(Eighth in a series)*
They come, thousands every year, to see him, to be treated by him. Some famous, but the vast majority just regular people with regular lives. They arrive confused by what they're feeling and scared by what they've been hearing. Micky Collins examines them, and more importantly, he talks to them and listens to them. He tests them, and afterward shows them the test results and explains what those results mean. They are prescribed treatment, and over time the clouds lift and they feel like themselves again. And when they leave after their final visit, they walk back into the world understanding something that Micky Collins believes down to the marrow of his bones.
Concussion isn't cancer.
"When I first started doing this back in 1996, it was smelling salts and 'how many fingers am I holding up,' that predicated return to play. No one seemed to care about this stuff," said Collins from his office at the UPMC Concussion Center on Pittsburgh's South Side. "And now? It's on the front page of The New York Times on a regular basis. How did we get from there to here? The pendulum has swung from apathy to gross hypersensitivity. The truth is in between. The truth of the matter is that concussion causes a whole lot more problems than people had realized it did, but I don't think we should be sensationalistic at this point in time."
Michael Collins, Ph.D., – or just plain Micky to his friends – has the bonafides to make definitive statements about concussion, from his extensive clinical experience, to being the lead author on several groundbreaking studies that were reviewed by his peers and published in prestigious medical journals, to his 2005 Innovations in Treatment Award, presented to him by the North American Brain Injury Society "for developing and implementing innovative and efficacious treatment for persons with brain injuries."
Micky is healing patients who come to him with concussions, and because the bulk of those patients have to be brought to him by their parents, he's in a fight for the factual high ground on the issue. The other side has the name-recognition of Junior Seau, and the tragedy perpetrated by Jovan Belcher, and the sheer numbers involved in the lawsuits filed against the NFL, to say nothing of the emotion all of that can engender. His side relies on the science.
"It bothers me tremendously to see concussions portrayed like this in the media," said Collins. "Concussion is not cancer. There is something wrong with these brains that are being analyzed. If you examine the structure of those brains and you examine the pathology, there is something wrong there. The point is that there is no science that is showing concussion – in and of itself – is what's causing that damage. It could be many other factors that have not yet been accounted for. The research hasn't evolved to the point … there is no proof.
"There are so many questions that have not been answered scientifically. Personally speaking, it really doesn't connect with me because that's not what we're seeing here in our clinic. It's not like we're seeing kids with long-term effects of this injury. I don't believe this is something where you're normal, and then it bites you 20-30 years later. We wouldn't expect that from a neurologic disease standpoint. Parents need to be armed with the right information, not the sensationalistic information."
The right information, in Collins' view, begins and ends with a simple tenet: concussion is a manageable injury.
Dr. Collins believes that concussion is a manageable injury, because that's what he and his staff do daily at the UPMC Concussion Center. In a clinic that in many ways resembles a well-apportioned health club, patients are diagnosed and then undergo rehabilitation programs that focus on the specific systems of the brain that are injured, because concussion is an injury that's functional and not structural.
Break a bone, tear a ligament, separate a shoulder. Those injuries show up on an X-ray or an MRI, and the treatment/rehabilitation involves traditional methods that patients – and those parents who are bringing in patients – expect and understand.
"With concussion, certain chemicals come out of the cells that shouldn't come out and certain chemicals go into the cells that shouldn't go in," said Collins. "Those chemical changes from the brain moving inside the skull are what produces the problems we see with the vestibular system, that we see with different aspects of the injury. You're not going to see structural changes; you're going to see functional changes."
The vestibular system contributes to a person's balance and sense of spatial orientation, and an injury to it takes a long time to heal. But more on the vestibular system later. Because a concussion is a functional injury, Collins and his 20-plus person staff set out to determine the specifics of the patient's concussion and then determine the best course of treatment.
"We sit down and talk to them, we educate them," said Collins. "That's a strength of our program, the explaining of it in a way that a patient or the parent can understand exactly what's happening. We de-mystify it.
"You think about a body part like the knee. If there can be almost 30 different knee injuries, why do we think there is just one type of concussion. The brain is infinitely more complex. It has taken 15 years of study, but when I see someone in clinic, I can tell whether it's going to be weeks or days. I know what we're dealing with by the time they leave here at the end of their first appointment – we're getting better at prognostication and understanding outcomes."
One of the key elements in every diagnosis is the ImPACT test, but it is just one of the elements. The optimal use of this would be to test the athlete before a concussion, which is called baseline testing, and then test the athlete again after a concussion to determine the nature and degree of the declines in function. Even in cases in which a baseline score is not available, the ImPACT test can be used effectively. There also is the knowledge and experience of the staff, and that staff's ability to ask the proper questions to get at the patient's issues. There is diagnosis, and then the staff works the patient through the rehabilitation. That's what you get as one of Collins' patients.
"Like a mechanic does when he wants to diagnose a problem, we start the car up, so to speak," said Collins. "We start the brain up and see how it's functioning, and we can start to see where the aberrant signals, the abnormal signals, are coming from by doing the testing that we do. As clinical neuropsychologists, we specialize in brain behavior and functional relationships. So we're really well-trained to understand how the brain functions. That's what we do."
What they are doing is treating an injury, but in a different way because it's a different type of injury.
"The best way to prevent problems with concussion is to manage it effectively when you have one. Our clinic here treats this injury, and we treat it effectively," said Collins. "It is very rare for us to see someone leave our clinic – and it may take us a year because we do have cases like that, trust me – but there are viable treatments and viable rehabilitation strategies and viable ways of managing this injury to the point where kids get back to normal. And the great majority of these concussion don't take a year – we're talking weeks sometimes to get better. We also know that high school kids are different than the professional athletes, because it does take longer at the high school level."
"If I never saw another concussion, that would be wonderful, but you're never going to stop this injury from happening. Helmets are not the answer. Concussions are going to occur, but when they do occur, make sure the athlete gets off the field and then gets managed effectively to get them back to health before they get returned to play."
A large number of Micky Collins' patients are injured while at play. They come to him from organized sports like football and basketball and hockey and baseball, all of which now have leagues for pre-teens. But there are also the recreational activities, such as bike-riding and skateboarding, that send children to his clinic to be treated. Statistics show that the recreational activities are as likely to provide the Concussion Center with young patients as are organized sports, but football has become the demon. Scott Hallenbeck is the Executive Director of USA Football, and he has said he regularly has parents ask him, "Why should I let my kid play football? Why should I take the risk?"
Collins said his answer to that would be: "Concussion is a manageable injury. You're not going to end up being Junior Seau. You need to be educated on it. One of the first places to start is to make sure the parent's aware that with a well-managed concussion you're not going to end up having chronic CTE (chronic traumatic encephalopathy). You want to make sure that when an athlete has an injury, he gets off the field and is taken to a clinic like this one that knows how to evaluate it and treat it. We can get him back safely, and you're not going to end up with CTE. Concussion, when managed properly, we can hit the reset button on a great majority of these kids, and parents need to understand that. We see 18,000-20,000 cases a year here, and it's rare for me to retire someone from football. What I would argue with parents is to think about the benefits of the sport to your child. Teamwork, competition, physical activity, fortitude. Football is a wonderful sport."
The education is critical, because it's the understanding of what a concussion might look like and when to seek treatment that's at the front-line of every recovery. And herein lies the real insidious nature of concussion, because as Collins explains, when it comes to concussions severe are mild and mild are severe.
"When you think of a severe concussion, you think of someone who loses consciousness. The ambulance comes out, all the players take a knee to offer a prayer, the guy gets carted off the field," said Collins. "We have found that patients who lose consciousness have quicker (recoveries) than those who end up having on-field dizziness. Being dizzy on the field is more than seven times more predictive of taking a month or longer to recover than is losing consciousness. And dizziness is something that can be totally unrecognized, and it's all subjective because really it's just the patient feeling it. We've done studies where we looked at what symptoms on the field predict poor outcomes, and the loss of consciousness was not predictive. It doesn't mean he can go right back out and play, but they actually see better outcomes in those cases. Sometimes those guys who lose consciousness end up returning to play much faster."
Dizziness is the indication the vestibular system has been damaged, and Collins will tell you that can be more dangerous than getting KO'd.
"Injure the vestibular system, and that's the movement system of the head/brain, the thing that controls motion movement," said Collins. "When you have that system impaired, then it just takes longer because those movements are so important to an athlete. An athlete who injures his vestibular system is not going to be back to play for a while because we have to rehab and treat it. That's probably why dizziness is most predictive of a concussion, because it's the system that takes the longest for us to recover."
It wasn't all that long ago that tearing an ACL or an Achilles tendon meant 12 months of rehabilitation. Now, it's often less than that. Twenty years ago, a torn ACL could end a career. The science of concussion might be advancing most quickly of all.
"The fun part of this job is that every day we learn something," said Collins. "We're so much better than we were three years ago, and I've been doing this for 15 years. I think the science is way more advanced than people realize. A lot of people think concussion is cancer right now, and that's so far from the reality and the truth. We have a lot of work to do as scientists to educate the public about what this injury really is. The science has evolved tremendously in terms of understanding the injury and how to manage it. The science has evolved to the point where I'm very comfortable with that."
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