1. Concussion – Challenges, Treatment, and the Future
Michel Rathbone M.B., Ch.B., PhD, FRCPC (NEUROLOGY)
Professor Medicine (Division of Neurology)
McMaster University

2. Conflicts of Interest Financial conflicts of interest
Neurology consultant to ABI and Concussion clinics
Provide expert medical legal evidence
CEO of Libramen Naturals Inc.
Non financial conflicts of interest
None
Unapproved drug use disclosure

3. Collaborators
TRI Dinesh Kumbhare Queens University PMR Alasdair Rathbone McMaster University Pediatrics Surejini Tharmardinam McMaster University Kinesiology Mitchell Locke Aimee Nelson McMaster University Rehabilitation Science William Parkinson
Rathbone Group
Pamela Middlemiss (Study coordinator)
Teresa Gambale (Research Nurse)
Shazia Malik
Shaji Khan
Adrienne Atayde
Rosemary Nam
Sabrina Campbell
Rahim Ahmed
Tegveer Kamra
Jennifer Guan
Ling Yang
Angela Dong
Radhika Khanna

4. Concussion – Challenges, Treatment and the Future
What are we dealing with?
What is concussion?

5. Trauma induced alteration in mental status
Mild Traumatic Brain Injury

6. American Congress of Rehabilitation Medicine
Traumatically induced physiological disruption of brain function described by:
1.Any period of loss of consciousness (after impact)
2.Any loss of memory immediately before/after
3.Mental state alteration at time of incident
(dazed, disoriented, confused)

7. Concussion – Challenges, Treatment and the Future
A concussion involves:
Mechanical forces
Acute biochemical cascade
Subsequent repair processes including inflammatory cells

8. Concussion – Challenges, Treatment and the Future
We do not treat concussion
We treat the sequelae
‘postconcussion syndrome’

9. Concussion – Challenges, Treatment and the Future
Shakespeare Henry IV Part I – Falstaff
What is ‘post concussion syndrome’? A word. What is in that word? Air. A trim reckoning

10. Post-Concussion Syndrome

13. THE GREAT RAILWAY MYSTERY
IS PCS DUE TO PSYCHOSOCIAL ISSUES?...
OR….
IS PCS DUE TO ORGANIC CHANGES IN BRAIN?

15. Risk factors for MHI and post-concussive syndrome
Substance abuse (especially alcohol)
Lower socio-economic status
Overcrowded areas
History of psychiatric problems, learning disabilities, relationship difficulties
Past head injury
Migraine/headache or other Pain Condition
High symptom reporting

16. PCS – Structural ?
Better technology improving identification of changes
Do visualized brain changes represent brain damage or altered psychological function?
Will SPECT or fMRI images alter treatment?

17. J. Neurol. Neurosurg. Psychiatry 2008;79;300-306
Mild traumatic brain injury does not predict acute postconcussion syndrome
S Meares, E A Shores, A J Taylor, J Batchelor, R A Bryant, I J Baguley

18. Post Concussion Syndrome
Dizziness ?
Headache
IL-10
TNF-ɑ
IL-1β
Irritability
IL-6
Post Concussion Syndrome
Reduced tolerance
IL-1β
IL-6
TNF-ɑ
Fatigue
IL-6
TNF-ɑ
IFN-ɣ
Personality Changes
IL-1β
TNF-ɑ
IL-6
Cognitive Difficulties
IL-1β
IL-2
IL-6
TNF-ɑ
IFN-ɣ
Depression/Anxiety
IL-1β
IL-2
IL-6
TNF-ɑ
Sleep disturbances
IL-1β
IL-4
IL-6
IL-10

19. THE GREAT RAILWAY MYSTERY
RESOLUTION
PSYCHOSOCIAL, ENVIRONMENTAL, AND ORGANIC ISSUES LINKED VIA INFLAMMATORY MECHANISMS

20. Have all patients that present to a concussion clinic truly sustained a concussion?

21. American Congress of Rehabilitation Medicine
Traumatically induced physiological disruption of brain function described by:
1.Any period of loss of consciousness (after impact)
2.Any loss of memory immediately before/after
3.Mental state alteration at time of incident
(dazed, disoriented, confused)

22. According to the ACRM Criteria
2/3
Concussed
1/3
NOT concussed
? SYMPTOMATOLOGY ?
Are there differences in symptomatology?

23. If the brain is injured - logic predicts cognitive and behavioural consequences

24. Symptoms
Physical
Behavioural
Cognitive
Affective

25. Frequency (%) Emotional/ Affective Other Physical Dizziness/ Balance
No significance between symptom groups yet again, different sample sizes
Emotional/
Affective
Other Physical
Dizziness/
Balance
Cognitive
Personality/
Behavioural
Headache
Pain
Fatigue
Sensory
Sleep
Symptom Groupings

26. Concussion No Concussion1
Cognitive %
Headache % 2
Headache %
Sensory % 3
Sensory %
Dizziness %

27. Concussion – Challenges, Treatment and the Future
More questions
Improve treatment

28. DIZZINESS Mechanical Vestibular? Imaging? Imaging? Central?
Measurement?
Central?
Mal de debarquement

29. Concussion – Challenges, Treatment and the Future
Exercise
HIIT vs Endurance
Outdoors? Why?
In the woods? Why?

30. Concussion – Challenges, Treatment and the Future
Explore the symptoms
‘Environment and Psychosocial’
Do visualized brain changes represent brain damage or altered psychological function?
Imaging – may be abnormal before concussion

31. Concussion – Challenges, Treatment and the Future
Explore the symptoms
CHRONIC CHANGES
Changes in brain circuits and transmitters
Do identified brain changes represent brain damage or altered psychological function?
May indicate novel pharmacological therapy

33. Study: Investigating Brain Function in Post-Concussion Syndrome
Who: Patients diagnosed with post-concussion syndrome, age 18-50
Commitment: One visit, ~3 hours (*Participants will be compensated*)
Contact Us:
Investigator: Mitchell Locke
Neurolab, McMaster University:
Research being conducted at McMaster University to better understand the long-term changes in brain function associated with Post-concussion syndrome. For this important research, we are currently looking for patients with PCS to participate in this research. If you or someone you know may be interested in participating in this research, please contact us at the following and for more information about the technology used in the NeuroLab, please visit the link provided.
IMAGE on right: 2 students from the NeuroLab at McMaster University demonstrating the basic set-up of TMS, whereby a coil held over the participants head is used to non-invasively activate neurons directly below the coil. From this, we can record muscle responses to infer how neurons in the motor area of the brain are communicating.

34. Concussion – the Future
Early treatment of PCS
Will that reduce PCS?
Identify those likely to have PCS
Novel treatment strategy – reduce brain inflammation – study commencing

35. Concussion – Challenges
Late presentation
Mixed population
Funding for proven symptomatic therapy
Resources

36. Concussion – Challenges, Treatment, and the Future
Michel Rathbone M.B., Ch.B., PhD, FRCPC (NEUROLOGY)
Professor Medicine (Division of Neurology)
McMaster University