Dr. Mark Barisa, Understanding, Identifying, and Treating Concussions
Dr. Mark Barisa, Understanding, Identifying, and Treating Concussions
Show Notes & Links:
- Dr. Mark Barisa, board-certified clinical neuropsychologist
- Chalk Talk Series at the Sci-Tech discovery center – July 23, 6pm
- Baylor Health Concussion Management Program
- Baylor Frisco
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Scott Ellis: Welcome to the Frisco Podcast. I’m your host, Scott Ellis and this week, we’re here with Dr. Mark Barisa and we’re going to be talking to him a little about an upcoming talk he has at the Sci-Tech Discovery Center on concussions in sports. This is the conclusion of this years Chalk Talk series at the Sci-Tech Discovery Center. If you want to come out and hear his talk, that is going to be happening on July 23rd, from 6 PM to 7:30 and it is free, again at the Sci-Tech Discovery Center. Dr. Barisa, welcome to the show.
Dr. Mark Barisa: Thank you so much. Glad to be here.
Scott Ellis: Good to have you here. First of all, what kind of a doctor are you?
Dr. Mark Barisa: I am a board certified clinical neuropsychologist. In essence, not a lot of people know what that is. It’s a psychologist that specializes in the brain and bring behavior relationships. We do assessment and treatment of injuries or illness that impact the brain and how that affect thinking as well as some behavioral abnormalities that can occur.
Scott Ellis: Okay. Right now, you’re preparing to give us a talk on concussions and sports. I thought this would be a particularly interesting topic for our audience because we’re a sports crazy town. There are a lot of kids involved in sports here whether it’s football, soccer, basketball, what have you. I know that the topic of concussions has been of interest and perhaps more notable or well-known more recently. This is something that people need to pay attention to, right? This is pretty serious business.
Dr. Mark Barisa: It is. I think we’ve come full circle. I think back when I was younger and playing sports. Unfortunately, a few decades ago, our approach to concussion management was simply wake them up every hour, make sure that they don’t sleep through the night. That was about it. They took 7 days off. They went back to play. We didn’t think about concussions being a serious injury, a serious event. In fact, oftentimes, the word concussion was prefaced by the word just a, meaning it was just a concussion and were a bell ringer, things of that nature. We didn’t think much of it. They were a pretty common place. The thing is they’re still common place but with almost come to the reverse of that where now, people think of concussion as being one of the most severe things that can happen to their kids in sports, when in actuality, there’s a lot of other injuries that are far more devastating in terms of long term effects and things. That being said, concussions affect the brain.
We know in our youth and in our high school and college professional athletes, the brain is the one thing people don’t want to see get hurt and not get hurt permanently. In the media context, we’ve seen a lot of attention and focus with lawsuits of the NFL level and other professional sports. It’s a brought in a new awareness of these injuries. Any time we get more awareness, we also get increased diagnosis. We get increased perception of, “Could this be an injury? Could it not be an injury?” My approach as director of neuropsychology with Baylor Rehabilitation, as the director of our concussion management program, is to take a rational approach.
Are we dealing with an injury that’s permanent or are we dealing with something that’s temporary? How do we manage that? What we know about concussion is that in general, the vats majority of people, have full recoveries within anywhere from, we have 4-6 weeks up to about 3 months. We are dealing with an injury that does have a conclusion. It does have an end point. People do recover and they’re able to get back to sport. The important thing to remember, is they have to be managed appropriately to avoid those potential long-term consequences that we see in the media.
Scott Ellis: Okay. Let’s back up for just a moment. For those of us who don’t really know or understand what a concussion actually is, can you define that for us so that we have a little of idea of what we’re talking about?
Dr. Mark Barisa: Sure. If you look concussion up on the internet, you’ll get this definition that talks about pathophysiological changes due to biomechanical forces impacting the head. Very confusing definition. It’s, very simply put, a concussion is a mild traumatic brain injury. By definition, there’s some criteria that come into play. A mild traumatic brain injury or concussion, is an event that is some kind of either impact to the head or violent shaking of the head that causes a disruption in our mental status, in our thinking ability, in our brain function. Now, there’s 3 criteria for that to be a mild injury. The first criteria is loss of consciousness ranging anywhere from 0 to 30 minutes. 90% of all concussions have no loss of consciousness. The assumption that you have to lose consciousness for a concussion to occur is simply not true.
Scott Ellis: Okay.
Dr. Mark Barisa: The second criteria is 0 to 24 hours of something called post-traumatic amnesia. Now, post-traumatic amnesia is not, “I forgo where my keys are.” It’s not, “I can’t remember my grocery list.” It is a dense memory loss for all events during a time period. There’s a window of time before an injury to after an injury. That window of time in a mild brain injury or a concussion is anywhere from 0 minutes, meaning they don’t have it at all, up to 24 hours. That’s quite a long period of time for someone to have absolutely no recall but that does occur. Then, the last criteria, is normal radiologic findings. If they CT scan or an MRI, there’s no structural changes seen in the brain. What we end up dealing with are those 3 criteria, the things we look at to differentiate a concussion from something more significant, more severe that would have long-term impact, that would have long term damage.
Scott Ellis: Okay. I think that definitely helps frame up what we’re talking about now. I don’t want to say that we’re making too much out but because it’s clearly, it is something to be taken very seriously but have we swam too far to the other end where we’re … Are people making more out of concussions than they necessarily need to? In other words, are they self diagnosing and getting scared? Is it becoming a more traumatic event that is as to be necessarily?
Dr. Mark Barisa: I think anytime we have increased awareness, we do tilt the pendulum sometimes too far. Now, that being said, I’m going to be the last person to say, “these are significant injuries.”
Scott Ellis: Of course.
Dr. Mark Barisa: These are definitely significant injuries but part of the key is how are they managed? What we know about concussion, is we’re dealing with a chemical, a metabolic injury as much as a physical injury. The simple way to put that is if you’re imagine some chocolate milk that someone poured orange juice and hot sauce in it and you didn’t know it, when you drank that, you would experience this kind of awful physical reaction. You would have an emotional response that someone messed up your chocolate milk. You might even be confused what happened. That chemical change in the brain is very similar to that. We get an influx of some chemicals in to the powerhouse of the cell, mitochondria, the energy of the cell that creates that same kind of bad chocolate milk in the head.
Scott Ellis: Okay.
Dr. Mark Barisa: That lasts anywhere from a few seconds, few minutes up to a few hours up to 7 to 10 days, maybe a little longer in kids. The interesting about that is it does resolve but how we manage a concussion, that’s where sometimes, we can get a little too far.
Scott Ellis: Okay.
Dr. Mark Barisa: We know we want people to have rest but one of the things we have to be careful of is not to pull them into what we call cocoon therapy, where we put them in a dark room for 2 weeks, 4 weeks, 3 weeks. We’re waiting 3 months in some cases where we’re waiting for these individuals to have no symptoms. I think you and I can both agree, we wake up some morning and we have some kind of symptom.
Scott Ellis: I’m pretty foggy most mornings, at least until I’ve had my coffee.
Dr. Mark Barisa: Exactly.
Scott Ellis: Yeah..
Dr. Mark Barisa: What we have to be careful is, we’re looking for a benign symptom presentation. If someone goes into a concussion with headaches, they’re going to have headaches afterward. If they into a concussion with a proneness toward anxiety or worry or school difficulties, those don’t go away because they got hit in the head. We have to be careful not to over attribute normal difficulties to an event that occurred. That’s where we can have some very prolonged recoveries. We have to be careful that it’s not that were over diagnosing, we have to make sure we’re managing these properly, we’re doing the proper assessment and we’re gradually working them back to keep them safe.
Scott Ellis: I want to talk about some of the ways that a concussion might be managed in a minute. Before we get there and I know you treat this at levels from children all the way into professional athletes but for the benefit of the Frisco families who are mostly going to be either recreational athletes themselves or perhaps more significantly, children, their kids who are participating in sports. What are the things that parents or spouses need to be looking for in someone if they suspect they may have had a concussion or if they’re just taken a good blow to the head. Maybe they aren’t immediately showing any particular signs but is there anything that we should be keeping an eye on so that might tell us something’s up.
Dr. Mark Barisa: Sure. One of the major things that we see in the acute or the immediate stages after a concussion is balance disturbance, dizziness, light sensitivity, headache, noise sensitivity and then that mental fogginess you described. Those are some of the big things that we look for in the acute setting. We have a luxury here in Frisco. We’ve got some of the best athletic trainers I’ve ever worked with in the country.
Scott Ellis: Good to know.
Dr. Mark Barisa: They’ve all been trained in concussion assessment. They’ve been trained in appropriate management in getting our young students back on the field after such an injury in a safe way. They take a conservative but a rational approach. I’ve been impressed with them more than I could ever say. It’s that partnership of having the medical providers partnering with those athletic trainers. To provide input communication back and forth, we look for those kind of symptoms. As a parent, you want to watch of the headache, you want to watch for the dizziness. Of they just not seem right? Oftentimes, it’s just as simple as that. I asked a child in my office, “Can you tell me what’s going on?” They’re like, “I just don’t feel right.” “Well, specifically, what is it?” “I don’t know.” That’s one of the vague things about concussion that makes it such a problem in terms of appropriate diagnosis and appropriate management is we are dealing with a symptom based approach rather than actual signs or actual objective evidence of here’s the problem.
Scott Ellis: Is there any way for you to physically diagnose a concussion and be certain that’s what it is without a CAT scan for example or something like that?
Dr. Mark Barisa: Actually, the CT scan is used to rule out a more significant injury.
Scott Ellis: Okay.
Dr. Mark Barisa: The reason a CT scan is brought into an evaluation when someone comes to the ER for a concussion, is they want to make sure there’s no bleeding on the brain.
Scott Ellis: Got you.
Dr. Mark Barisa: That would require acute medical intervention. We go back to those 3 criteria. We want that normal CT image. It’s one of the few injuries or illnesses where you go to the doctor with all of your complaints and the do the test and go, “It’s normal. You have X.”
Scott Ellis: Got you.
Dr. Mark Barisa: It’s an odd thing. Really, from a sign and symptom presentation, we do look at balance. We look at any visual abnormalities or eye movement abnormalities. There’s some objective things within that balance cognitive assessment, some of those things. There are objective measure that we can be pretty clear, pretty definitive that that’s what occurred. There’s not a concussion-o-meter that we can plug them in and it will read positive of negative.
Scott Ellis: Okay.
Dr. Mark Barisa: That’s the tricky part.
Scott Ellis: I’m going to say something that might sound like a joke and I don’t necessarily mean it that way but your description of the symptoms, to me, sounds the way I have felt after a night of hard drinking on a few occasions.
Dr. Mark Barisa: Actually, I would point that that’s probably pretty accurate because if you think about the effects of alcohol, what is it? It’s a central nervous system depressant, so your thinking is slower, your mental processing is slower. It affects your balance and your equilibrium, so there’ll be maybe some dizziness but with drinking, it’s primarily vertigo. It’s that external turning. All of those are what we commonly see after an acute concussion. I don’t think your example is a bad one at all, it’s just not what I get to use in a clinic setting because parents don’t want me always talking about alcohol [crosstalk 00:12:58].
Scott Ellis: I’m sure they’re not going to be talking about your 10-year old going on a bender but I’m just wondering, is the effect of the concussion on the brain, in any way, chemically or neurologically similar to what happens when drink to much? Are those chemicals that you were talking about causing that sort of depressive effects or they similar symptoms but really unrelated types of actions?
Dr. Mark Barisa: Similar symptoms but different pathology is how I would look at it.
Scott Ellis: Okay.
Dr. Mark Barisa: One of the pieces of that is the brain has an ability to balance itself. When we talk about that chocolate milk syndrome, that chocolate milk phenomenon within the cellular structure of the brain. Well, what we’re dealing with, there’s something that the brain has gone into protection mode and it’s saying, “Don’t do that.” Similar to someone who sprains an ankle and you run on the ankle, it hurts. Well, if you have a concussion and you feel okay but then you decide, “I’m going to go back and play.” It’s like drinking the bad chocolate milk again. You experience it. You’re not making it necessarily worse unless you’re taking another hit but you’re experiencing the badness that is that chemical injury. Over time, that gradually gets better, so when you go and try it, it’s not quite as bad but it’s still bad.
Scott Ellis: Yeah.
Dr. Mark Barisa: That’s what we see this gradual improvement. That’s why appropriate management of concussion is so critical, that we don’t want to see these kids, “I feel better, so I’m going to go back and play.” That actually outs them at risk fro more significant injury. That’s what I think has been the appropriate side of the swing toward increased awareness. We want to avoid these catastrophic kind of events that we see on television and in the news where someone gets something like a second impact syndrome where there’s bleeding and hemorrhaging within the brain. That’s not concussion, that’s a far more significant injury. The difficulties we’ve faced now is we started to equate these mild injuries with these more severe injuries. We’re starting to say, “Yeah. We’ve got a concussion. That means there’s going to be long term emotional problems or long term behavioral problems, long term cognitive issues.” When that’s actually not the case. The research regarding concussions would indicate that we actually get very positive recovery trajectories and people do get better and are able to get back to sport. The difficulty comes when we start adding concussions on top of each other.
Scott Ellis: Okay. We’ve talked about what a concussion is, we’ve got some idea what the symptoms are and how to identify that possibility. We know who to talk to; our trainers would be a good first place to start especially here in Frisco, it sounds like we’ve got some great people. Now, let’s talk about the management side of this. You or child has been diagnosed with a concussion. What happens next? We know we’re not going to lock them in a dark room for 3 weeks but pulling back from there, how do we begin and how do we treat the concussion?
Dr. Mark Barisa: I think just that — we need to pull back. Without going into great detail, we need to understand that each concussion is an island and [inaudible 00:15:59] itself. There’s some generalities. There are some common things that we expect to see some averages but I try approach everyone who comes to my office as an individual and what they bring to their concussion is very similar to going to an airport. You don’t know what the cost of your flight is until you see how many pieces of luggage you brought with you. Well, if you’ve got pre-existing migraine headaches, a family history of migraine headaches, some history for anxiety, some history of learning disabilities. Well, that’s going to add to the cost of this concussion and it’s going to link then the amount of time and the types of interventions that would be needed. What we look at from the front end is we want them to rest for a few days. That’s pretty standard, I think, throughout the literature. There’s support that we need, at least a brief period of rest.
Once we get through that brief period of rest, then we need to start gradually adding activities. It doesn’t mean we go out and we run a 5k. It may mean we go for a walk around the block. We just gradually start getting those normal daily activities into place. As people remain or continue to get better and then remain with a benign symptom or not a pathologic or a significant symptom pattern, then we can gradually increase activities to some of their athletic exercise, those types of routines and then under the direction of the athletic trainers, if they’re in school sports, there’s actually a standard gradual return to play protocol that can anywhere from 5 to 10 days depending on the extent of the injury and the types of things we’re seeing where literally, they gradually start adding physical activity until they get into non-contact practice, then in the contact practice before their final year at least to full competition. There’s a process to this.
All of that being said, we do have some that have lingering vestibular balance issues. We’ll have some that have some lingering visual ocular motor problems in some of the more significant cases. That symptoms requires additional physical therapy to help regain the balance system back in place. The body adapts, so we have to repeat things to get the brain to start going, “Okay. This is how I balance.” To get that back and the same with the visual motor aspects, there’s some different kind of therapies that can be done on a visual end. On the cognitive side, sometimes, there’s some short term medications that can be used that help with the tension, help with the sleep/wake cycle because that gets disturbed. If you sleep all day, then you’re not sleeping at night. We try to get that back in order. There’s a variety of different things that are available but it’s really based on the symptoms that are presenting and how long they’ve been presenting. Sometimes, we need that short little 1 to 2-week window just to see how they’re going to do and manage from that point.
Scott Ellis: Okay. Sound like, first of all, the good news is, the research and out understanding of concussions, has come a long way since you and I were maybe school-ages athletes and it is largely something that people should expect to recover from.
Dr. Mark Barisa: Depending on the approach and the management that’s been taken and the individual aspects. Like I said, there risk factors for longer recovery periods. All of that being said, it’s never a good idea to bang your head against the wall. It’s never a good idea to get multiple injuries to the brain. We don’t want to minimize the importance of watching out for these injuries, preventing these injuries with proper head gear, proper fitting head gear, with proper exercise techniques, proper tacking techniques, proper sport technique in general so we’re hitting balls in the right way in soccer. We’re making tackles with the head up and using our arms instead of our heads to tackle in football. In lacrosse, making sure we’re wearing appropriate helmets and other gear.
In girl soccer, we get a large number of injuries because of the muscularture, the neck’s not very strong, so it doesn’t withstand the whiplash effect, so strengthening of the neck and those kind of things. There’s some things we can do to prevent that. One of the things we’re even looking at now, is we’ve …Baylor’s partnered with a group called Fusionetics that looks for injury, susceptibility and one of things, we’re even going to look at with them is the neck strength. There are exercises we can do to improve the neck strength and limit that risk to some extent as well.
Scott Ellis: Okay. That’s good advice. Let’s go out on this one. I want to leave you plenty to talk about when people come hear you at The Sci-Tech Discovery Center. In terms of things that people can do to help prevent injury, do you have any recommendations to leave us with?
Dr. Mark Barisa: The main thing id proper technique and proper protective gear. People get confused sometimes when you look at what are the number 1 and number 2 causes of traumatic brain injury in children. The assumption is contact sports. The number 1 cause of traumatic brain injury in our youth is actually bicycle.
Scott Ellis: That actually would make a lot of sense. I know when I was a kid, we did not wear helmets riding bikes and I don’t see kids anymore without helmets riding bikes, at least not in our neighborhood.
Dr. Mark Barisa: Exactly, but we put in emphasis on the sports. One of the the other highest of traumatic brain injury in youth is playgrounds. Hopefully, we’re not going to move towards outlawing bicycles and playgrounds in the near future.
Scott Ellis: I hope not.
Dr. Mark Barisa: I will say that there’ve been multiple legal cases about playgrounds. If you look at the playgrounds we have now compared to when you and I were younger, they’re very different.
Scott Ellis: Yeah.
Dr. Mark Barisa: They’re much safer.
Scott Ellis: It’s got the rubber, kind of like recycled tire stuff laid down. It’s not just bars on concrete. That was …
Dr. Mark Barisa: Yeah. I like swinging and jumping off the swing in the gravel.
Scott Ellis: Yeah.
Dr. Mark Barisa: I miss that but that’s one of the things we have to think is our kids are out there to play. They’re out there to get exercise. They’re out there to breathe the fresh air. As parents, we get so frustrated that our children spend so much time on video games and on their phones or other devices yet we’re seeing a dramatic reduction in youth participating in sports due to fears of concussion. Quite honestly, sometimes the effects of a ankle sprain, ankle rupture, ICO, those types of things are far more long term in their effects than concussion but we don’t hear about that as much. With a lot of the lawsuits, with a lot of the movies that are come out, there’s this new emphasis toward concussion and we should hold our kids from contact sports for concussion, yet we have to look at the risk and benefit approach. I think it’s important that our children get the opportunity to participate in that group concept that, “We’re a team. We’re working together and we’re getting exercise and doing things that are actually good for out bodies as well as putting some risk and therefore, harm.”
Scott Ellis: There’s definitely a balance to strike in there and I don’t think what we want to encourage is people to hold their kids back from sports because a sedentary lifestyle is not a healthy one either.
Dr. Mark Barisa: Absolutely.
Scott Ellis: We can host a different reasons for that or different ways but yeah, it’s not time to quit sports, it’s just time to be aware and keep our eye on what’s happening. Dr. Barisa, thank you very much for coming out today. I really appreciate this.
Dr. Mark Barisa: Thank you.
Scott Ellis: Again, everybody can out on July 23rd hear you at the Sci-Tech Discovery Center. That is at 6 PM. It is free to get in so if you want to learn a little bit more about this topic, I would encourage you guys to go out and hear Dr. Barisa talk.
Dr. Mark Barisa: Thanks so much.
Scott Ellis: Thanks for joining us. We’ll talk to you guys next week on the Frisco Podcast.