Welcome to Brainhub Podcast where you will discover the top news and tips on keeping your brain healthy.

Matthew: Hi, welcome to the Brainhub Podcast where we discuss the latest in neuroscience and brain health.  I am Matthew Holmes and with me today is Dr. Carlo Rinaudo a chiropractor and the head clinician and owner of Brain Hub Clinic in Sydney Australia.

Carlo: Hi Matthew, how are you?

Matthew: I am great Carlo, yourself?

Carlo: Very good thank you.

Matthew: This is obviously our first podcast, what we are going to be doing today and in subsequent episodes of this podcast is that we are going to be diving into the field of neuroscience and brain health.  The thing about neuroscience and brain health is that it is a rapidly expanding field, there is thousands of papers published each month on neuroscience and aspects of brain health and so forth as a full time clinician it is a really full time job just to keep up with that sort of rapidly emerging field. What we are going to do in this podcast is distil that information and present it to you in an easily digestible form, ideally it is going to give you practical tips for improving your brain performance and longevity.  Do you have anything to add on that aspect Carlo?

Carlo: Yeah, I mean, it is a great point, i think translating some of the research that can be quite technical at times into small chunks that other clinicians or more important for this media is for our patients to understand what is happening in research and how really it relates to the presenting conditions or symptoms.  So we have to be very informative to them.

Matthew: Excellent, well research is a bit of a thing that is quite dear to your heart, isn’t it?  I believe you are currently doing a PhD, do you want to tell us just a little bit about which institution you are running with and so forth.

Carlo: Sure, I guess PhD is travelling down a very small rabbit hole, very very deep so I hope to come up the other end with a lot of information and expertise in them in a particular small area although it, the vestibulo-ocular reflex is a very important area of the vestibular rehabilitation.  For those who aren’t aware vestibular rehabilitation is all about retraining and regaining ones balance, reducing symptoms like dizziness and vertigo.  I am very fortunate that my research is part of a world leading lab in vestibular research at Neuroscience Research Australia, or NeuRA which is affiliated with the University of New South Wales and fortunately my lab is also tied in with John Hopkins University, School of Medicine in Baltimore in the States.  So I have got some great supervisors and team members as part of their research group.  Our research focuses on a very important reflex that we all have called the VOR or vestibulo-ocular reflex which its job is essentially to stabilize our vision when we move our head or we move our body.  Very important, so when it doesn’t work our eyes and our inner ears where we have these movement detectors don’t talk to each other particularly well causing our vision and our balance to be affected. And what our studies focused on is doing clinical trials on patients with poor balance and using a novel rehabilitation device that we have developed hoping to retrain these reflex so people feel better.  So it is very much tied in with the Brain Hub clinic but it is also a very expanding and exciting area of neuroscience that a lot of physical therapists, chiropractors and even medical practitioners see in their practices because dizziness disorders makes up a relatively large and significant portion of patients that we see.

Matthew: Yes and I know that some of the research is coming out and talking about how these vestibular deficits can be responsible with problems with cognition and clear thought and memory and all sorts of aspects like that which ties in well with the concussion aspect that we are going to talk about later doesn’t it but I know the Brain Hub Clinic that you run deals with a lot of issues like concussion and I think some people might sort of say well you are dizziness and balance clinic. How does that relate to other aspects like migraine, whiplash and concussion when you are doing a lot of vestibular rehabilitation.  Do you want to tell us a bit of the Brain Hub Clinic and the work you do and so forth?

Carlo: Sure, as you mentioned I am the clinic director of Brain Hub which is a very specific hub clinic that deals with dizziness and concussion and we hope people with a range of vertigo and poor balance conditions which will also include whiplash, vertiginous migraine and obviously the point of today’s talk is those that suffer from post concussive symptoms.  There is a strong link between all of them, they are not random conditions or symptoms that I feel like that I want to help people with but they are often related.  There is obvious commonality between the areas of the brain that is affected and the connections between these areas are also known.  So we often find people with concussions symptoms will have balance problems, will have vertiginous or vertigo based problems, they will have problems when walking, they will be unbalanced, they will have eye movement symptoms and also have cognition problems like poor memory, anxiety and fear.  Now if we look at a patient that has a chronic dizziness that is not a concussion patient but a chronic dizziness patient they will often have the similar signs and symptoms, they will have poor memory, brain fog, fear and anxiety, they will have problems with their eyes.  So we often see a commonality in signs and symptoms what we often describe as comorbidity between a lot of these conditions.  So our practice helps people with concussion symptoms while using specific vestibular rehabilitation and also brain based rehabilitation and the research now is showing good signs that these form of assessment as well as treatment is actually proving very beneficial to those that have suffered from concussion problems.

Matthew: Excellent yes, that ties in very well with what look at today which is the Concussion movie and for those who are not familiar with it is a movie that has been released in the USA it hasn’t come out in Australia yet so we haven’t had the benefit of actually seeing it yet. We have seen the trailers, we have read posts about the movie and obviously we are both very familiar with concussion itself but we are going also look at some of the bigger issues behind the movie and how it is all stuff is flaring up in the US, the reaction of the public to the film and the way that sports and so forth are dealing with the issue of concussion within the larger picture.  So what I will do first is I am just going to quickly give you a summary of the film so that those who haven’t much about it or aren’t familiar with it have got a bit of background so that they are not going in completely blind to watch what we are talking about.  This is a film, which has been as you say starring Will Smith, it is basically a movie about an accomplished pathologist, Dr. Bernard Omalu who is a Nigerian person who is practicing medicine within the United States and he is a pathologist that is working for one of the local counties in the United States in America.  Prompted by the death of a famous football player at the age of fifty this Dr. Bernard Omalu undertakes research that leads to the discovery of the condition known as Chronic Traumatic Encephalopathy.  So Carlo, do you want to just give us a quick bit of background on what is Chronic Traumatic Encephalopathy is or CTE?

Carlo: Sure it is a very devastating condition or disease that often results from repeated head injuries, how I describe it to patients who unfortunately by definition we can’t diagnose it at this stage until someone has died.  But when we start seeing early signs of it what I often describe the patients something that we want to avoid is where the brain after these repeated injuries turns to marsh. The brain shrivels in size and a post-mortem examination show the brain to be much smaller in size, almost bruised as I said it almost looks like marsh in post autopsies.  At the moment aren’t any markers that we could use while someone is alive to help identify it, some preliminary test or research is showing that things like functional magnetic resonance imaging or FMRI, external tractography where they are able to look at how viable healthy and alive are some of this parts of the brain as well as even some markers in blood tests are showing promise to maybe giving people when alive a sign that all is not too well. Basically this CTE happened as I said from repeated injuries and repeated concussions, it takes many years to develop, some of the signs and symptoms of it are brain fog, dementia, Alzheimer’s, depression is probably one of the most common sign and this is thought to lead to why suicide levels in people with CTE is extraordinary high. You only have to look at, I think the best example of this and particularly as it relates to the movie is studies are being done in NFL players, the stats are scary, when you look deep into some of the stats and I can understand why the NFL the National Football League in the States probably didn’t want this movie to be promoted is almost a hundred per cent of former players that have since died they perform post-mortem autopsies on them and as I said almost a hundred percent of these patients of the former players actually have developed CTE.  So it doesn’t look great for people that have had repeated injuries and this is why we try to check out a lot of our patients particularly our kids in sports to wear appropriate headgear or maybe choose an appropriate sport that doesn’t involve repeated head traumas.

Matthew: Yes, when you talk about a hundred people of people, is that people who have died of natural causes as well or those who have say died of unnatural courses like suicide?

Carlo: Suicide, yes, I think both, a relatively high percentage I think two to three times the average rate in society of mental illness and suicide are generally reported in this population. So they tend to die either of both sorts of conditions, both in suicidal and normal history they are both detected CTE.

Matthew: So that is quite damning isn’t it, so I suppose a little take away there is even though you may not be getting symptoms from having some sort of brain damage from chronic repetitive trauma you can still have brain changes going on that you are not aware of.

Carlo: Exactly and some of the subtle warning signs are something that as clinicians we want to educate our patients and in particular our sporting people, I think if we could focus on some of the early detection of some of the subtle signs potentially through reparative or preventative means can maybe slow down that process or halt it in some ways.

Matthew: Good that is some good news for those who have potentially had some head trauma in the past. I suppose what you have been saying they are linked in very well with the film in terms of precipitating episodes that cause this doctor to get into investigating the CTE further is the fact that there are several suicides, you know, there is this trend showing up.  I suppose one of the whole premises of the film is that the way the American Football is played, players basically bang their heads together or their helmet together as part of the offensive nature of the play like the offensive as the defensive and so forth and that chronic repetitive trauma is what causes the brain damage.  It is easy for us perhaps in Australia and other parts of the world where American Football isn’t that common to think that well this doesn’t apply to us but research is suggesting that any sort of repeated head impact whether that be concussion in Australian Rules Football or heading the ball repeatedly in soccer is going to affect the brain. That is the case is it?

Carlo: Correct, AFL in Australia and Rugby League there are some cases and some case studies that are now coming to light over the last several years that have shown former players with confirmed CTE.  So it is not isolated to only NFL I think just the numbers and obviously the intensity which they play in and they just had a lot of head collisions that are part and parcel of the game are more prevalent in that sport but it certainly has been seen in soccer, IFL, NRL and also boxing, I mean. let’s keep in point boxing is, if you just look at it, I mean, we often cringe looking at boxing thinking that has got to hurt, well, later in life it does hurt.  So it is something that even in our clinic we do see boxers with concussion which is really described as a mild traumatic brain injury and those that have had repeated head concussions which essentially you can look at boxing as being CTE is probably likely to happen in the number of elite and amateur boxers.  Interestingly we also see people with blast injuries in the military and the armies and armed forces are starting to see the early warning signs of post-concussion syndromes including PTST or post traumatic stress disorders in returned and active military and the though is that they are suffering very similar conditions.

Matthew: Yes, I know in the United States that has been a big driver because of the large military involvement the number varies around the world, a lot of their colleagues in the States do report seeing a lot of military and you are saying the same trend here in Australia?

Carlo: Yes in Australia from the returned military personnel that I have seen, they often when reporting to the doctors or specialist it is very much an unknown condition so there is a push amongst those people to make it known amongst the medical fraternity and there are a few clinics including ours that actually can help identify, if not a name to it, can put a list of symptoms and more importantly can put a regime of therapy, rehabilitation therapy to help people overcome a lot of the symptoms associated with this.

Matthew: Yes, that so that sounds great, I suppose perhaps of one of the big issues, the movie is that this film movie has basically flopped in the United States as far as I am aware and the reception to it has been very poor, we have a lot of people who perhaps are very passionate about football and the last thing they want to see is it will end up being something just like touch football as opposed to the heavy type of contact sport.  Does that sort of fit in with your thoughts about what some of the resistance to these concepts are coming up against an endurance of the condition and a desire of fans not to see these sports watered down.

Carlo: Exactly, I think in particular with the medical fraternity because mild traumatic brain injury or concussions is not seen on any image, if you would do an MRI or a CT scan as long as it is not an open wound which is not by definition not a traumatic brain injury anywhere or a concussion, if I would get an image nothing would be seen so it is hard for someone to say aah that is what you have got because I can see it on an image. It is really a combination of symptoms, so it is not turned into structural injury, it is turned a functional injury nowadays.  So the difference between the two as I said a structural will be seen on a scan and it is very identifiable.  A functional image is something with, obviously it is not identified on any structural image but there are symptoms associated with how the person is functioning and typically dis-functioning.  So the common symptoms maybe they just have troubles reading or they have got some brain fog or I have this sleepy or that muscle achy or lethargic, the balance is not right.  So a lot of these things appear to be vague symptoms and something that doctors see on a lot of their patients.  So it is hard to say well that is what you have got based upon those but the criteria now and the guidelines and standards say that we need to identify, we need to observe, assess the signs and this is why some of the testing that we do and the research they are showing can help identify some of these early concussion signs and they include posture, so we look at how someone’s balance and posture is, whether they can walk in a straight line, whether they can stand on one leg with eyes open or eyes closed. We look at their eye movement functions, are they able to focus on a particular point, are they able to track a moving object either slowly or fast, can they look at a visual stimulus as a passers-by accurately.  So these are all now becoming quite big markers of concussion so the guidelines are catching up, they are not quite there yet put as a protocol, as an international standard but I think we are not far from that being developed at this point.

Matthew: Yes, so I think probably some of the resistances or part of the challenge perhaps rather than the resistance is either it takes years of clinical expertise to be able to see the subtle changes in eyes or eye movement and posture changes and so forth or the need for fairly expensive equipment in order to do that which isn’t practical or reasonable when you are dealing with even a large AFL law in a real game to have that sort of by the side of the pitch to be testing people though it maybe some of the balance place test to be coming in a little bit more.  But it is something that really something that really needs to be done in a specialised facility and that is part of the problem?

Carlo: Year, as you said, for you to be able to quantitate accurately how they are functioning then you need equivalent equipment so to be able to assess that and unfortunately this equipment is not that cheap or readily available to a lot of clinics.  So there are side line testing measures that a physical therapist or a medical practitioner or even a trainer can perform on the side line are showing some degree of correlation and they are good tests and certainly not the best and but on a side line it is better than nothing. So that is often what they use as a side line testing but if symptoms persist past the natural history of a concussion which is within a week, if they persist it is generally that time when a more dedicated balance and dizziness concussion clinical laboratory is generally recommended where most of these equipment are available and testing can be performed.

Matthew: Indeed and there is also a push towards getting a baseline testing done, where pre season people are getting themselves screened so that if they do get a dong on the head they have then got some normal measurements for them in order to be tested further.

Carlo: Exactly, baseline testing is something that we promote in our practice to a lot of local sporting teams to, just say get a baseline as to where they are at and all comparison should be made back to the person.  So as they go throughout the season if they get a dong on the head or get their bell rung then we can then test them and measure the performance at that time relative to how they were at the beginning of the season or preseason. And then we don’t return them to play or allow them to return back to training and play itself until we are satisfied that they have met as close to if not at the same level that they were preseason.  So it is a great thing and we are encouraging, we are working with a lot of local teams to advocate this sort of testing as a way of really getting a baseline and understanding as to where each team member is at the beginning of the season.

Matthew: So I think particularly when you are dealing with kids with local clubs and so on, if kids should get better over the space of a season, shouldn’t they, if they are coming to you and they have preseason testing and they are worse after getting a knock on the head and you at very least want to get them back to their preseason level because that is where they were six months ago or whatever and the natural evolution of a child’s development is that they should be getting better, they should be better than when the baseline testing was done, certainly not worse.

Carlo: Exactly, and parents often bring their kids in or are referred by the coaching staff because they have noticed not only is their performance deteriorated in terms of balance, in terms of the general performance of that sport but parents might say my son is just not sleeping well, he is sleeping excessive or is just waking up at night and is always tired, the teachers have commented that his report cards have deteriorated, he is losing focus, he is irritable, his concentration has worsened.  So there is a lot of things that parents note, parents are pretty good at noting at noting some subtle signs in teenagers and they are not the normal teenage things, obviously can’t be that but in such a period of time following a head trauma the correlation is got to be there and it is during that stage when parents drag the kids in and say look I need my son or daughter assessed, please let’s find out what is going on.

Matthew: Absolutely, I suppose we kind of covered some kind of really good stuff today, we probably need to wind up there, we will no doubt come back to the issue of concussion and how it is being dealt with and further practical tips as we go through the podcast series.  I suppose some practical takeaway ideas for people are that if you are involved in any sort of contact sport you really should be looking at getting baseline testing done at the start of the season.  Also if you have had a concussion and you have got symptoms that are persisting beyond a week then you really need to be looking at getting some sort of assessment done as well and also if you are involved in a sport that has lots of contact maybe you need to reconsider it particularly if you have multiple concussions already and you are a little bit concerned that you might be even developing some of the early signs of chronic traumatic encephalopathy.  Does that kind of summarise it for you, is there any other tips you would like to add.

Carlo: No, it is great Matt, I think if all those points could be disseminated and taken on board by our listeners, it starts with education, I think going back to the movie if there is anything that I feel weren’t appraise from the movie would be the ability for the information to get out in awareness of that concussion in the media.  I think if we can get this information out to players, military and the general public I think it is great.

Matthew: Yes, I definitely agree with you there.  So that winds up our episode today, don’t forget to subscribe so that you don’t miss any of our upcoming episodes, if you are on iTunes you can very easily do that from the iTunes platform.  If you are listening to us on Android we are going to be syndication this through platforms like the Google Library and Stitcher and other platforms like that, so be sure to subscribe and also subscribe to the newsletter on the Brainhub website so that you can be sure that you keep up to date with any of our latest posts and blog post as well as any podcast episodes.  If you would like any further advice please don’t hesitate to get in touch with us via brainhub.com.au, that web address brainhub.com.au it is all one word for brainhub.  And any sort of closing points that you would like to make?

Carlo: No, I think we have summarised it quite well I hope it is helpful to people in the awareness of head concussions.

Matthew: Good, thank you very much.  We will see you all soon

 

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