SIO105: Traumatic Brain Injuries, with Dr. Topher Stephenson

Transcript

This transcript was generated automatically and may contain errors — the audio is the record.

0:00:28 Thomas: Hello and welcome to Serious Inquiries Only, this is episode 105, I'm your host Thomas Smith Alright, today we're going to be talking with Dr. Topher Stephenson Chairman of the Board of Directors of the Brain Injury Association of California I The way this came about actually is an old coworker of mine got in a motorcycle accident and had a very serious brain injury and it completely changed his life. He's in the long process of rehabilitation to try to get things back to how he was, but it's really profound. It's been a really tough journey for him. He's He's doing really well, all things considered, but it's incredible how quickly our entire lives can be changed by an injury to our brains.

0:01:14 Thomas: And I want to learn more about that and also talk with Topher Stephenson about sports, about the ethics of A, you know, the NFL or B, you know, should we allow our children to play sports? What are his views on that? Of course, that's always going to be a personal decision for anyone, but what's his input on that, what sports things does he view as safe and what might not be. So much interesting stuff. So many very difficult issues to work through. So very excited to talk with him. Let's get over to it.

0:01:57 Thomas: I am joined now by Dr. Topher Stephenson. Thanks so much for coming on the show.

0:02:02 Topher: It's a pleasure. Thank you for having me.

0:02:04 Thomas: Absolutely. Apologies that I'm a bit sick. First question, as someone with some medical training, can I eventually get every single cold and then just be done with colds forever?

0:02:18 Topher: Statistically, it's possible, but highly improbable. I

0:02:23 Thomas: Darn it. Yeah, with the baby starting daycare, I have a lot of this to look forward to, I'm sure. Sure.

0:02:28 Topher: Personal experience than medical experience that that is going to be a common theme in your household.

0:02:39 Thomas: You nailed the first question. Good job. Okay. Now, with that aside, would you mind telling us a bit about yourself, your training, how you got into it, that sort of thing?

0:02:49 Topher: Certainly. So I'm an MD, a physical medicine and rehabilitation rehabilitation specialist, also known as a physiatrist. Or if we were on the East Coast, I would be a physiatricist. But on the West Coast and being a West Coast trained physiatrist, I'm a physiotrist. So physical medicine and rehabilitation is a specialty that started started shortly after, well, really around the Second World War, when there were a lot of soldiers returning with various injuries from combat. And the internal medicine doctors that were taking care of them realized that there needed to be something in between a, well there was really a combination of maybe part internist, part neurologist, part orthopedic surgeon, and lo and behold, physiatry was born.

So I became a physiatrist. What really appealed to me was the focus on function and quality of life and really functional independence, and as a I can take care of patients with brain injuries, musculoskeletal injuries. So whether that's knee pain, shoulder pain, back pain, neck pain, I can take care patients that are living with amputations, with strokes, with MS, with Lou Gehrig's disease, any number of conditions that would affect the person's quality of life and their functional independence.

0:04:39 Thomas: Okay. Yeah. I wasn't familiar with physiatry exactly prior to speaking with you. Is that the kind of thing it it sounds the kind specialty that would be on the sidelines, you know, like, of one of these NFL games or something, someone who's ready to tackle a broad scope of injuries and help rehabilitate a person. Or am I wrong in saying that?

0:04:59 Topher: That's absolutely right. So physiatry was really sports medicine before there was sports medicine. But it's not just just sports medicine. There are multiple other niches, if you will, that a physiatrist can address. So it's, you know, there, and recognize that there are not a lot of physiatrists out there for, for all of Northern California, there are only, let's see, I want to say nine new physiatists per year. And that's between the only two PM&R residency programs in Northern California, Stanford that graduates, I think, six a year and UC Davis that graduates three a year.

0:05:07 Thomas: Hmm. Oh, okay. Oh

0:05:48 Topher: So there aren't very many of us.

0:05:49 Thomas: Okay. So I was really interested in speaking with you about head and, and brain injuries. I know a friend of mine, I think is a mutual acquaintance of yours. At any rate, he had a very traumatic brain injury as a result of a motorcycle accident. And I thought it would be very interesting to talk about brain injuries in general, and also it tends to be again to mention the sports bias, I'm really interested in the issue of, like, the ethics of the fact that we are, we pay people a lot of money to kind of butt heads together until they have brain damage, and then it's our entertainment. And I'm a really interested in the ethics of that issue and your thoughts on that, but Oh, good.

0:06:55 Topher: Concisely or to be as concise as I can be, the Brain Injury Association of America and also the Brain Injury Association of California, we are the voice of brain injury. We are advocates for people that are affected by brain injury, we work at the various legislative levels, whether it's It's community-based, pushes for more support, research, awareness programs, all the way to the state and the national levels. And so that's clearly, well, as a physiatrist and with my background as the board member of the BACAL, Brain Injury Association of California, I just want to make clear that that's certainly part of my experience and arguably my bias.

0:07:49 Thomas: Right, right. Good to mention. I also would ask, what led to your interest in getting involved at that level to advocate on behalf of people with brain injuries? Was there something that happened or anything that led you toward that particular path?

0:08:04 Topher: It was really my exposure to brain injury during my training. And I remember very clearly when one of the senior residents, after we had seen somebody, and I think this was probably when I was still a medical student, as we left the room, and And this was a patient that had sustained a severe traumatic brain injury who had been previously quite high functioning, had been an executive, a tech executive with a family. And, you know, life was going very well and had a skiing accident and he's he would never be the same. And so as we left the room, the senior resident said to me, you know, that's what we call the walking wounded because you look at him and he can walk, he can talk, he can have basic interactions and dispense with social niceties.

0:09:03 Topher: But if you start to just scratch below that surface, you realize how profoundly he was affected and how, to this day, he will still be affected, and he'll be affected for the rest of his life. And it doesn't affect just that single guy. That affected his wife, his kids, his business. It affected the community and the state where he lives because he couldn't work anymore. More. And so as I recognized the profound implications of head injuries, and I moved through my training, I just naturally gravitated towards that as one of my clinical special interests, if you will.

0:09:57 Thomas: Yeah, that's really heartbreaking. It occurs to me that it is really different than a lot of things typically that can happen to a person where, you know, you break your leg, you broke break your arm. Even if it's a pretty catastrophic thing, it's like, well, you know, we do our best to like reconstruct it and then get on with your life. But with a brain injury, it is like you can appear to be totally still the same and unaffected from a distant, you know, like if someone is just looking at you from a distance, but you don't know like how in their life are they still able to do all the same functions? Are they still able to process things in the same way? It's really kind of a scary thought.

0:10:33 Topher: It is. And if don't know somebody that is living with a brain injury and still living with those symptoms, it can be very easy to overlook. It's not glamorous. It's Not easily identified just by looking at somebody, but when you start to dig below the surface and you recognize the magnitude of the cognitive difficulties, so the difficulties with memory and with reason and with comprehension. And then you also throw on top of that the emotional deficits that these folks are living with.

0:11:22 Topher: And you're talking about, you know, know, depression and incredible cognitive fatigue and their, their anxiety and, and post-traumatic symptoms. And you put all of that together and you have somebody that may have been very, very high functioning previously. And in just a moment, their, Their lives are profoundly changed and recognize that this This can happen multiple different ways. The person that I'm treating, who's a colleague of yours, that was a single motorcycle accident. And he won't be the same.

0:12:08 Topher: Now, he's made an incredible recovery. Recovery. But if you know him, and you start to talk to him, and you sort of dig into, well, what's your life like now? This is a completely different person. This is a completely changed person. And not only has he changed, but the life he's living has changed. His relationship with his family, with his loved ones has changed. And so, you know, his ability to work a full day or to enjoy recreation, whether it's playing soccer or going to the movies or whatever it is, is completely radically different.

0:12:51 Thomas: Yeah, yeah. It's really profound to think about. And is that what made you want to try to start advocating on behalf of people like him? Is it because, are they falling through the cracks in any major ways that you perceive? Or what really led you to want to, or what are the kinds of things that I suppose your organization is trying to make happen? In.

0:13:12 Topher: Absolutely. So there are multiple reasons that this population population really stood out. And there are some outstanding people out there doing some outstanding things for brain entry. And that's, I mean, everybody from researchers at the Department of Defense and the VA that are doing just groundbreaking research to the clinicians that are treating these patients every day, the nursing staff, the physical therapists, occupational therapists, speech therapists, neuropsychologists. It takes a team approach to effectively treat this population, whether it's short term and it's acute in, let's say, in the hospital setting, or it's long-term in the community. So clearly established that there are multiple ways a brain injury can affect somebody, but recognize it really affects every American out there, every Californian out there. And there's an incredible financial cost associated with, number one, the treatment of this population.

0:13:35 Thomas: Right.

0:14:28 Topher: And I'm talking mild through severe brain injury. And there's a significant financial loss because of it. And that we're talking about days missed at work, people that are maybe able to only work part time or, people that need caregiving from family members so that they don't, they're not a danger to themselves. So there are multiple, answers to the question. So there's some, again, there's some really outstanding people doing outstanding work out there. And we can talk about that later. But I don't, I certainly don't want to sell them short. And, you know, really the group that I should make, probably should have come up first, would be the family members of people living with a brain injury, because they are clearly the front line.

And when you ask about in support that exist in the paradigm where we live as Americans and Californians, there are huge gaps. There are gaps in funding for research, just understanding that the brain is so incredibly complex. We understand just a sliver of how it works and why it works the way it does. So there's gaping hole when it comes to research, when it comes to awareness, and that's awareness of everybody from the, you know, let's say the elementary school PE teacher to the parents that are volunteer coaches to high school athletic coaches and beyond.

0:15:20 Thomas: Yeah.

0:16:14 Topher: So that awareness and understanding is critical, and there's still a long way to go with that. And really resources for this population to support them adequately, I would suggest is profoundly lacking. I mean, one of the biggest struggles of the patients that I see that are living with chronic traumatic brain injury symptoms is the, just this, this inadequately funded patchwork of, of care options that are out there. And it's, again, there, there are some programs doing some great work, but they're, you know, day programs are incredibly underfunded programs that, that are monitoring these patients and And evaluating them and making sure they get what they need, again, massively underfunded.

0:17:11 Topher: And then we go to the acute side. And if somebody gets a moderate to severe brain injury, and let's say they have quote unquote good insurance, after they've been medically stabilized, let's Say they go to an acute rehabilitation unit. Well, in California, if they need care beyond the rehabilitation unit, they're up the creek. And that is really wildly inappropriate, to be honest with you.

0:17:42 Topher: And BACAL, the Brain Injury Association of California, has lobbied for this. And we've put some really significant resources trying to change that specific fact at the state level and have really, unfortunately, run into some major roadblocks. But, you know, there's, let's say an example would be Texas. So in Texas, if somebody has a similar injury, they get stabilized in the hospital. They then get acute inpatient rehabilitation. Rehabilitation, after that, if they need more care, their insurance carrier is actually required to give them that care. And there are good data points out there that show that that additional post-acute care is actually financially a win.

0:17:42 Thomas: Yeah, yeah.

0:18:31 Topher: It's a win for the state because these patients need less care long term, and more of them go back to work. So it really just is sad that we are where we are. But there's, again, there are a lot of great people that are doing some great things and are dedicated to doing the research and advocating and a whole lot of other things.

0:18:53 Thomas: Yeah, I mean, I apologize for getting political, but I really do think we, we need to put so much more thought and funding into healthcare and, like, the way we have it now, it seems to me, I don't know what your thoughts are, but it seems to be kind of the worst of all worlds where it's like, if we, you know, if we, if we switch to single pay or we switch to anything like that, it would actually save money because our system is so helter skelter. But either way, sounds like with something like this, where, as you mentioned, there's such a cost to not just the individual, not just their families, but, you know, to everyone, productivity on the whole to their community. There's a real cost there that we don't really see. All we see is, oh, you know, we have to put a 2% tax on something. So we don't like that. You know, in order to raise the funds. And it's like, it's because we're not comparing apples to apples.

0:19:45 Topher: Absolutely. And we really need to ask these hard questions. And it's as you, I mean, I mean, as everybody is aware, you ask hard questions and you rarely do you get a clean, concise, easy answer there. We understand that. Well, I understand that there's no easy answer to these these questions that I'm proposing or that are the sort of the logical endpoint of the points that I'm making, but they need to be asked. This is a population that suffers.

0:20:07 Thomas: Right.

0:20:23 Thomas: Yeah, absolutely. You know, I'm just curious, I don't know if you have this data in front of you, but can you give us an indication of some of the leading causes for brain injuries? Is it car accidents? Is it, you know... Is there anything surprising there that we wouldn't necessarily think of?

0:20:39 Topher: It's nothing that is surprising as you would consider. So car accidents, falls in the older population, just ground level falls are a significant contributor to the almost 2 million traumatic brain injuries that occur in a year. You've got car accidents, you've got sports injuries, and so there are, and then you obviously there are things, there's violence, there's other sources of trauma, but those are really the big ones.

0:20:52 Thomas: Yeah.

0:21:18 Thomas: Yeah. Okay. And then I know we're literally talking about one of the the most complicated subjects there could be, but could you give us an indication on the kinds of different brain injuries that happen? I mean, is it something where, you know, you hit, you damage this region of the brain and X happens, or you damage this region or the brain, or is it that clean cut or is just so complicated that it's hard to really tell?

0:21:20 Topher: It's Difficult to generalize. Now, by by definition, a traumatic brain injury is requires some sort of force that causes neurologic alteration of the normal function of the brain. Now, what we're starting to understand now with all of the incredible advances that are happening on the technology side of things, so specifically with with brain imaging. We're recognizing that one area of the brain does not just exist in isolation. There are tracts that connect all of the areas of the body to the brain. So front to back, back to front, side to side.

0:22:28 Topher: And so an area where there may be specific trauma, let's say there's some bleeding bleeding seen on an MRI, that may in fact affect areas that are far downstream compared to where the actual bleeding was seen.

0:22:48 Thomas: Do different people's brains function so differently that it's hard to even predict, like, one injury might result in totally different symptoms to two different people?

0:22:57 Topher: Absolutely. And that's a great question, because why doesn't a kid whose head hits the ground when they're playing soccer, if you have two kids, one of them is totally unaffected and the other one is out of school for six weeks because they have a traumatic brain injury. So, you know, every individual and their tolerance for trauma, or you, something happening to the brain is totally different, and it's unique, and it's individual, and, you know, I should really make a a little bit here. So in modern we refer to, we say, okay, we talk about concussions. And then we also talk about traumatic brain injury. We talk about CTE, chronic Traumatic encephalopathy, and recognize that a concussion, and I explain this to my patients every day, is a concussion is a brain, a traumatic brain injury.

0:23:41 Thomas: Mm-hmm. Yeah. Okay.

0:24:00 Topher: So we can't, historically, I mean, I remember, you know, playing soccer and playing football and getting injured and getting, you know, quote unquote, my bell rung, and a coach telling me, well, just, you know, how many fingers, okay, well, you can, you can tell how many Figures and you see them, all right, just Hop

0:24:17 Thomas: Yeah. Rub some dirt. Rub some dirty dirt on that brain and then, yeah.

0:24:20 Topher: Yeah. Exactly. Exactly. You know, spit on it, rub, rub some dirt on it, and you're going to be fine. But that's not the case. That is not the case, not the cause. So we've got to understand, I'm there. There's an active discussion in the, in the TBI, traumatic brain injury, community, you know, should concussion be retired. I, it's very legitimate conversation to have. Because any time a label carries this baggage or this meaning, it's inaccurate, and it's really selling short what the injury is, or what it truly means, or what it could mean, that needs to be reconsidered. Recognize there are almost 4 million sports concussions a year. So, I mean, that's an incredible number.

0:25:09 Topher: Number, I mean, you're talking about a huge number of the population. Now, a lot of those concussions or mild traumatic brain injuries get better and people heal. And I'm not saying that just because somebody has a concussion or traumatic brain injury, wherever that falls on the scale, you know, not everybody is doomed to this, you know, these deficits with with, with cognition and with emotion, and they're, they're not going to lose their job and be doomed. I'm certainly not, not indicating that, but it's, we have to recognize that there's a subset of that population that is going to be affected long-term. And we have to recognize what, you know, how we identify those people, whether it's an athlete on the the field, whether it's a youth athlete or an adult, whether it's boy or a girl, because those are totally different populations.

0:26:03 Topher: Girls are at different risk, higher risk on average than boys when it comes to athletic concussions. They tend to have worse injuries. And so as the research continues to come out, we need to continue to ask these difficult questions where we probably won't know the complete answer. We can't know the complete answer in any sort of short time frame, but we need to continue to dig And And pull this information out Clearly

0:26:31 Thomas: Yeah, yeah. And also, I mean, I have to imagine there's still got to be under diagnosis, don't you think? I mean when we started from, yeah, okay,

0:26:40 Topher: Clearly Clearly That I, so in my clinical practice, I see quite a few people with brain injuries that have been injured in a car crash, and I would suggest, and this is just off the cuff, this is not something that I have, I have actually kept scientific track of, or, but I would suggest at least 60 or 70% of those patients that I diagnose with a traumatic brain injury that have been to an ER have not been diagnosed with a brain injury.

0:27:15 Thomas: So what is something we should look out for? Like if, you know, us or our kids, if something happens, they're in, like you said, car accident or maybe sports, whatever it is, what should we look for if they've bonked their head and And what should, when is, are there any signs that you tell us, oh, shoot, this is serious versus it might be nothing. Is there any way to try to gauge that?

0:27:38 Topher: This is where you're going to get my, first answer is going to of course be, well, if you suspect that there's been anything, any sort of trauma to the brain, get to a healthcare professional. I mean, that, I know I sound like a, you know, a bad, a pharmaceutical ad or something, you know, if you, if you have uncontrollable diarrhea or vomiting, or you know, your your spleen jumps out your throat. But no, in all reality.

So if there is that has changed, and this is, so I coach soccer, and this what I tell my players and what I tell their parents is, look, if you have gone up for a header, if you've collided and hit heads with another player, if you've run into a goal post, or if you've hit the ground with your head, or even if if you haven't, and you feel like something, you feel like you're off, and I recognize that's very non-scientific, but if you feel dizzy, you feel like your bell was rung, you feel like maybe you're seeing double, you're a little bit nauseous, you'RE a little bit confused, disoriented, you know, number one, that player needs to be taken off the field, and whether this is an an athletic event or otherwise.

You know, this is, you know, that person needs to be needs to be evaluated. And most of the concussions or mild traumatic brain injuries that we're talking about in that situation, get better within a relatively short amount of time. But it's the it's the the the dizziness, confusion, being a little bit disoriented, a little little bit, you know, punch drunk or having the bell rung.

0:29:26 Topher: You know, those are phrases that we've certainly all heard, but that needs to be further evaluated. And recognize that the large majority of those people that have received that sort of brain injury, when we're talking about that group, most of them don't need a CT scan, an MRI. They don't needs to admitted to the ICU or anything like that, but to they should, they should be evaluated and they should be monitored, and there are certainly algorithms to getting people back to back to their normal normal day-to-day activities and back to their sporting events, their preferred sporting activities, after they've had a concussion, and there some some great groups out there that have have done an some incredible research in really formalizing these protocols to get athletes back onto the field safely.

0:30:23 Topher: And they're a lot more concrete than they used to be. It used to be, well, how are you feeling? Well, I still have a headache. Okay, well let's have you play. Well, no, if you're still symptomatic, you still have that headache. No, you're not ready to get back to play? Are you back in school? Does being in a classroom give you, does it give you symptoms? Is it giving you that headache? Is it making you nauseous? Is making you sensitive to noise or to light? Well, you're not ready to be back in schools yet. So there are some really good protocols out there. And honestly, some of the folks that are the best at using those protocols are the pediatricians, because they're really the front line. They're the ones who are seeing these kids come off the football field, the soccer field, the basketball court, or just off the playground with mild traumatic brain injuries, and they're getting good at saying, okay, look, here's the protocol.

0:31:21 Topher: And they're getting good at knowing when they need to have that patient see a specialist, whether it's a neurologist, a physiatrist, or let's say physical therapy, occupational therapy, speech therapy, neuropsychology, there are multiple specialties that can really help address the symptoms that patients are living with. So sorry, that long answer to a short question.

0:31:47 Thomas: Yeah, I mean, I know, obviously, the technical answer and the safest answer is going to be go get evaluated no matter what. But I mean understanding we live in a reality where a lot of people, they can't just go to the doctor or go to the ER. Are. It's not any, you know, it's a tough decision for some people to like, do they want to incur that financial liability? And I'm sure it puts people in a tough spot of deciding when, you know, because if it's nothing and then they get a medical bill for nothing, it can be really devastating.

0:32:18 Topher: Absolutely. And there definitely definitely is a balance there. Now, when I get a call, a parent has a kid who's playing in the club where I coach, it's not one of my players, and they say, look, is concussed, do I need to take her to the ER? Typically what I'll talk to them about is, look, are you seeing any focal neurologic symptoms, and I'm talking about something like uncontrolled nausea, vomiting, uh, some, you know, uh, really impaired balance, um, one pupil that's bigger than the other, you know, those are those are neurologic emergencies that need to be, or Potential emergencies that needs to be evaluated. And I, but recognize that that's the, the vast minority of these mild traumatic brain injuries that we're talking about. Yeah.

0:32:58 Thomas: Right.

0:33:10 Thomas: Yeah. So what do you think about, You know, what do you say to parents or how have you made the decision of whether or not you'd let your kids play, uh, sports? I know your kids play soccer. Um, what can you say about that decision as a parent, right?

0:33:12 Topher: No.

0:33:25 Topher: It's a, it's, uh, it's, it's very personal decision. Parents Need to understand what the, what the risks are. And they need to under stand the sport. They need to understand the, the ability of the coaches and what the, what the culture is of the team and of the league and they, what are they teaching the kids? What do the coaches know about concussion? And that's a very realistic question. And I think it's a very appropriate question for, for a parent to ask when their, their child is, is looking at playing a sport where there is a risk for head injury, whether it's, it's girls' lacrosse, boys' lacross. I mean, basketball, I've seen concussions from volleyball. Obviously, football, soccer, ice hockey, those are all big ones.

0:33:31 Thomas: Yeah, yeah.

0:34:18 Topher: And so it needs to be considered from the family's perspective. Can certainly ask about options for protective headgear. And that's, you know, that's a certainly a hot topic in sports concussion, particularly for youth today.

0:34:39 Thomas: Using Headgear in sports where typically it was never used, like soccer, volleyball, or or others. Um, it's seen some people look at it as, as sort of the, uh, I, I don't know, like, like the softening of, of America. You know, it's like, our, our children have to wear helmets to play soccer. But I mean, what do you say to that kind of thing where it's, do they need to be walking uphill in the snow both ways to go play contact sports?

0:34:39 Topher: Yeah, You know, and again, this is a very personal question that families have to answer for themselves. I, me give you my, just my personal take on this And recognize that I, fully aware, I am fully aware that I am, I have a very clear bias. And, and that's okay. I'm okay with acknowledging that I'm biased. So, for coach my daughter's team. They're now an under 16 team that plays at the highest level of competitive soccer. And I've coached this same group since they were seven years old. And at this point, we've had three girls that have been out of and off the soccer field for a minimum of a month because of concussions.

And so recognizing that there is risk, there is something that parents just, they really need to address, and then asking, look, is there a way to change that risk? In my personal, biased Opinion is that on the soccer pitch there is, there are, there are now, there's now headgear that is, is available for soccer players. And after a lot of conversation with my girls' team, the parents have been very supportive. And the girls, I mean, a 15-year-old girl is not going to be terribly excited about this. And I recognize

0:35:16 Thomas: Right. Yeah.

0:36:38 Topher: That wearing basically what looks like a thick headband messes up the way you tie your hair up in a ponytail, tail. And it's, it can, it can feel like it's warm and it can feel like it's of squeezing your head. But I, I understand the, the, the physics of brain injury, and I understand, well, I mean, let's look back at it, are, you know, the, the history of parents, you know, between your age and my age. So did, were we wearing helmets when we were cycling?

No, we just got out there and we, we rode our BMX bikes and we crashed and we whacked our heads. And, you know, did we did we grow up, you know, for those of us that ski or snowboard, did we start skiing or snowboarding with helmets? No. Are both of those essentially the standard now? Yes, they are. So we're talking about a cultural a cultural shift in the paradigm. And so, my very biased opinion is that, at least for soccer, and that's where I've got the most experience, – for youth soccer, it's going to become the standard for kids to wear protective headgear in the near future.

0:37:16 Thomas: Yeah, yeah.

0:37:55 Thomas: Is it a bigger risk if you're a kid and you're, you're still developing? Is there, is it a big risk of damage or is it pretty much, you know, the same injury is going to have a bad effect on you, regardless of how old you are.

0:38:07 Topher: No... there's increased risk just – and I'm going to speak in very general terms here. So the brain of a child anywhere from zero to early 20s is in a constant state of flux, more so than an adult. The way I'm defining adult is somebody who's beyond that state of flex. Let's call it over 21 or 22, and it's actually probably a little bit older than that. But the brain of a child and young adult, those are brains that are just constantly changing and new connections are being made. And there's stages where kids' brains are going through massive pruning and reorganization. I mean, that's where, you know, as the father of a 15-year-old daughter, sometimes I just shake my head and I look at her and I can't.

0:38:12 Thomas: Mm hmm.

0:39:00 Topher: I think to myself, "My God, you are just dumb as a rock right now," for this very intelligent young woman who's and who's kind and intelligent and motivated and all these great qualities that we, know, hope that we can describe, adjectives that we all hope to use to describe our children. Children. Sorry, that was not very articulate. But sometimes I look at her and I just shake my head and think, "My God, child, you are dumb as a rock right now." And that's not that she's in fact dumb as rock. She's still intelligent, motivated and everything else. But she's going through such a massive stage of pruning and architecture change, fundamental changes of the structure and function of the brain that there is no way she couldn't be dumb.

0:39:46 Topher: I mean, you know, Double negative aside, it's just, it has to be. And that's why boys end up, the risk-taking behavior as their frontal lobes reorganize when sometime between say 14 and 22 or 30 or 40. That's part of that. That's what we're talking about. So that younger brain is clearly at higher higher risk because if you injure that architecture and in, in brain injury, traumatic brain injury we're talking about these injuries are microscopic. We don't have, we don't have tests that are, that are good enough yet that, that have enough fidelity to show us down at the microscopic level where these injuries are and what sort of, how much of the brain and what tracts of the brain they're affecting. So when you're talking about these young, very plastic brains, you're talking about somebody who, if they're living with residual deficits from a traumatic brain injury, that's going to affect the way that brain continues to develop, and it's going to continue to affect them potentially through their adulthood.

0:39:57 Thomas: Yeah. Mm

0:41:02 Topher: The age of injury is is definitely that's something that has to be considered and recognize that, again, we just don't have the technology. Now, the technology is getting better, and this is tremendously exciting. You know, the imaging technology, there's a relatively new imaging technology called diffusion tensor imaging, DTI, and it shows those tracts in the brain and how they connect side to side and front to back. And you can actually use that to see, after a brain injury, where a normal traditional MRI or a CT scan would be read as normal, would show no injury, you can look at these, a DTI, and you can see where there are interruptions in these tracts. And so, you know, in 10 years from now, 20 years from now, out into the future, you know, we're going look back at today, we are going to look back to the end of 2017 and think that was the dark ages.

0:41:06 Thomas: Hmm, yeah.

0:42:04 Thomas: Well, it definitely

0:42:05 Topher: So clearly,

0:42:05 Thomas: Is, but maybe for different reasons then.

0:42:09 Topher: I'm not quite ready to call it the end of days, but you know sometimes you might want to to think that, well,

0:42:09 Thomas: Yeah. Yeah. Yeah, Well, I'm really, I know you only had an hour here. I'm worried you're going to run out of time. So I want to make sure to ask about the NFL, because I do think it's a major ethical question. What's going on there? A couple quick questions. Do you think that you've talked about some of these protocols. I know the NFL has tried to make sure that people who suffer a head injury are evaluated before they go back and play. Are, is that enough? Is that going to make a difference? Or is it just such a violent sport that no matter what, they're going to have all these little brain injuries? And also involved in that question, I've seen a lot of things where it's like, it's not about one hit where a receiver gets taken out because he wasn't able to see and gets taken on the head. It's not about one injury.

0:43:00 Thomas: It's about every single play having some trauma. And if that's the case, then I don't see how you could fix it. You know, if every play there, it's adding up enough to cause CTE, is any measure going to be enough or is it just too dangerous?

0:43:16 Topher: Want to get rid of brain injury, specifically in the NFL, and this is going to be a massively unpopular answer, the only way around that is to get rid of football. And now, I recognize the odds of that happening are slim to none. Done. It's all those little brain injuries, those mild traumatic brain injuries. Those quote unquote concussions that add up. And those little ones add up to big brain injuries and that's what we're talking about with CTE.

0:43:29 Thomas: Yeah. Or at least the contact part, right?

0:43:51 Topher: And so,

0:43:47 Thomas: Yeah. Yeah. Can you give us any insight into that? That like, can you define kind of what CTE is and, and talk more about the fact that it's little injuries?

0:44:00 Topher: Sure. So, you know, really the chronic traumatic encephalopathy. Encephallopathy is just a fancy medical term for talking about, you know, obviously, apathy is a pathology. And encefalo is something to do with the brain, brain of the head. And so it's this cumulative, it's of brain injuries that are basically not being allowed to heal. And the player goes out and gets injured again. And we understand more and more that player, whether it's a kid or an NFL player, if they're back on the field and they sustain another concussion when they haven't healed their first concussion, they're at significantly higher risk for having permanent deficits.

0:44:52 Topher: So the only way to diagnose CTE at this point, and this may be changing, there are some, again, that we could talk for another hour about technology and what's happening on that front. But the only the only Way to diagnose it is on on on autopsy. And there There was a study that came out, oh gosh, what was it, about six months ago, where it was 90-something percent of the,

0:45:03 Thomas: Yeah.

0:45:17 Thomas: Is it the one where, yeah, I remember though, there was, I think with the caveat that it was, the sample was people who thought they might have it. So it wasn't as though, yeah. Okay. But yeah.

0:45:25 Topher: Yes, and that's absolutely true, and you've got to look at the population that they were pulling from, and they were pull pulling from ex-NFL players, and so you absolutely are going to have a higher incidence there than you are and say, you know, a bunch of adults that have made it through adulthood and pass away and they all played youth soccer.

0:45:34 Thomas: Right. Right, right. Yeah, just like a random sampling. Something. Yeah, yeah.

0:45:51 Topher: Those are radically different populations. There There are multiple potential areas of research that are going to bring the, they're going to provide better tools for diagnosing not just CTE but also concussion. You know, diagnosing, knowing, hey, when can I, when, are there biochemical markers or imaging markers that I can look for as a clinician so that I can tell a patient, "Okay, it's time to get you back to school, back to work, back to your sport?" So there's a tremendous amount of research that's being done on that front. Again, I mentioned the Department of Defense and the VA. There's some incredible studies going on there out of the Palo Alto VA and DOD Center that I'm just peripherally aware of.

0:46:05 Thomas: I Yeah. Right.

0:46:44 Topher: I'm not involved in them. I have colleagues that are. So back to the sports, how do you prevent CTE or brain injuries in NFL players? And, you know, if there was an article a couple of weeks ago in the Wall Street Journal, and this, it covered Drew Brees. And so he has actually started a flag football league, and he actually coaches his kids. And one of the big reasons is he's, he's concerned about the, about brain injury. And so, you know, look, I get it. Americans in particular love blood sport. And I, you know what, I, I understand that.

And in fact, I mean, I treat football players, I treat, I tweet, you know, there's here in Sacramento, there there's a big MMA contingent that trains and fights. And I see these guys and I treat them and I talked to him about brain injury. And, you know, they say, Look, I mean, this is this is my this is my shot. I've trained my whole life for this. And you know the fact that I'm I I may be a little bit concussed. It doesn't mean I'm going to stop training and keep fighting because my career is only so long. And respect the individual making a, hopefully an informed decision. I can't say that medically, I think that's the best decision.

0:47:11 Thomas: Mm hmm. Yeah, yeah. Oh, yeah. Yeah yeah.

0:48:21 Topher: So, you know, should there, how do we, back to the question, how do we make make football as we know it safer? Technically, is going to play a role. There There's some amazing technology that's being evaluated. In It's a collaboration over at UC Davis with a private company, and it basically, it's this sort of a hearing aid, so the athlete just wears it behind their ear, and it has an accelerometer and it's Bluetooth enabled, and it can tell an athletic trainer or a coach when that athlete has sustained enough, enough impact and enough rotation that they should be evaluated and taken out of play.

0:49:06 Topher: So there's some really cool stuff out there. And look, I can't claim to be an expert when it comes to all the different helmet designs that are being worked on. There are all kinds of ways to make football safer, but at the end of the day, you've got incredibly powerful, fast athletes that are, that are truly phenomenal athletes, and they're moving really fast, and and the object of for the defense is to take down the offensive player with the ball and to stop the play from happening, and that involves physical contact. And so, I don't know that, that football, tackle football, NFL football, can be played without and totally, totally mitigating the risk of brain injury. I just don't think it's possible, but recognize both my kids play soccer, and one of them has had two concussions. So, you know, this is, again, this comes down to individuals making, hopefully informed choices.

0:50:08 Thomas: And, And I think you also highlighted, you know, a big difference between an adult making an informed decision versus an adult, making an uninformed decision, versus a kid, who really, we can't expect that young kids are going to be able to necessarily grasp the weight of what a long-term brain injury could mean for their lives, especially when you talked earlier about not being able to not engage in risky behavior as a kid. I think there's big differences, is there, in terms of the ethics of making those decisions. And I think that for kids, especially subjecting them to something that could cause them long-term damage when they don't have any way of really grasping the full weight of consequences, has got to be a bad idea.

0:51:00 Topher: Right. Well, and, you know, welcome to welcome to being a parent. You know, what's what's right for your kid. And, you know, I team sports have been for just my again, my personal perspective, team sports are incredibly important for our family. And you know the for the the development of the the social and athletic and physiologic and social development of of our, of our kids. And I love, I love those teams sports for that. And soccer is clearly a contact sport. I'm not about to not about To quibble with that. So again, yeah, it's, you know,

0:51:04 Thomas: Yeah. But

0:51:39 Topher: We, well,

0:51:39 Thomas: It seems like just, again, talking in generalities, it sounds like your opinion is Soccer can be made, you know, more or less safe, but NFL, you know, tackle football, no matter how many of these measures they try to do, is it your view that it just isn't quite enough, that there's enough smaller brain injuries that there's no way to mitigate that, barring some new technology or something that maybe could solve it?

0:52:06 Topher: I think we have to be careful, I can't qualify soccer as being as being safe. There is risk with soccer. And even if, even if these, these headbands, as I, you know, I'm aware of a big study that's going on back East right now, looking at these headbands in, see, I think it's, it's high school teams. So it's going to be, they've got about a year to go on the study. Um, but I I would not call, I would not call soccer a quote-unquote safe sport. There's still, um, well,

0:52:12 Thomas: Hmm. Oh, okay. Well, I didn't mean to say it was, yeah, there's always risk, But is it, in football, in tackle football, I mean, like you alluded to earlier, by design, almost every play is going to involve and end in a head injury of some kind. Like, there's going to be trauma. Whereas soccer, for the most part, while it's contact, isn't it more an aberration that there's, like, someone's head butting someone else than, like a design of the game?

0:53:04 Topher: I I suppose statistically you're going to have less potential, um, exposure in a soccer match for brain injury as compared to football. Um, again, I don't, that tackle football as we know it could be made, quote unquote, safe. And again, this sort of begs the question of what's your threshold of risk? Where do you see the risk benefit ratio? That's coming down to individual choice. And, know, hopefully the research will continue and we'll continue to we'll be able to translate that research, the research community and the clinical community. And we'll be able to present people, and by people, I mean parents, clinicians, therapists, whomever it may be, coaches, with more and more understanding of what the risk factors are and how we can mitigate those risk factors.

0:53:23 Thomas: Yeah. Yeah. Yeah.

0:54:08 Topher: Something I would like to throw out there is the Brain Injury Association of America has got an information hotline, 800-444-6443. Really good resource. Also, the CDC has a really good, a website for coaches for parents for who's interested in brain injury, everything from from training for parents and coaches to statistics that so look at both Check both out. I think those are both great resources.

0:54:49 Thomas: Dr. Topher Stephenson, so thank you so much for coming on. Is there any place you want to send people if they can, if they want to help out with your efforts in,

0:54:58 Topher: Yeah, quite all. Brain Injury Association of California, B-I-A-C-A dot org. Also the Brain Injury Association of America, B-I-A.A. dot org, and every community is going to have TBI support groups. These are community-based organizations that are running, they are running on the, just the razor's edge financially. There are, they frequently hold fundraising events, and I would encourage everybody to learn more, get out, and support the brain injury community. There's some incredible opportunity to make real differences in people's lives.

0:55:37 Thomas: Absolutely. Thank you so much for coming on.

0:55:39 Topher: It's my pleasure. Thank you.

0:56:05 Thomas: Another big thanks to Dr. Stephenson, I learned a ton, there's... there's still a lot to talk about, I'm sure. But that is, it's scary ground because it's terrifying to think that we might be subjecting our kids to stuff that's just not safe. And it sucks that there's so much focus on things like GMOs, which are safe, and vaccines, which aren't safe, and at the same time that people are worried about invisible fake things that might hurt their kids, they're not worrying enough about allowing them to just run into each other all day playing peewee football, which is definitely going to hurt your kids. Um, so that's, that's a tough ethical question there and I hope it can be made safe enough. I know that I don't think my kids are gonna be playing football, but they could be playing hockey.

0:56:55 Thomas: And I, I don't know. I mean, hopefully non-contact hockey is still safe enough for kids, but I might have to look at some studies, make sure that's an, that's an ethical decision. So lots to think about. Thanks again. And, uh, just a reminder, there's so many people have signed up on patreon.com/seriouspod. Thank you so much. It's going well. I hope you're enjoying the bonus feed, the extra content. I'm going to get more. I think I have an exciting thing I'm gonna be getting for the website users very quickly, somewhat soon here. But But thank you very much for that support and I will see you on Thursday.