What you don't know about concussions... - Dr. Steven Geanopulos

Dr. Steven Geanopulos

What you don’t know about concussions…

Posted on March 13, 2016 by Dr. G

Here is a little taste of what our doctors, coaches and trainers don’t know about concussions.

My practice has 3 areas of focus

  1. Metabolic concerns including immune and autoimmune related conditions that impact hormone production, neurological function, GI and digestive issues among others.
  2. Brain based disorders including concussion, neurodegeneration, depression, anxiety.
  3. Scoliosis, in both children and adults.

These are seemingly unrelated areas of expertise and I am often asked, why do I specialize in such disparate areas of study.

The truth is they are not disparate at all, they have a lot in common.  They all involve a detailed knowledge base in how the nervous system, endocrine (hormone) system, nutrition and immune systems interact to cause complications in all areas of the body involved.  

Concussions do not require a blow to the head

Concussions, also known as mTBI (mild traumatic brain injury), can be the result of a fall, motor vehicle accident, sports injury, or blast injury, as seen in the military. It is a common misconception that the injury must involve a blow to the head. The fact is that a significant change in direction experienced by the head and neck. For example, “whiplash,” experienced in motor vehicle accidents, falls and sports collisions, can cause the brain to collide with the inside of the skull without a head trauma.

These injuries result in an acute inflammatory response in the brain where the injury took place.  No different than an inflammatory response you would get from any injury, sprained ankle, rotator cuff injury etc.  Inflammation is the body’s innate, intelligent response to remove and replace damaged cells at the area of injury so there could be a full return to normal function of that particular type of tissue.  

In the case of the shoulder or ankle injury, we can identify and isolate the damaged tissue and we fully understand the function of that tissue.  We can image, test and stress the tissue in order to determine if healing has taken place.  Tendons, ligaments and muscles can be examined thoroughly, there is no mystery about the function of each tissue type, and there is plenty of room for inflammation to take place.  

Brain tissue however can have very different functions, there are areas of brain tissue that are involved in language, hearing, vision, taste, touch, motion, emotions, focus, concentration, decision making, short term memory, long term memory and much of brain tissue is devoted to digestion, balance, posture, blood pressure, and linking all of these different functions to each other as a conductor organizes all of the sections of an orchestra to make beautiful music, etc.  Each concussion impacts these areas in different people in a completely unique way, impossible to predict.  However modern research has given us clues as to what patterns we can expect to see.  And it is not so simply limited to basic cognitive, spatial and temporal skills or psychological sequelae.    

The immune system is in charge

It’s important to remember that inflammation is mediated by the immune system.  The immune system is the “repair crew”, they will have to carry out 1,000’s of chemical processes in a very specific order in order for healing to take place.  When the repair crew is done, they need to pack up and leave so the area can get back to normal.  Just like if a repair crew is working on a stretch of highway, they interfere with the regular flow of traffic, cars have to bottle neck to 2 lanes instead of three, the speed limit has to be lowered, etc. The road cannot function normally until the crew makes the repairs and opens up all the lanes to full traffic at full speed.  

The brain, unlike all other parts of the body, is fully encased in bone and therefore swelling is NOT well tolerated.  A knee or ankle can swell to 2 or 3 times its original size to accommodate the need for inflammation to take place for proper healing.  The brain however is housed in hard bony encasement fixed in size and therefore limiting the extent of inflammation that can take place.  The brain is so averse to inflammation it has developed a barrier that prevents the majority of the body’s immune system from entering the brain.  The “construction crews” seen in the rest of the body are kept out of the brain by the blood brain barrier.  A barrier that only lets very specific components of our blood into the brain tissue and that excludes most of the immune system.  The brain has its own local “repair crew” not shared with the rest of the body.  They are called microglia cells.  Microglia spend their whole lives not really getting experience with big “construction and repair projects” but rather the microglia are more like glorified maintenance workers keeping the brain in working order.

When the brain is injured, we call upon the “glorified maintenance workers”, the microglia, to become construction repair crews, and as you can imagine they are not very experienced or very good at it.  In the case of concussion/mTBI they do a good enough job 85% of the time.  However 15% of the time they just can’t get it right and the repair crew remains there trying to repair the area chronically, preventing the damaged region from getting back to normal.

I know my analogies are overly simplistic but I assure you they are incredibly accurate and relevant.  The challenge to those 15% who have chronic persistent symptoms after mTBI or concussion is to find a practitioner who understands these mechanisms and how to coax the brain’s unique immune system to get the job done, pack up and go home.  This requires:

  1. An understanding of how to accurately and repeatedly assess the area of the brain that are most commonly impacted by concussive forces.
  2. An understanding and experience rehabilitating key areas of the nervous system that have impact on many different regions of the brain.  For example, mid-line cerebellar pathways that control eye movement and deep postural muscles, that are easily assessed for function and fatigue have a secondary impact on areas of the brain that are involved in focus, concentration, anxiety and depression.  Rehabilitating these pathways will impact the secondary regions as well.
  3. An understanding of the signals used by the microglia (the brain’s own immune system, construction and repair crew) to increase and decrease activity based on what can cross the blood brain barrier.  
  4. An understanding of what activities, nutrients, medications, toxins and behaviors can send the wrong messages to the microglia.  And being able to test for them.

So you can imagine that merely asking a person how they feel, doing some very basic physical exam procedures tests in an office setting, and medicating away symptoms with medications that actually delay and prevent healing can be the wrong approach.  In many cases the doctors performing these assessments and making decisions about returning to play, school or work have very little understanding of what is being discussed in this simple post. Yet this is the most common approach practiced by the entire medical establishment.  The public places a tremendous amount of trust in the medical profession to make the right choices and get the right education but the fact is the average practitioner cannot keep up with the latest information and research on these subjects.

Thanks for reading!

Dr. G

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