To start off can share a little bit about your background.
Dr. Moreau: I was in private practice in Northwest Iowa, south of Fairmont and Jackson, Minnesota; there’s a cluster of lakes called Okoboji near where I practiced. I practiced in that area for about 30 years. Then I did a year at Palmer as a Vice Chancellor of Institutional Advancement. Then I worked at the United States Olympic Committee for 10 years, finishing as Vice President of Sports Medicine. I was the Chief Medical Officer for the last two Olympic Games, and now I’m the Chief Medical Officer at the University of Western States. I’ve probably done over 600 invited lectures and authored 40 manuscripts. My specialty area is sports chiropractic and within that specific area, sport-related concussion.
Can you talk a little bit about your experience, especially with the Olympic team, what you saw?
Dr. Moreau: We’re very restricted in the types of supplements you can give Olympic or Paralympic athletes. They need to have a special NSF sport certification. And if they didn’t have that, we are not able to provide supplementation. And so, really what I’m interested in is identifying evidence-based neuroprotective and neurorecovery supplementation. So, that’s where we’ll investigate that line. It’s called the neurometabolic cascade of concussion. The neurometabolic cascade of concussion is essentially why people with concussive head injuries aren’t able to function neurologically. They might have memory loss, they might have visual problems, or they might have a lot of problems, but it’s not because they actually have a structural damage to the central nervous system; it’s an inflammatory type of a cascade. And because of that, there’s a possibility to facilitate the recovery of people with sports-related concussion by attacking the neurometabolic cascade that’s associated with the injury.
Regarding concussion, there is always the initial injury that one see issues from. Then there is also the other side where someone has a concussion, and they seem to go back to normal, then suddenly slip back. Maybe you can talk about that a little bit.
Dr. Moreau: The methodologies that we’re currently using to assess people for concussion are crude. That’s just the best that we have now. I’ve done research that has been published in an American College of Sports Medicine journal called MSSE, Medicine & Science in Sports & Exercise. That’s demonstrating that ten months after a concussion, some people still have a cognitive disconnect to neuromotor function.
The types of tools that we commonly use to assess concussion would indicate that the person’s recovered, when in fact they haven’t. Then once they sustain a second injury, and sometimes it’s just simple exercise, it will exacerbate their problem, then they have a reactivation of their concussive symptoms. But it’s difficult and somewhat surprising and we just haven’t figured it out yet.
If you think about when you hit your head on a cabinet in your garage and maybe you’re woozy for four or five seconds and then you clear up and you’re good to go and don’t have any more problems. It’s hard to understand how that can be the same injury where a person can’t remember a phone number for a month or has dizziness or tinnitus in their ears for months later. This is strange to think that those would both have the same label of the concussion diagnosis when in fact they have a far different clinical presentation.
Because of that, do you find that people with concussions are significantly underdiagnosed?
Dr. Moreau: A lot of concussions are being missed, but in addition to that, how we return people back to sport is subjective. In fact, it is subjective. The standard of care currently does not include anything that’s an objective assessment of a head injury. It’s all dependent upon what the patient tells you, what the patient does, but it’s not that you can for instance, have a biomarker or other things. We know that balance testing has been validated as a good way to evaluate concussion.
But more importantly, the key to unlocking concussion will be doing measurements of eye movements, saccadic movements, we call them. That’s an objective sign of the head injury. When people have abnormal saccades, it’s not something that you can actually consciously control, how your eyes track, they just do it. And people with concussion have a high correlation of abnormal eye movements.
So then when you observe your patient with a potential head injury, a skilled examiner can see that, but you may not have inter-examiner reliability because it really depends on the experiences of the person who is performing the exam. The new things that are coming out are high level tracking software that can actually focus in on the pupils as they go through different movements. Put a measurement on the lack of synchrony of the eye movements in different planes and then attach a numeric value to that so that we can define what is normal, what is typical or what is atypical, and also as you take care for the patient, you would have a numerical value of improvement if that makes sense.
When you think of concussions, it is people who sustain some type of event and they ended up going to their doctor or the ER or maybe even just a sports medicine doctor who was at the event, who indicate they’ve a concussion. But surely there’s a lot of people who are active and they have a concussion – they don’t realize, were never diagnosed – but then have other issues that were probably caused by the concussion.
Dr. Moreau: Exactly right. A common number that’s expressed is 3.8 million concussions in the United States related to sports on an annual basis. Those are concussions that show up in the emergency room. Concussion incidence is far greater. The exact multitude is unknown, but I would expect 400 percent higher than what that 3.8 million number is. You hit your head in a garage, you woozy for a bit, you get on about your day. That concussion never gets reported. And we know for a fact that sport concussion is grossly underreported.
I did a research study on that. I followed a football team of 72 players through a season, the coaches thought there were four reported incidents of concussions in the 72 players, but a post season survey revealed that over 60 percent of those kids sustained a concussion during that season. So four versus 60, that’s a far cry. It’s a 15-fold reporting error.
People also downplay the significance of concussions. Talk little bit about what happens with people who are concussed and how it impacts their overall health.
Dr Moreau: That’s absolutely right. We have a lot of discussion around return to play, but the new discussion is around trying to develop Return-to-Learn programs. So, simply trying to identify programming that helps individuals with concussion return to the classroom. It’s not uncommon for people that sustain a significant concussion to have substantial difficulties in the classroom. We’re developing programming; it’s got to be a multi-disciplinary and well-coordinated program with the school district, the school nurse, perhaps a school psychologist if they have one, the treating clinician, the athlete, the parents on how do you get these kids back into the classroom. For example, one of the first classes that you would return somebody to would be art. And one of the last classes you return somebody to would be calculus and physical education. And so, by using a strategic method to bring people back, that’s been proven to have some good outcomes for folks.
When you look at people that don’t have a structural problem, meaning they haven’t sheared neurons, those neurologic pathways aren’t firing; however, they’re intact. You have to pose the question: why is that? And our current best knowledge is that metabolically that nerve can’t repolarize. And so, there’s all different kinds of changes that occur with blood flow through the area: excitatory neurotransmitters, glucose, calcium, potassium, permeability issues.
And a lot of people think that some of the protracted post-concussive syndromes are inflammatory in their nature. If we can figure out how to decrease the post-inflammatory cascade and address these, hopefully preventing it from happening through neuroprotective interventions. And then facilitating any more rapid recovery that would be as really a huge thing for the management of head injuries.
You made a good point in the beginning of your response. I understand not participating in physical education, but when you mentioned calculus, I had never thought of how a concussion impacts brain processing.
Dr. Moreau: It’s right. What happens is during this neurometabolic cascade, there’s many inefficiencies that occur in the injured nerve cell in the brain, the axon. And so, what happens is that axon has great difficulty repolarizing and so it can’t set up the electrical potential to fire. And when the axon doesn’t fire, then that hurts your thinking ability.
The heavier the mental lifting, it makes sense that it is the larger portion of the brain that we’re engaging. And when you repeatedly try and fire an axon that is unable to repolarize, it doesn’t allow it to heal. The lack of repolarization due to repeated attempts as firing the dysfunctional neuron indicated the neuron needs to be “rested” to repolarize. We use cognitive (or thinking) rest so that these injured axons have a more of an opportunity to slowly heal and set up the action potential or the ability for the neuron to fire. The outcome, we use cognitive or thinking rest so that these injured axons have a more of an opportunity to slowly heal and set up the, we’d called the action potential or the ability for the neuron to fire. As you give that neuron time to rest, then it increases or enhances the likelihood that that nerve will eventually function again. When you bring them back into class, that uses a different type of thinking and calculus. And so, if you’re working through a calculus problem here, engaging more of these injured axons, which then could potentially make those axons even less likely to repolarize and become functional again.
Do you think most practitioners understand that, or do you think that they just think of more of the physical aspects?
Dr. Moreau: That would be a good question to find out. I don’t know, this is really what I think about every day and I’m not sure that people outside the field of sports medicine with certificates of additional qualification really think a lot about sports related concussion and the actual cause of dysfunction. And I don’t think that they could articulate what a neurometabolic cascade is associated with the injury regardless of their terminal degree. People need to know a lot about a lot of things and we just tend to dive into a topic and really gain greater understanding.
Is it an important topic that sports trainers are focusing on?
Dr. Moreau: Absolutely. Every state in the United States has a concussion law, and it basically says that only individuals who are adequately trained in the management of concussion can return people with a concussion back to play.
People are so much more aware now than they were a decade ago. There are many more concussions being identified, but now what we need to do is gain better understanding about how do you one, keep them from happening; we’re not very good at that. And two, how can we help these people have the most effective and efficient recovery from their injury when there’s such a gradient from very mild, to severe impairment.
One day in the future, concussion will probably be called something else and the current garbage can of everything you’d dump in and call concussion will probably be divided out under some sort of evidence guided type of a platform into a different type of a head injury. Concussion is classified as a mild head injury, that’s based upon the Glasgow Coma Scale, versus, for example, traumatic brain injury such as an acute subdural bleed. Yes, concussion is a mild head injury, but every head injury is important.
To wrap up then, what about from a nutraceutical perspective, being able to provide patients who have concussions, the proper nutrients to help heal better?
Dr. Moreau: That’s exactly what my presentation will be investigating. It’s going to have two different components. One is an exploration into the possible neuroprotective supplements. But there’s some early evidence that some things may have a neuroprotective quality to it; for instance, green tea is one that’s been mentioned. And what we’ll do is take an evidence guided approach to looking at those neuroprotective supplements. Is there something that can help people so that they’re a little less likely to sustain the injury?
And then the second piece would, if they have sustained an injury, identify what type of nutraceutical interventions will be most effective because I would suspect that the first two weeks in nutritional intervention would be different than a month later because of the metabolic changes that are occurring. This will be a complex answer and that the answer won’t be one thing fits all.
Most people recover without any intervention in about 10 days. 80 percent get better with nothing done to them in about 10 days. However, children, whose brains have less myelination or less protection, they’re still developing. It’s well known that they will take significantly longer to recover from a same or similar injury as an adult.
I find this to be a fascinating topic and one that has been unfortunately ignored by the health care practice.
Dr. Moreau: A lot of people are talking about it, but it’s a complicated answer. And what I was trying to suggest is that in a concussive injury, the acute, subacute, and chronic phases are different conditions on a neurometabolic perspective. And we should suspect that the concussed individual who may respond to a nutraceutical intervention might have different types of nutraceuticals at different phases of their injury. And that’s really the big nut to crack, is what works best when.
The research on concussion is hard to do but nevertheless, there is some evidence that things like omega-3s could be helpful. And so, there’s all different kinds of approaches to preventative or management-based supplementation to consider. The human brain is such a complex organ. All the pieces that must come together for the brain to properly function correctly are so complex. The opportunity to use an evidence-guided approach to help people get better is really a battle worth investigating.
Do you think that concussion has any related issues with people who suffer from dementia/Alzheimer’s at a later point in life?
Dr. Moreau: That’s a large and somewhat controversial discussion. We’d call that traumatic encephalopathy, chronic CTE, chronic traumatic encephalopathy. People that have dementia, they have atrophy or shrinking of the brain tissue. But they also have depositions of what’s called the tau protein, T.A.U. protein, in their brain. And that’s an entanglement of neurofibrils.
And this research is lead by Dr. Robert Cantu out of Boston; he’s really one of the fathers of the science of studying concussion. And so, Dr. Cantu is a well-known expert and he’s the one that has been suggesting that the repeated blows to the head result in the depositions of these tau proteins, not from dementia but from trauma. He says that the tau protein deposits and chronic traumatic encephalopathy are found more in the periphery of the tissue. Whereas the people that have dementia typically have tau protein deposits that are more centrally located inside the tissue that there is some difference in the location of the positive. And this is what these big brain banks are doing research on.
You can’t diagnose CTE, or chronic traumatic encephalopathy, in a live person. You can only do it after they’ve passed and their brain is removed, and it’s thin-sliced and stained with a stain that then will show the tau protein. Once again this suggests the relationship of this function is affiliated with an inflammation. And so, any of those mediators that are anti-inflammatory may be a pathway to help decrease the chronic degenerative changes in the central nervous system that’s like dementia.
People, when they think about concussion injuries, they think about, “ it’s just a brain injury.” But it really impacts total health, which is interesting. Concussion globally impacts lifestyle because they can’t do things that they used to be able to do. So, as a person that’s had over ten concussions myself through American football, I understand what they are saying.
Bill Moreau, DC, is the leader of medical services for the United States Olympic Committee (USOC), Dr. Moreau worked with Olympic and Paralympic teams where he was responsible for the care of thousands of Team USA athletes, provided by more than 200 clinicians from numerous health care disciplines. During his tenure at USOC, Dr. Moreau served as the Team USA chief medical officer during the Rio 2016 Summer Olympic Games, and the Pyeong Chang 2018 Winter Olympic Games as well as serving as the medical director for the the London 2012 Summer Olympic Games and the Sochi 2014 Winter Olympic Games. Over his more than 30-year career, he has also treated collegiate, high school and recreational athletes. Dr. Moreau is a licensed chiropractic physician and a board-certified Diplomate of the American Chiropractic Board of Sports Physicians (ACBSP). He has presented more than 500 lectures and postgraduate education programs throughout the world. Dr. Moreau is currently president of the ACBSP and is a member of the Journal of Chiropractic Medicine editorial review board.