sometimes we do telemedicine a month later, but this guy's coming back to see me 'cause he's pretty sick. We have medications that can help sometimes with this. Depends on what the problem is, but there's meds. I, I'm not gonna do that. I don't ever try to do meds initially. We wanna see if we can treat this behaviorally, and then we'll do meds if we need to.
- PAPeter Attia
What, what are some of the, the meds that might be kicked in? I mean, are there meds that help with sleep, for example, like trazodone or-
- MCMicky Collins
Yeah, I, I don't like trazodone too much, um, because the sleep is coming from the nervous system problem, so you're treating a secondary problem by treating-- by putting him on trazodone. Sometimes it's an SSRI, sometimes it's a tricyclic, sometimes it's-
- PAPeter Attia
Mm-hmm
- MCMicky Collins
... you know. So there's different meds that we'll use for that. There's certain SSRIs that are a little more effective than others in treating the nervous system profile. I don't like SSRIs.
- PAPeter Attia
Which, which ones are?
- MCMicky Collins
Uh, sertraline is a medication that can actually affect not only the vestibular system but the nervous system as well, so we've had decent outcomes with that. But sometimes-
- PAPeter Attia
Mm
- MCMicky Collins
... you need a Wellbutrin, sometimes you need an Effexor, sometimes you need, you know, s- there's, uh, Lexapro or e- escitalopram or whatev- There's different meds that will help-
- PAPeter Attia
Yeah, yeah
- MCMicky Collins
... with these problems, but... And we have a psychiatrist here that's phenomenal, and he's not-
- PAPeter Attia
And is this one of those things where it's just kind of empirical and-
- MCMicky Collins
Yes
- PAPeter Attia
... you have a hunch as to what you're gonna do, but if in a month it's not better, you, you sort of-
- MCMicky Collins
Yeah
- PAPeter Attia
... abort regardless of what y- you, the data say?
- 56:43 – 1:02:47
Exploring alternative treatments: hyperbaric oxygen, synthetic ketones, and more
- PAPeter Attia
I wanna ask you about a couple of other things that I get asked about a lot for which I have no answer, right? So one of them is the use of hyperbaric oxygen. Um, have you guys studied this?
- MCMicky Collins
Yeah, and I'm not a believer in it. Um, and it's not something that's gonna reverse the problems we see with this injury. And quite honestly, I don't want patients doing superfluous treatments that aren't well-founded empirically because it leads them into this sort of anxiety sorta model where they're just feeding into the problems. And we see that a lot with this injury. And, and I don't blame them because no one's getting them better, so they're trying all kinds of different things. But no, I will not have patients do hyperbaric treatment with this injury because it just leads to more searching and seeking that's not targeted. And we see patients that wanna do hyperbarics, but there's no data that has compelled me to tell you that hyperbarics would have any effect positively or negatively on outcomes from this injury.
- PAPeter Attia
Yeah. And the one thing I always discuss with my patients, they're usually asking me in a different context, which is, "Hey, does hyperbaric chamber, uh, improve longevity?" And they always point to this very poorly done study in Israel that supposedly showed that telomeres got longer in a hyperbaric chamber, although I have to break it to them that telomere [coughs] elongation has nothing to do with longevity. But the point I always make to them is the one of opportunity cost. So if, you know, we're here in Austin, there's a, there's a hyperbaric chamber in town. So if you wanna go and do hyperbaric, you know, work, you gotta go drive 30 minutes to get there. You're gonna spend an hour in the chamber at two atmospheres, and then you're gonna drive back. So you just put two hours a day into this for four or five days a week. And so the question is, even if you're completely cost agnostic, are you truly time agnostic? What could you have done with that time vis-à-vis improving your health? And in the case of longevity, I, I mean, if you spent half that time exercising, the-- you're gonna get, you know, 10X the, the value. And I suspect in the case of your patients, the same is true, right? If they-- you're, you're not-- you're asking for 90 minutes to two hours of their time in total to do the brisk walk and this vigorous exercise. Well, you know, the-- that's, that's more time than they would put into a chamber. And, and, and, and of course, the, the data it sounds like are that the chamber isn't efficacious. I-is that true? Y-you know, another question I get asked is, if you could get into a hyperbaric chamber the day of the injury, would that move the needle? Has that been studied?
- MCMicky Collins
No, because it's hard to study that. Um, but to my knowledge, no, there's no compelling data in any way, shape, or form that shows hyperbaric treatments to be effective at treating this problem. And I think you just stated things very well, Peter. I agree entirely with how you just sort of conceptualized that. The-- and to add to it, what do you do when you're in a hyperbaric chamber? Well, you think about crap a lot.
- PAPeter Attia
You ruminate, yeah.
- MCMicky Collins
Yeah. And we don't want rumination with this. It doesn't go well.
- PAPeter Attia
Another, uh, treatment option that I've had an interest in, um, is the use of synthetic ketones, uh, specifically acetoacetate or beta-hydroxybutyrate, being in the system if one could do that prior to an injury. So again, this assumes only in certain cases you would do it. It wouldn't help you against the car accident 'cause you don't know when you're gonna have the car accident. But if football players were drinking, you know, had, had synthetic ketones in their system such that they had one to two millimole of BHB coursing through their, uh, through their system at the time of an injury, there's at least a very strong theoretical argument, and there's some animal data to suggest that could ameliorate some of these symptoms because, of course, you immediately have a solution to that energy, that short-term energy crisis, in that you don't have to rely on glucose. You get 70% of that energy from, from ketone. Have you looked at any of those data?
- MCMicky Collins
No. Um, we're not doing animal model work here, nor are we doing that sort of research. I don't, to my knowledge, that has not been done. I think theoretically it's interesting. Um, there's a lot-- This injury is, is such a h- hot focus on it. I'd be interested to look at that specifically in the literature, but I'm not aware of any research that... But it, it makes sense, but.
- PAPeter Attia
Yeah, I mean, I guess you'd- you'd to study that rigorously, you'd want to have a pool of presumably athletes where the frequency of concussion is high enough that you could basically study. I- is it safe to say like, I don't know, collegiate, uh, h- high school or collegiate football players would have the highest, uh, incidence of concussion?
- MCMicky Collins
Yeah, football leads the way. Um, but it's, it's... But women's soccer is, you know, is very high as well. Women's basketball is high. Um, but yeah, football is the most com- Actually, the sport that carries the highest risk of concussion in terms of lifetime incidence, what do you think that sport is? So they'll-
- PAPeter Attia
I mean, I would have to guess boxing.
- MCMicky Collins
N- no. N- uh, 90% of equestrians have concussions over the course of their careers. So equestrian sports carries the highest-
- PAPeter Attia
I love that I'm now O for three.
- MCMicky Collins
[laughs]
- PAPeter Attia
Just we gotta keep this quiz up.
- MCMicky Collins
But, but given that-
- PAPeter Attia
Tell me why.
- MCMicky Collins
Given that-
- PAPeter Attia
It, it, are they falling or is it the bouncing?
- MCMicky Collins
Yeah. No, it's not the bouncing. It's the falling, and the horse is a very large beast. You know, you fall from a high degree. But, but given that the goal of boxing is to render your opponent concussed, I would expect that probably is even higher than equestrian sports, but the research just hasn't been really good there 'cause a lot of patients don't report the problems that occur. Um, obviously boxing is a very common sport where this happens, so. This is a very common injury. I don't know if you realize, Peter, but the 1.8 to 3.6 million concussions per year alone in sports rec- in sports and recreation in this country per year. It's crazy. It's very common.
- 1:02:47 – 1:07:57
The natural history of a concussion if untreated and the effect, if any, of concussion on subsequent risk of brain disease
- PAPeter Attia
What is the natural history of this if untreated? So l- let's start with what percentage of patients that sustain a concussion, and let's just take all comers, so we're not gonna differentiate how they got their concussion, whether it's in a car or on a horse or whatever.
- MCMicky Collins
Yeah.
- PAPeter Attia
What percentage will end up like the gentleman you saw today where this thing ain't getting better until he sees a specialist? Is that like 5% of people, 25% of people?
- MCMicky Collins
I, I wish I knew. I don't f- No one's done that kind of work.
- PAPeter Attia
We don't know the denominator basically.
- MCMicky Collins
We, we don't. If you walked a day in my shoes, you'd think it was very common [laughs] because they're coming-
- PAPeter Attia
Right. You, you have a huge selection bias obviously of the sickest people
- MCMicky Collins
... huge selection bias. So basically-
- PAPeter Attia
Yeah
- MCMicky Collins
... but I, I really do feel like a lot of kids will, will be fine after concussion. Uh, but there's certain, meaning that they probably work out of it and they're fine. You know, I mean, I don't know about you, but I've had moments in my life where I remember playing sports and getting hit and, and feeling foggy and dizzy, you know? And it, and I didn't have any problems from that, that I'm aware of. Uh, so this happens I think fairly commonly, and kids are fine. But there's, I think, certain, certain risk factors, certain personality types, certain biomechanics. It's a, it's a confluence of factors that end up with these patients ending up down this pathway where they can really get in trouble with it. So, and I don't think it's that, all that infrequent. I mean, it's, it, it does happen.
- PAPeter Attia
Micky, do we know anything about the effect of concussion on subsequent risk of brain disease? So one of the things we talk about a lot on this podcast, of course, is dementia.
- MCMicky Collins
Yeah.
- PAPeter Attia
Both Alzheimer's d- dementia and of course all other types of dementia, everything from Lewy body to-
- MCMicky Collins
Right
- PAPeter Attia
... you know, small vessel, et cetera. Do we have any insight into a relationship between those? Does a, uh, if two people who are identical in every way in terms of predisposition and whatnot and other factors, one person sustains multiple concussions in their life, the other does not. Do we know if that has any bearing on risk?
- MCMicky Collins
There's been some pretty good research done on that. Um, a lot of work done out of, uh, uh, Mass General in Boston. Uh, Grant Iverson's written really well on this topic. And the studies that have come out from him and his group, and I respect that group, we, we, we can see some relative increases in anxiety in some of those patients. But overall, the studies have been pretty good about showing there's, we don't, we're not seeing any proclivity towards dementia with these patients-
- PAPeter Attia
Hmm
- MCMicky Collins
... or proclivity towards Lewy body or proclivity towards other neurodegenerative illnesses. Now, it depends on what research you're looking at. [laughs] As, as you know, the, the, the research world is highly variable. Um, and you know, you look at other camps that would support that people that have repetitive head injuries will end up with, you know, chronic traumatic encephalopathy and, but those are s- You talk about selection bias. I mean, they're studying patients who are donating their brains because they have problems. And so we have a study going on right now here at UPMC. [lip smacks] I think it's one of the best controlled studies done in the area where we have a number of former NFL players, uh, a very large sample size coming to us, and we're doing a three-day evaluation. We're doing a full neuropsych battery. We're doing really fancy imaging with them. We're doing, uh, lumbar punctures. We're looking at CSF. We're looking at different biomarkers. We're looking at sleep study. We're doing a full deep dive on their neuro- neurological health. I mean, like a, the deepest dive you could do. And then importantly, we're matching them to controls that haven't had the exposures, and we're doing a very well-controlled study looking at the prevalence of neurodegenerative issues in patients that have had repetitive head injury versus patients that have not. And we're year two and a half into that study right now, and we're just about to dive into our first statistical analysis looking at all this information. So this is one of the better controlled studies out there right now, and there are other groups doing similar work. So we're gonna have very good scientific answers on this question, and then r- relatively near future, in the next several years, you'll b- see studies come out from these different groups, and that's why we do research. You don't wanna get your research in The New York Times, that's for sure. You wanna do well-controlled empirical work, which we're doing, and I think we're gonna have a very good understanding of this issue and more clarity to it in the relatively near future.
- 1:07:57 – 1:11:21
Chronic traumatic encephalopathy (CTE)
- PAPeter Attia
Is it, and I know that CTE is not your area of expertise, but is it your intuition that CTE is the result of untreated concussions that accumulate repeated injuries? Uh, the, the, uh, speaking of The New York Times as my source of information, my, my vague recollection of this was the idea that CTE was not so much the result of major concussions, but basically constant accumulated, you know, sub-concussive injuries. Uh, but, but again, I could be totally misremembering that.
- MCMicky Collins
No, I think you're remembering it right. Now, whether that's scientifically accurate or not is a different story.
- PAPeter Attia
Hmm.
- MCMicky Collins
Um, and I don't know the answer to that, and that's why we're doing the research. But, but the, the science hasn't evolved to have a definitive statement on these issues, in my opinion. And what I know anecdotally is I see patients who are absolutely convinced they have CTE that get better with our treatments and don't have problems after we treat them. And there's nothing worse than patients that think they have some debilitating, life-threatening disease where there's no possibility for help. It doesn't go well in those patients, when in fact, a lot of the problems that we see, there are treatments, and a lot of patients aren't aware of that, and it's very sad to see that happen, and we see that a lot.
- PAPeter Attia
That's kind of an amazing thought. I never really imagined that, but it's, it's certainly possible that there are gonna be a lot of people who either played sports professionally or at a very high level who could easily think that they're in the stages of CTE, um, and maybe they're not. Maybe this is a concussion that hasn't been appropriately treated. And of course-
- MCMicky Collins
I'll even take that a s- take that a step further. We see patients that are suicidal from this, and it's very scary where this will take you. 'Cause remember, we're talking about patients that have biologically derived sympathetic nervous system arousal and high anxiety, and they feel horrible. They're not working. They're not exercising. They're not regular with their sleep. They're not social. They're ruminating all day long. I mean, the suicide risk in that population is very, very high. And so you wonder [lip smacks] where this leads to, and some of the suicidality that we see in patients, like what percentage of those patients didn't have those problems but they believe they did?
- PAPeter Attia
Yeah.
- MCMicky Collins
And that's a function of, again, when I talked about earlier about how when you have an increased awareness with no solution, it can really lead to a lot of hysteria, and unfortunately, we can see that, and it's very devastatingly sad to see that in some of our patients. And, um, I think we need responsible science to lead us to better answers till we really understand this. And I understand the need to talk about this stuff in the media, and s- like you said it earlier, like we see so many patients because of that awareness, right? And that's a good thing. I mean, it's really leading to a lot of people getting help that wouldn't have received help. But on the flip side, it can be very dangerous as well.
- 1:11:21 – 1:17:42
Advice for parents of kids who play sports: when and where to seek treatment for a possible concussion
- PAPeter Attia
There's gonna be a lot of people listening to this, Micky, who are parents, right? So they're gonna be-- Their, their, their, their athletic heyday might be behind them. They're not taking the high-risk, uh, activities. Their risk of concussion, we'll talk about later 'cause that's gonna be the car accident, the fall. Uh, literally, I know somebody the other day that was bending down to pick something up under a table, and when they came up, they had that enormous posterior whack of the head, sustained a concussion there. But in thinking about their kids who are playing sports, whether it's, you know, soccer, football, you name it, what is the best advice you offer to those parents? So they're saying, um, "I think little Billy or little Susie has a concussion, you know, just based on the symptoms. Uh, we just took him off the field right away. Do we need to come out and see you in Pittsburgh? How many other centers of excellence are there in the country where we could go and get this level of bespoke treatment?"
- MCMicky Collins
That's a hard question to answer, Peter, and it's, but it's a great question. And yes, there are centers around the country that do a really good job with this injury, and you wanna start at places that have experience, and they, they call themselves concussion clinics or specialty clinics. I think they're much more equipped to do the work than a general pediatrician. I mean, you wanna, might wanna start with your pediatrician, but you, if you have specialist clinics in your area, you wanna start there, um, because they're familiar with the literature and the tools, and, and by and large, are well, very well equipped to do, to manage these injuries. Um-
- PAPeter Attia
A- approximately how many of these are there?
- MCMicky Collins
Well, there-
- PAPeter Attia
Does every major medical s- center have one now?
- MCMicky Collins
[chuckles] Isn't that crazy? We were the first program literally in the world, um, doing clinical work or studying this injury, and now I would say that every major geographic, you know, area has a center like this now, which is really exciting. It's crazy, isn't it? Um, blows my mind just to talk about that. It's only 20 years later, you know? So yes, this does exist in most places. Uh, if you're in rural Idaho or something, you may not have access to it, but, you know, now that telemedicine is a, is a medium that's widely used, I mean, you have that option available a lot of times, et cetera. So the, the access is better than it ever has been with that.
- PAPeter Attia
What, what are, what are kind of the just, just off the top of your head, kind of top five programs in the country that, that you would say would be great places for people to start if they're willing to travel and there's availability? Obviously, your program. What would be s- the other five that you would put on that list?
- MCMicky Collins
Another program I have an incredible amount of respect for is INOVA in Washington, DC. One of my former fellows is there. We've had 33 fellows train under us, under me, and they're at various sites around the country. I think they do a, most of them do a really, really good job. Um, I would say off the top of my head, um, uh, I think Boston Children's does a pretty good job overall. Um, I know there's clinics down in Houston, Texas, that do a good job. There's clinics in, in Phoenix that do a really good job. There's clin- clinics in California that do a good job. I mean, I, my, one of my fellows is in North Dakota right now doing great work. I mean, they're, they're out there. You could even go to our website and kind of find out who we train and where those patients are. There's access to places. But there's, there's really good programs out there I have great respect for, and we're actually collaborating with a lot of these programs and doing research as well, so, which is a good thing.
- PAPeter Attia
And would your advice, Micky, to that parent be... Let's, so let's just say, you know, the child e- experiences a concussion on Monday afternoon. Is your advice to them, "You know what? Why don't you just kind of keep the kid doing his thing, her thing, and if in two weeks it's not better, go see the specialty clinic"? Or do, is your advice, "No, go to the clinic right away on Tuesday"?
- MCMicky Collins
I agree with that. Because again-
- PAPeter Attia
Mm
- MCMicky Collins
... based upon our research, the earlier we see someone, the quicker they get better.
- PAPeter Attia
Got it.
- MCMicky Collins
And you do wanna start these treatments pretty quickly, and I, I would say if you can be seen within seven days of an... You know, the first thing you gotta do, Peter, is make sure there's not an intracranial bleed, right? I mean, like [laughs] -
- PAPeter Attia
Yeah, yeah
- MCMicky Collins
... so-
- PAPeter Attia
You have to do the medical thing. Yeah
- MCMicky Collins
... you gotta make sure-
- PAPeter Attia
Yeah, of course
- MCMicky Collins
... there's, you know, the red flags aren't there, et cetera, and rule that out. But once that's ruled out, I do think seeking specialty care within a week of injury is gonna lead to a much quicker outcome, which is what we're looking for.
- PAPeter Attia
So basically, it's never too early, and it's never too late to seek help for this, is what I'm hearing.
- MCMicky Collins
I completely agree with that. Yes. Yes.
- PAPeter Attia
Does all of that apply as we now move from the kid to the parent? So if it's me and I'm out there playing with my kids and they somehow talk me into climbing a tree, which they often do, but I fall, whack my noggin, same thing. If, like, let's say I go to the ER, I, we get the CT scan, I don't have a bleed, there's, there's nothing going on, but I'm... Let's say I feel totally fine. I'm like, "I got a bump on my head, but I feel fine." Would you s- And I'm medically cleared. Should I go and get evaluated, or only if I have a symptom?
- MCMicky Collins
Yeah, if you feel fine, I wouldn't necessarily feel that's necessary, no. But, um, again, the symptoms can be subtle, you know, what we talked about.
- PAPeter Attia
Yeah, that's, that's, that, that's my point is, like, without someone in the ER who's gonna do the real oculomotor test or whatever, I, I can speak to the symptoms, but I can't speak to the signs on my own, correct?
- MCMicky Collins
Yeah, and it's even hard to speak to the symptoms, you know. But dizziness, fogginess, fatigue, light sensitivity, noise sensitivity, headache obviously, difficulties falling or staying asleep, nausea, car sickness, difficulty in busy environments, cognitive issues. You know, all those things can... You know, I mean, but as long, if you're not having any of those problems, then no, live your life, man. It's, it's okay, you know?
- PAPeter Attia
Yeah.
- MCMicky Collins
But it can be subtle, that's for sure. But it's not gonna bite you, Peter. You know what I mean? It's not like I don't wanna... Like, it's something where if your symptoms are, are pretty nasty and they're not getting better, yeah, you better see someone, right? I mean, you wanna get in.
- PAPeter Attia
Yeah.
- MCMicky Collins
The sooner you get in, the better it's gonna be. If the symptoms are very subtle and improving, I'm not that worried about it, honestly. You just don't want another head injury while that's going on, and so that may be a reason. If you're a weekend warrior, you got a pickup basketball game you wanna play in the next weekend, you probably wanna get it checked out to make sure l- this, everything's normal. If you're not a weekend warrior, you're not gonna hit your head again, and it's getting better, I'm not nec- so sure you need to see someone.
- 1:17:42 – 1:18:40
Is there any evidence that the APOE4 genotype increases susceptibility to concussion or TBI?
- PAPeter Attia
Okay. Do you know anything about the role of the APOE4 genotype in terms of susceptibility to concussion or any traumatic brain injury?
- MCMicky Collins
So apolipoprotein has been looked at with this injury, and I haven't, we have, there is no compelling data to suggest that would put you at greater risk. It's not augmentive. Concussion plus APOE4 allele leads to X, Y, or Z. So no, I wouldn't say there's any hard data suggesting that to be a big risk factor, although it's an interesting one to look at. And I don't think the-
- PAPeter Attia
Yeah
- MCMicky Collins
... research is definitive, nor is it comprehensive in looking at that. But no, nothing to date has been... I raised that issue in the JAMA paper we published in 1999. That's the same place I went-
- PAPeter Attia
Mm
- MCMicky Collins
... when I wrote that paper is, like, people need to explore that relationship. But I, nothing has been found to be definitive there, no.
- 1:18:40 – 1:23:36
The increased risk of concussions in older adults and a case study of a 90-year-old patient who suffered a head injury in a fall
- PAPeter Attia
And I guess the last thing I want to just chat about, uh, is a little bit more of an understanding of what you said ear- about the, the older folks. So-
- MCMicky Collins
Yeah
- PAPeter Attia
... we, we talk a lot about this on our podcast, right? Which is once you hit about the age of 65, your mortality from falling, uh, becomes really high. Uh, it's, it's actually surprising when you look at the population-adjusted mortality, uh, a- associated with falls, accidental falls. And, um, we talk about it mostly through the lens of, hey, here's all-cause mortality that, you know, in the first year post a fall of, and, and that results in a fracture of the hip or femur. Um, one of the things that's happening in the aging person, of course, is their brain is shrinking a little bit, and their skull is not. So presumably, that's making them more susceptible. Uh, they're gonna have more movement of the brain within the head. Is that, is that why we're seeing a greater susceptibility in an aging population, in addition to the fact that they're obviously more susceptible to a fall?
- MCMicky Collins
I don't know. It's a great theory. Um, but yeah. I mean, obviously s- we see atrophy in that population, etc. Um, and the other thing is there's a lot of unprotected falls in that population. There's a lot of syncopal events in that population, uh, and there's a lot less motor control when you do fall, and so the mech- the biomechanics are gonna be more violent in that population. And also, cerebrospinal fluid is not as robust in that population, so you don't have as much-
- PAPeter Attia
Hmm
- MCMicky Collins
... protection of the brain moving inside the skull either. So there's a lot of reasons for it. Um, but oh my goodness, is that an understudied area, and boy, is it a huge problem that we see day in, day out in our clinic. I have a definite passion of working with older people that have this injury, and we're doing some of the first research looking at concussion in, in, in geriatric population, and it's a very reward- rewarding population to work with because you can treat it. It's so exciting to see someone... I just saw a 90-year-old this morning, Peter, th- that fell, and they wanna get better so bad. They have so much energy and-
- PAPeter Attia
H- how long ago did this person fall?
- MCMicky Collins
About eight weeks, and they're not well. You know-
- PAPeter Attia
Te- tell me about the fall. What wa- what was the, was the fall like?
- MCMicky Collins
If I remember right, they had a syncopal episode where they hadn't hydrated well, maybe a little stress going on in their life, uh, dysregulated blood flow, you know, dysautonomic stuff. They get up from going to the bathroom, collapse, hit their head on the, on the, on the linoleum floor.
- PAPeter Attia
Hit, f- fall forward off the toilet-
- MCMicky Collins
Correct
- PAPeter Attia
... face-first, basically?
- MCMicky Collins
Facial-
- PAPeter Attia
Okay
- MCMicky Collins
... facial fracture, small subdural, bad concussion. Fortunately, no intracranial intervention. The, the blood from the subdural reabsorbed, but they're left with this pretty bad concussion. Um, very, very dizzy in bed, very, very dizzy in life, don't like busy environments, feel fatigued all the time, bad headaches they've never had before, a lot of anxiety that they're not even aware of, and of course, they're living alone. They were living alone at the time, and now family members are around. They have to get support from them, and they get enabled, and they get really protective. They think they're gonna fall again, so they don't move as quickly. And of course, the vestibular problem doesn't get treated 'cause they're not moving. They're not doing anything. They're not exercising. They're not going to busy environments, and so the anxiety levels are up. They have benign positional vertigo that no one ever noticed. That's why they're getting really dizzy in bed. We can fix that.
- PAPeter Attia
Hmm.
- MCMicky Collins
And w- well, we get them in the right physical therapy, the right vestibular therapy, the right approach. We get family members on board and tell them how to approach things and get them more active and, and challenge them more and make sure the parents aren't protecting them as much as, as they [chuckles] you know, overprotecting them, and explaining how you treat this problem, and oh my God, they do really well. It's, it's amazing. It's very, very rewarding to treat a patient like that, and we'll get that person better, and they'll be... They'll look great here in another f- few weeks hopefully.
- PAPeter Attia
And again, they, this, this person will be doing how much exercise as a part of their rehabilitation program?
- MCMicky Collins
Walking for now. Um, you know, they're not a fall risk. We looked at them. See our vestibular therapist. They're not a fall risk, which is good. So we gave them some balance exercise to work on. We gave them some vestibular exercise to work on. Tell them to go to grocery stores. Don't carry, don't hold onto the buggy, you know, walking up and down the aisles, challenging themselves, going out to busy restaurants, going back to church, you know, explaining to family members how to approach all that stuff. It's really cool to see this stuff wash off the patient when, in fact, they, they are helpless. They don't think they're ever gonna get better. They think their life's over, like literally. And they think it's the beginning of something, the beginning of the end, you know?
- PAPeter Attia
Yeah, beginning of the end, for sure.
- 1:23:36 – 1:29:46
Funding for concussion research and fellowship programs to train concussion specialists
- PAPeter Attia
It, tell me, your research is mostly funded through NIH?
- MCMicky Collins
Oh, we get funding from a lot of different places, but we do have NIH funding. We have funding from the NFL. We've got funding from, uh, Centers for Disease Control. There's a really cool foundation here in Pittsburgh called the Chuck Noll Foundation, um, for the former coach Chuck Noll.
- PAPeter Attia
Yeah.
- MCMicky Collins
Um, I talked a little bit about baseline testing. Uh, Chuck Noll was... The Steelers were the first team to ever do baseline testing, and Chuck Noll was a huge proponent of treating head injury the right way, and, uh, Joe Maroon had a lot to do with that. But anyways, the, the Chuck Noll Foundation gives out grants to, to, for researching head injury, and we've received a lot of funding from that, um, and many other grant sources. I, it, it's, it's pretty cool. It's a pretty hot topic, and so there's a lot of monies available to study this, which is exciting.
- PAPeter Attia
And d- do you, I, I assume you mentioned this, but I assume you have neurologists in your group now as well?
- MCMicky Collins
Yeah, we have, um, um, we have a few, but, uh, you know, neurology, a- and they do a, and there's neurologists that do a phenomenal job with this injury, okay? But you're not trained about concussion in medical school. Like, that's not in the curriculum.
- PAPeter Attia
[chuckles]
- MCMicky Collins
So just because you're a neurologist doesn't mean you know concussion. Just because you're a neurosurgeon doesn't mean you know concussion. This is-
- PAPeter Attia
Yeah
- MCMicky Collins
... new, new science, new information, and that's why it's really important to see a specialist. Just don't assume that you go-
- PAPeter Attia
Yeah
- MCMicky Collins
... to one of these people that they're gonna know this injury 'cause most of the time they don't.
- PAPeter Attia
How many fellowship programs are there in the US now for, uh, training concussion specialists? So, uh-
- MCMicky Collins
Yeah
- PAPeter Attia
... I mean, what I'm hearing from you is y- you have a neurologist that would have to then specialize in concussion. You-
- MCMicky Collins
Yeah
- PAPeter Attia
... you have a psychiatrist. You have vestibular therapist or oculotherapists. I mean, everybody basically has to be under a concussion training umbrella. How many places are there besides UPMC?
- MCMicky Collins
I would say conservatively 15 to 20 fellowship, you know, maybe 10 to 15 fellowship programs, that's off the top of my head, that would do training specific to this topic. So it's not that many, um-
- PAPeter Attia
Mm-hmm
- MCMicky Collins
... but they do exist.
- PAPeter Attia
Well, Micky, this has been really interesting. I know you've got a busy day in clinic, so we were lucky to get time with you today, but I, uh, I want you to get back to those patients. I cannot believe the volume of patients you see. That is staggering. It probably also speaks to how amazing your team is, and it's, it's sort of like you've got that kind of, uh, almost the executive physical situation where people can come in for two days and they can see every doctor in the, in the medical center. Um, it sounds like it's that, it's that fine-tuned. Um, I, I, I came away from this discussion actually, um, far more optimistic. I don't think I had nearly an appreciation for how positive the prognosis was even in those patients with long-standing concussion with the right therapy. I, I really, uh, I thought it was the exception and not the rule that one could get better if you were two years out and still suffering.
- MCMicky Collins
No, Peter, it's been great. I've really enjoyed it actually. And you do a phenomenal job with what you do, and you have an interesting job. You get to hear a lot of different people talk about a lot of different things, and I think you conceptualize this very well, and I really appreciate your time. It was a lot of fun.
- PAPeter Attia
Thanks, Micky. Do you want to ask me one more question just to see if I can go oh for five?
- MCMicky Collins
No.
- PAPeter Attia
Do you have any other trivia for me?
- MCMicky Collins
We'll just-
- PAPeter Attia
Or we'll just leave it at oh for four
- MCMicky Collins
... we, we'll stick with the oh for here, yeah. Um-
- PAPeter Attia
[laughs]
- MCMicky Collins
I set you up on all those though, Peter. I did. Um-
Episode duration: 1:29:46
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