Diagnosing Concussions with Dr. Uzma Samadani
Show Notes:
One of the main contributors to concussions being designated "the invisible injury" is the absence of physical damage observed using traditional visualization techniques, such as CT scans or MRIs. Addressing this issue with us today is Dr. Uzma Samadani, associate professor, attending neurosurgeon, and founder of Oculogica. The mission of Oculogica is to diagnose and classify different types of brain injuries using eye-tracking.
Join us today as we dive into how Oculogica is achieving these goals and why FDA approval is such a big achievement. Find out why Dr. Samadani chose to become a neurosurgeon, how the diagnosis and treatment of brain injuries have changed over the past few decades, and what the underlying cause of a brain injury can be. We learn why "mild brain injuries" are so dangerous to patients and their mental health, and how sport has been good for shedding light on brain injuries. We also address the guilt, blame, and shame surrounding a brain injury and how inequity can impact a patient's outcome. For all this, and so much more, tune in today for another fascinating episode!
Key Points From This Episode:
• Welcoming today’s guest, Dr. Uzma Samadani.
• What first got Dr. Samadani interested in brain injuries.
• How the diagnosis and treatment of brain injuries has changed over the past few decades.
• The different biological causes of brain injuries, and why hearing “it’s all in your head” can be so damaging for patients.
• Identifying brain injuries undetectable in CT/MRI scans: Oculogica’s eye-tracking technology.
• Why Dr. Samadani feels ‘mild’ brain injuries are serious issues: addressing mental health.
• Questions that Oculogica aims to answer and how these will help patients.
• Learn more about the importance of FDA clearance.
• Effects of inequity on the outcome of brain injury and the spotlight sport puts on concussions.
• Why a support system is so crucial for recovery.
• Addressing the guilt, blame, or shame surrounding a brain injury.
• How Bella experienced the guilt, blame, and shame Dr. Samadani mentions.
Check Out Dr. Uzma Samadani’s work
Website: http://samadanilab.org/index.html
Learn more about Oculogica here!
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Transcript - Click to Read
[INTRODUCTION]
[0:00:05.4] BP: Hi, I’m your host Bella Paige and welcome to The Post Concussion Podcast, all about life after experiencing a concussion. Help us make the invisible injury become visible.
The Post Concussion Podcast is strictly an information podcast about concussions and post-concussion syndrome. It does not provide nor substitute for professional medical advice diagnosis or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition.
Never disregard professional medical advice or delay in seeking it because of something you have heard on this podcast. The opinions expressed in this podcast are simply intended to spark discussion about concussion and post-concussion syndrome.
Welcome to today’s episode of The Post Concussion Podcast with myself, Bella Paige, and today’s guest, Dr. Uzma Samadani. Dr. Uzma founded Oculogica in 2013 and her laboratory has developed the eye tracking methodology and published six papers in its utility. She is currently an associate professor in the department of bio informatics and computational biology at the University of Minnesota for the graduate faculty appointment in neuroscience.
She is also an attending neurosurgeon at the Minneapolis Veterans Administration Medical Center. She serves on the executive committee of the American Association of Neurological Surgeons, Congress of Neurological Surgeon’s joint section on neurotrauma and critical care.
[INTERVIEW]
[0:01:50.5] BP: Welcome to the show, Dr. Uzma Samadani. Do you want to start by telling everyone a bit about your background and what created your interest in brain injuries?
[0:02:01.5] US: Sure, I’m a neurosurgeon and I became interested in brain injury because once I started interacting with patients as a medical student and then as a resident and finally, as faculty, I realized that there is so much that is unknown about brain injury. It’s difficult to detect and it’s very, very difficult to treat. I think it’s one of the most challenging medical disorders that we’re dealing with in our society.
It’s a major cause of morbidity and mortality. Neurologic disorders in general are hard to measure and hard to treat and brain injury certainly, is no exception.
[0:02:40.0] BP: Absolutely. I really like that you touched on how difficult it is to diagnose and treat. It is something that has changed a lot in five years, 10 years, 20 years and it’s actually kind of crazy how much it’s changed. The recommendations that I got 10 years ago are not the recommendations that people get today after suffering from a concussion.
[0:03:03.8] US: Yes. It’s actually gotten a little better whether slightly better understanding, at least brain injury now is taken seriously. 10 years ago, it wasn’t. There were lots of people who were told, “Oh, you’re just imagining things, there’s nothing wrong with you, we can’t see anything on the CT scan so there is — it’s all in your head.” Which you know, actually is in a sense true but it’s not in their head in the sense that they’re making it up.
It’s legitimate, there’s an organic pathology that’s wrong, it’s just not easily detectable with conventional imaging all the time.
[0:03:35.9] BP: Absolutely and that “in your head” comment is something I received as a teenager and then it made me overthink, I would be like, “Is it in my head? Am I making up the chronic pain that I’m suffering from?” I was only 17 at the time, I didn’t know that much better and I’m very glad that it’s improved since then.
Recently, I was asked about imaging and concussions. Knowing that concussions do not typically show up on any scans such as a CT or MRI, could you elaborate on why that is?
[0:04:09.5] US: A concussion basically is you know, it depends on how you define it, there are lots of definitions that are out there but I like to think of a concussion as a disruption of physiologic activity in the brain after some sort of injury. The injury can be an obvious injury like someone getting hit in the head is an obvious injury, someone falling and hitting their head is an obvious injury or it could be a non-obvious injury.
The classic example of non-obvious injury might be an inertial injury where someone’s in a car accident and the car slams on the brakes and their head jerks backwards and forward and you know, the car goes from say, 60 to zero in two seconds but the person never hit their head but they may still have an injury because of the rapid speed at which they stopped.
Then there are other examples of the injuries to the brain that result from things where there’s no direct flow, things like blast and then forces to the body. Getting back to your question, what does it mean when you can’t see it on imaging? Well, CT is really sensitive for vascular injury, so when someone has blood that’s leaked out into a space in the brain, you can often see that and the different spaces that get blood are usually the subarachnoid space.
I would say, that’s the most common and can also be the subdural space, the epidural space but it’s possible to see those changes on a CT scan. MRI is also helpful but it doesn’t necessarily reveal all concussions because some concussions happen at a molecular level. They happen at the cellular level or at the molecular level where there’s a disruption in electrical activity in the brain that slows the conduction of signal from one part of the brain to another, so parts that are normally talking are not talking to each other.
That can cause a problem that can result in symptoms either immediately after the injury or in a delayed fashion after the injury. I think that it’s critical to realize that not all concussion is easily picked up on MRI or CT. Generally speaking, it’s not picked up on those scans because that’s the definition of concussion is a sort of a radiographically less obvious injury.
[0:06:26.2] BP: Absolutely and I like that you touched on the non-obvious concussions and mild traumatic brain injuries. We have a lot of people that reach out to us about, “Well, I’m just learning about this now, I’ve been struggling for a long time and didn’t put one accident together with what’s been going on” because they didn’t realize what had happen, they didn’t hit their head like you use as an example.
They got in a car accident or something else occurred to them and they didn’t put it together and then they struggled for a while and then now, they’re starting to put the pieces together and they’re starting to realize, “Oh well, okay, I didn’t hit my head but I still, I’m suffering from a concussion or a mild traumatic brain injury” and I think it’s really important that awareness around that is created even more because there’s lots of people suffering undiagnosed and then it’s already difficult to treat but if you have no diagnosis, then you’re kind of walking blindly with this injury.
I also like the molecular level that you touched on, it’s very true and I think a lot of people have trouble because they want to see their injury. They want to see it on a scan like a broken bone to prove that this is what they’re going through and it’s just not the case.
[0:07:45.2] US: Yes, you’re absolutely correct, that’s very important.
[0:07:49.2] BP: How can we see concussions if we can’t see them on a scan?
[0:07:56.1] US: The technology that we have developed is an eye tracking technology. What it does is we measure the pupil position so the cartesian coordinates XY of your pupils, over time. What that enables us to do is we can look at how your eyes move while you’re doing something such as watching TV and we can figure out if there’s disruption in the coordination or in the control of those eye movements.
That can tell us if there is disruption of physiology in the brain. Because so much of the brain is involved in eye movements, we can pick up problems that are really, really subtle and with our technology, we actually assess a large number of the nerves that are important for maintaining some of the — what they’re called cranial nerves for maintaining some of the sensory functions of the brain.
For example, cranial nerves two and three, cranial nerve two is involved in vision, cranial nerve three constricts the pupil, three four and six move the eyes and five and seven control blink. Just by looking at eye movements, you can get an assessment of multiple cranial nerves, basically, cranial nerves two through seven and so, looking at eye movements, looking at blink, looking at pupillary reflex, tells us a lot about brain function and that’s super valuable information.
[0:09:19.2] BP: Absolutely. Something I personally watched was your TED Med Talk and you began by using your fingers saying following my finger and it’s something that’s still used today by medical professionals and how much can the system that you have created help be a lot more diagnostic and help improve survivors versus just using a finger and watching the eye movements?
[0:09:47.0] US: Well, I think, it goes back to exactly what you said before where people feel vindicated because right now, someone has a brain injury and they don’t feel right or they don’t feel normal or they don’t feel well and everyone just tells them, “Well, there’s nothing wrong with you, you’re crazy.”
If you don’t have an objective measure that reveals the problem, then you do think you're crazy. You think, “Well, maybe this is my problem.” You know, if you can’t see it on an MRI scan, you start to question your sanity and that is so difficult for a person because clearly, there is something wrong but nobody else can tell and the person otherwise looks well and that’s how they go crazy.
You know, brain injury to me, can be very serious. It’s particularly these “mild cases” where what happens is, someone has a brain injury and suppose it throws them off just a little bit. It makes their attention span a little shorter, makes their ability to concentrate a little bit les sharp, makes them more irritable when they’re talking to friends or family and you know, all of a sudden, they can’t do certain things as well,
Maybe they can’t do their job as well, maybe they can’t communicate with their family members at home as well, maybe they can’t socialize, they can’t go to a night club at night and decompress because then the noise, the lights, everything bothers them, so it changes their lifestyle and then what they have to do is they have to compensate for that and sometimes they’ll self-medicate for that.
They’ll take alcohol, they’ll try pot, they’ll do something to make themselves feel better and often, these people feel like, “Oh doctors can’t help me because there’s no treatment for concussion.” They may not even seek medical attention, particularly, if it’s not a work-related injury or something that can be attributed to some cause for which there would be some remedy, they often will be completely in the dark as to where to go for what to do.
Then, after they start self-medicating, that can create a vicious cycle, where it’s very destructive and they continue to experience symptoms. They continue to not be able to cope with whatever was bothering them and now, they’ve added the additional problem of addiction or dependency and then that can sort of push them over the edge.
All of a sudden, they become unemployed or they get into a situation where they have to separate from their partner or they can’t socialize at all and then that can be further destructive, that can lead to homelessness or that can lead to lost relationships and it can be very damaging to someone’s life.
It can cause, even if they remain married, it can cause an isolation or depression that can lead to suicide and so this is a very, very serious problem. There’s a six-fold higher incidence of suicide in people who have had a prior history of brain injury. These are not trivial problems. The consequences of brain injury are very real and we have to be very cognizant of that.
[0:12:51.8] BP: I like so many things that you touched on and everything that you touched on makes it stand out that there is nothing mild about this but that is what it is considered as a mild traumatic brain injury but a lot of the times, I use the word “Concussion” because the word mild makes it seem minimal like you said and there’s nothing minimal about it.
I am an attempted suicide survivor and I know exactly how the mental illness can be created from this and something I’ve been talking about recently on social media is mental illness and the connection with brain illness is a lot of the time with mental illness we start to question our thoughts and then we start to question ourselves, “Why do I think this way, why can’t I stop?” and understanding that it is a brain illness allows us to think, “Okay, this isn’t just me as the world portrays it, there’s something wrong” and it’s an illness that I can now look at it at a different way and start getting it treated and see how can I improve my lifestyle and prevent from going down a lot of the roads that you mentioned.
[0:13:59.2] US: Yes, correct.
[0:14:01.2] BP: It is absolutely amazing how many lifestyle changes a brain injury can cause and it often starts out very minimal like you said where you can’t go to work or for myself, I couldn’t go to school anymore and then all of a sudden, I couldn’t get out of bed anymore and once you add the mental illness like depression or anxiety on top of the symptoms that you're experiencing, everything gets heightened to unsustainable level and it can be very difficult to live with.
[0:14:33.4] US: Yes.
[0:14:34.9] BP: With all of that, we’re going to take a quick break and then we’ll be back to talk a little bit more about eye tracking and its benefits to concussion survivors.
[0:14:45.9] US: Sure.
[BREAK]
[0:14:50.9] BP: Wow, I can’t believe it’s been one year. The support from everyone has been truly amazing. Due to reaching our one year anniversary, you can now book one-hour sessions with myself, Bella Paige. I offer help with understanding loved ones, finding your new normal and finding specialists near you. Find the “Work with Bella” link in our episode description. I am looking forward to another great year.
[INTERVIEW CONTINUED]
[0:15:21.3] BP: Welcome back to The Post Concussion Podcast with myself, Bella Paige and today’s guest, Dr. Uzma Samadani. As the founder of Oculogica, can you explain, you’ve talked about your technology but what can you use this technology for once you’ve realized that someone is experienced a concussion?
[0:15:41.4] US: We are FDA cleared for aid in the diagnosis of concussion and that’s one particular metric that we can give you. We are currently using our technology in a research capacity to sort of, instead of say, “concussion, yes, no” we want to answer the question, “concussion, what kind.” Where is the impairment, what can we expect about how long it will take to recover and how can we characterize its nature or classify it so that we can treat it appropriately.
Because, one thing that we have realized is no two brain injuries are the same. You can even have people with very similar symptoms but the underlying pathophysiology might be different. One person may get better sooner than another person and the better we’re able to classify and characterize the nature of the injury, the better we’re going to be able to treat it. That’s where we want to be, that’s chapter two for what we want to do with our technology.
Right now, we’re in chapter one, we can say “concussion yes/no” and pretty soon, we hope to say “concussion what kind” and then once we can say “concussion, what kind” the next step is obviously, therapeutics and looking at using eye tracking as an outcome measure and using it as a predictor of things like “return to play, return to work.” Right now, I think we could do that technically but we do not have FDA clearance for those particular indications.
[0:17:07.2] BP: I really like that you're talking about FDA clearance for a lot of these things because one of the common issues within the concussion research, well, not really the research field, the treatment field is a lot of people claim they are treating concussions with a lot of random data and I wouldn’t say anybody is cleared for anything, they just do it, does that make sense?
They just treat concussions, they put a sign on their door and they now treat concussions and it’s really common and I like that you talked about where is the impairment because a lot of people want to know that. Like you’ve touched on before, they want to know why, “Why can’t I read, why am I having trouble with so many of these things?” and knowing why sometimes doesn’t seem like a big deal to other people but when you’re the one who is ill, it can make a really big difference for you mentally.
[0:18:03.2] US: Yes, this is true. I think that validating that there is something wrong and identifying or classifying the nature of the problems that you can identify, a particular therapeutic that might be effective, that’s half the battle for most people with concussion. The rest is figuring out how to make the therapeutics work.
[0:18:23.1] BP: Absolutely and they really are like I’ve heard it million times before, they’re like a snowflake and no concussion is the same and that can make it really difficult as well. Another thing you touched on is recovery and recovery, there’s so many other aspects we talk about it a lot here is lifestyle. It can really affect your ability to recover because we all have very different lifestyles.
If you can spend three months, six months, a year on recovery, that’s wonderful but if you have a job that you need to attend to or you have children that you need to attend to, that doesn’t always work that way on top of having a different injury that no one else has. Once you add all those things on top of it, it gets really complicated as we consider previous health conditions and things like that, which obviously affect it as well.
There’s so many considerations to a brain injury and its recovery that it is quite the complex thing to work on and research, so I think it’s very incredible that that’s what you’re doing at this time.
[0:19:29.1] US: Yeah, I think you make a good point and that’s with regards to inequity. What happens when someone has a brain injury is people who have more resources and can afford to take time off work and pay out of pocket for all the things that are not covered by insurance because there’s no objective measure for brain injury, those people tend to do better. The people who cannot afford to take time off work or cannot afford to pay out of pocket for different therapeutics, they tend to do worse.
There’s a huge inequity with regards to brain injury but there is also an inequity on the other end, you know, post. Here, we are talking about post-diagnosis but even pre-diagnosis. Patients who have a concussion who don’t have resources are less likely to go to the emergency department, they’re less likely to go to their primary care doc, they are less likely to ever get diagnosed in the first place, they are more likely to try and self-medicate or self-manage and I think that puts them at a higher risk for having complications from their concussion.
There are huge inequities in outcome after brain injury in general, so for more severe brain injury, you’re almost twice as likely to die if you are a person of color as opposed to being white. We know that there are tremendous inequities in how patients are triaged and prognosticated at the very earliest levels in the emergency department in the hospital and in the ICU. I think it’s critical to have objective measures for brain injury and eye tracking is obviously useful for the awake patient but other objective measures are needed for patients who are less conscious.
[0:21:06.1] BP: Absolutely they are and it’s incredible as you mentioned that out of patient cost, I think I don’t know about all of my treatments, nothing was covered because like you said, it’s not really something that they can measure how injured I am so most of the treatments that I’ve gone for and I live in Canada where healthcare is covered and even a lot of those specialized treatments, nothing was covered. In the United States as a lot of our listeners are from, it’s an even larger problem for sure.
[0:21:41.1] US: Yeah.
[0:21:41.9] BP: It’s something that the inequity as you mentioned is severe and then it goes on to how the media portrays brain injuries, we talk about it here and I like to talk about it as an athlete, it was something that you saw a lot but if you are not in that in world, it’s not something anyone talks about. You don’t see concussion research coming out, there is no — there is general concussion research, conferences and things like that but if you are not in that world, you would never see it.
Whereas an athlete, you see these types of events because they are creating more awareness, your coaches are supposed to be certified with more things but if you are injured like most people from things such as domestic violence, a car accident, being in the military, a slip and a fall, you aren’t aware of all of the treatments that might even be out there for you especially when you go to the ICU because they don’t provide them there.
[0:22:37.0] US: Correct and I think that you know sports has been good for brain injury because it’s increased awareness of the problem but sports concussion is actually very different than domestic concussion and the reason of that is that sports concussion happens in a person who goes from being extremely active to having their concussion and still being hooked up with that same support network, the athletic trainers, the physical therapist, the people who help people recover from orthopedic injuries for example.
They still have that infrastructure and that network very often particularly if they are playing college sports because the NCAA has dedicated the very best resources to the maintenance and preservation of the health of its athletes and that’s laudable, that’s good but the average person that slips and falls on their driveway because of the ice doesn’t have any of those resources.
There is no athletic trainer, there is no physical therapist, there is nobody and you know often, their primary care physician isn’t necessarily equipped to diagnose or treat complicated post-concussive syndrome and so they may not, the patient themselves may not go to see their doctor at all because they think, “Well, you know they’re not going to be able to help me anyway” and so this is definitely a problem and it’s an ongoing problem.
[0:23:59.0] BP: They can’t help is something I even went through a little bit when I was going through my mine, after doing a few years of treatment and no progress would felt was being made and I would just give up and then a few months later, I would try again because I had parents who were pushing me. They were saying, “Okay, you’re still not well. Let’s try again, we found something else for you to go to” but that support network was huge.
That’s what we try to instill here is some sort of support network for all those people that don’t have or the other problem we have with a lot of survivors is they have a support network that would be there if their injury was visible but because it is not visible, that support network doesn’t exists because their family members don’t see it, so they have a hard time believing that it is really an issue that they’re going through.
[0:24:49.2] US: Yes, you are exactly correct. When someone has a brain injury, they tend to have either guilt, blame or shame. There’s this blame idea that you get from parents who have a kid with a brain injury, so often it’s a kid who is engaging in some activity that has some level of risk and then there are parents who sort of look at each other and say, “Well, you’re the one who said she should do this. She could do gymnastics” or “You’re the one who didn’t enforce the helmet rule” or something like this.
The parents tend to blame each other and it creates huge amounts of conflict in a relationship. The shame part comes from when people blame themselves, so when someone has a cancer diagnosis or a birth defect or a kidney malfunction or something like that, there’s generally not blame ascribe to the victim or the sufferer but when someone has a brain injury, it’s always a question of, “Well, what are you doing drinking?”
“When you’re walking home at the bar late at night when you were drinking and intoxicated, you know that’s your fault” right? We tend to blame the victim, “You know, people should look both ways before they cross the street, don’t you know?” and the victim’s blame themselves and that’s what makes brain injury so incredibly different is that people don’t think of it as a disease with risk factors and it is. It is just like any other condition and there are risk factors that predispose towards getting it.
[0:26:14.1] BP: Yeah, I’ve never — I really like that, the guilt, blame, shame idea. That was something my family went through. I know my dad is super against show jumping horses and won’t let any of my nieces or nephews take part. In his mind, he says he won’t support it because that’s how I got hurt but you can get hurt anywhere at any time, which I always like to mention here and that shame, I had a lot of guilt towards my family and shame because I felt bad.
I felt like I was a burden on them. That was a big problem for me. I didn’t want to tell them that I had a headache every day for about seven years and waking up and them asking me how I was doing to tell them I had a headache again was something I didn’t want to say because I didn’t like the look. They try to hide it but I could see it. I could see it especially with my mom who would try to hide it and smile but you could see it because her child is suffering and has been suffering for a long time despite a lot of efforts that they’ve been making.
It is an emotional rollercoaster that goes along with this, as with a lot of other illnesses but it is true. A lot of the time we blame ourselves for the injuries we’ve received or how we’ve taken care of it. I blame myself for not telling anyone at the beginning. I had headaches for months and I have gone diary entries and things like that from then and it is amazing how you can convince yourself that something is not wrong.
[0:27:46.0] US: Yeah.
[0:27:47.0] BP: I’d blame the heat or stress or being too active and all these things. I was 15 years old, it was incredible to see how many things I could do to hide what was going on and then the guilt and anger I felt a lot at myself or not telling anyone the truth of what was going on because that only hurt me in the end.
[0:28:07.0] US: Right.
[0:28:07.3] BP: You have provided us so much amazing insights and information, is there anything else you would like to add before ending today’s episode?
[0:28:16.0] US: No, I think thank you for talking with me. Thanks for elevating awareness of this problem. It’s a very serious problem and your efforts are really fantastic at doing this. I think that the more people understand that this is not an imaginary problem, it’s a very real one even though it’s an invisible one, the better off people with brain injury will be because they will understand that this is not something that’s impossible to treat or impossible to diagnose and you know, Oculogica, the goal of our company is change the way brain injury is diagnosed and defined and if we achieve that, we will have achieved something.
[0:28:52.1] BP: Absolutely. Well, thank you so much for joining and sharing all of your work with brain injuries.
[0:28:58.0] US: Thanks.
[END OF INTERVIEW]
[0:29:02.3] BP: Support the podcast, if you truly love the podcast, please consider supporting us through our tip jar. Find the “support the podcast” link in our episode description. All tips are greatly appreciated.
Has your life been affected by concussions? Join our podcast by getting in touch. Thank you so much for listening to The Post Concussion Podcast and be sure to help us educate the world about the reality of concussion by giving us a share and to learn more, don’t forget to subscribe.
[END]
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