Some of us have never suffered a concussion. Yet we write about it (in my case) or examine people who have suffered concussions, missing that very unique qualification.
Dr. David M. Schwartz, on the other hand, knows what it is like to suffer a concussion, having experienced “a few.”
“I was concussed as a wrestler in high school,” he told Concussion Litigation Reporter. “I was concussed in a single car accident when the pledges raided our fraternity house. And, I was concussed as an adult when I participated in competitive martial arts.”
In his practice that spans three decades, Dr. Schwartz is committed to developing innovative and affordable solutions for issues arising from participation in sports, the military, and everyday functioning. Its his long career and his current post at Northside Hospital Concussion Institute that made him a great candidate for the following interview.
Question: How did your interest in concussions come about?
Answer: My interest in concussions has continued to develop since graduate school. I’ve always been fascinated with the brain and how it works. I was very fortunate during my postdoctoral fellowship to have the opportunity to study with some incredibly talented neuropsychologists as part of the Harvard Teaching Hospitals and Tufts New England Medical Center. My personal mentor and hero was Dr. Edith Kaplan. While I wasn’t one of her formal post-doctoral fellows, she adopted me and treated me like one of her own. Most of what guides me in my work with individuals who have had concussions and more serious traumatic brain injuries, as well as other neurological and neuropsychological diagnoses, is based on the Boston Process Approach that was developed by Dr. Kaplan. In short, it’s less about a final score or product, but rather on how an individual proceeds through a task to reach a specific goal.
Q: What professional accomplishment are you proudest of?
A: This is a tough question. If asked what overall accomplishment am I proudest of, I would say being told that I was a good and caring father to my 3 children, who are now grown. That said, the professional accomplishment that I am the most proud of is the fact that my patients tell me how much they appreciate how I treat them and how much time I spend with them. It makes me feel good when they recognize my general concern for their improvement and overall recovery.
Q: Tell us about your role as Clinical Neuropsychologist at the Northside Hospital Concussion Institute. What’s involved?
A: Being a clinical neuropsychologist at Northside is very fulfilling. We have an amazing team of health care professionals, abundant resources, and the support of administration to help us provide the best services for our patients. As a clinical neuropsychologist, I get the opportunity to expand on the educational aspects about concussions with our patients. There is a lot of misinformation out in the public and on the Internet. This often causes increased anxiety and concern in our patients. This increased anxiety and concern often complicates and prolongs the recovery from a concussion. Therefore, anything that can be done to alleviate anxiety and concern, facilitates recovery. Almost every patient comments on how the educational process helped them feel less anxious and more optimistic about their recovery. As part of my role, I do a diagnostic interview, do some physical testing, and review assessment data to help develop an accurate diagnosis and a meaningful, evidence-based treatment plan. My mentor used to say, “Once you’ve met one person with a concussion, you’ve met one person with a concussion.” This is part of what keeps it interesting. Each concussion between individuals, as well as, multiple concussions within the same individual, is/are different. So it never gets boring. Also, one of my passions is coming up with ways to help the individual return to their typical life. It may be returning a student to school so that they can learn, returning an athlete to sport, or returning an adult to their work and their families. Each plan has to be individualized because there is no such thing as a “one size fits all” intervention or path to recovery. It is exciting to come up with new and creative ways to leverage the incredible technologies we carry with us every day. For example, there are multiple iOS and Android applications that run on our tablets and cell phones that will compensate for skill deficits or augment ability weaknesses. There are also numerous desktop programs that will do the same thing. On top of that, we follow up with our patients until they are reintegrated into their typical routines and ready to be discharged.
Q: How has your experience and own research shaped your opinion on these CTE, second-impact syndrome, and the dangers of subconcussive hits?
A: CTE: Chronic traumatic encephalopathy (CTE) is not as prevalent as the hype would have you believe. Several mornings a week, I start my day by reviewing the most recent research in a variety of areas related to concussion. CTE is one of those that I keep up on. It is fascinating to watch how a problem has been identified (CTE), what the process and sequence to address that problem is required. Advancements in the detection and diagnosis of CTE are happening constantly. However, the state-of-the-art is still at the point that CTE cannot be definitively diagnosed until autopsy. And, I don’t know many people who want to participate in that process before they absolutely have to.
Second-impact syndrome: Second-impact syndrome tends to be relatively rare. The more we know about concussions, the more aggressive we get at protecting the individual who has sustained a concussion. Frankly, I don’t know of any organization that does not follow, at least to some degree, the Consensus Statement on Concussion in Sport as developed at the 5th International Conference on Concussion in Sport held in Berlin, October 2016. This advisory panel meets every 4 years. If not for COVID-19, we would be due to have the 6th International Conference this year. The bottom line is that at every level of competitive sport from PeeWees to the Pros, procedures have been put in place to remove an athlete from sport if a concussion is suspected. Each athlete must go through a prescribed return-to-play protocol that details what criteria need to be met before the athlete can return to sport. The rule of thumb is, “When in doubt, sit them out.” In many cases, there are multiple observers who can indicate that they suspect a concussion has occurred. These individuals include coaches, assistant coaches, referees, parents, athletic trainers, and teammates. Oftentimes, there are independent “spotters” who watch for a suspected concussion. They can stop play on the field and have an athlete evaluated for a concussion. This aggressive approach helps to minimize the likelihood of second-impact syndrome. All of this is to say, that in my 35 years of practice, I have maybe seen one “true” case of second-impact syndrome. I have not seen any second-impact syndrome patients that resulted in the death of an athlete or non-athlete individual.
The dangers of subconcussive hits: This is a topic where my opinion has shifted more than once, based on research and personal experience. Initially, when I was starting out, the concept of subconcussive hits made a lot of sense in terms of causing impairment in the individual that I was evaluating and treating. I have even testified in legal cases to this fact. It simply made logical sense that multiple blows to the head that were not sufficient to cause a concussion, the way we conceptualized it at the time, could lead to diffuse axonal injury and neuronal stretching and tearing. This was followed by a block of time in which the research started shifting to the fact that there was no conclusive research-based evidence that subconcussive blows could lead to neurological or neuropsychological impairment. This required us to modify our conceptualization and opinions about the impact of subconcussive blows. However, the research is shifting yet again thanks to the development of better neuroimaging techniques. For example, we now know that there may be some white matter swelling as much as 6 months after a typical concussion. This is giving rise to concerns that we may be returning athletes to sport prematurely. Further, we can see some changes in some individuals on neuroimaging where there was no evidence of a single concussive blow. Rather, these changes would be explained by multiple subconcussive hits. However, one of the problems with the ways this evidence has been developed is that it relies on a technology where there is not a substantial database of what constitutes “normal variability.” One of the key tenets of neuroradiology is that radiological procedures, with a few exceptions, only reflect structure, not function. Therefore, you can have an area of the brain that reveals an “area of interest,” but is asymptomatic and not clinically correlated. Similarly, you can have an individual who demonstrates objective results on multiple types of measures, but there is absolutely no evidence on neuroimaging. Currently, I am leaning in the direction that it is more likely than not that subconcussive blows can cause impairment in certain situations.
Q: What do you feel are the biggest factors when it comes to susceptibility to concussion and recovery from concussion?
A: Susceptibility to concussion? This is an area that I don’t give a lot of thought to typically. Realistically, we don’t understand why some people get concussions and other people do not. The scientific literature does not provide good guidance on this particular issue. It is being studied, but findings are inconclusive at this time. We don’t know why some people end up with a concussion after what appears to be a mild blow to the head. Other people may suffer a serious blow to the head or body and have absolutely no signs or symptoms of concussion. As a result, I often pay less attention to why the individual person sustained a concussion. I tend to focus on the individual who is sitting in front of me, the mechanism of injury, the severity of the injury, and time since injury. I integrate my clinical experience and the research to determine whether or not the individual who is sitting in front of me is consistent with the scientific literature and my clinical experiences. Another saying that applies here is, “It’s not the type of head injury, but the type of head.” That is about the best I can do on susceptibility to concussion.
Recovery from concussion? Frankly, I think this is what most people should focus on. If you have an individual in front of you who has sustained a concussion, usually their biggest concern is returning to the level of function that they had before they were injured. Obviously, there are secondary gain issues that have to be considered. That said, if you have someone who has a legitimate concussion, typically their biggest concern is recovery. In order to be effective and comprehensive in terms of recovery, there are multiple levels of function that must be considered. People have to understand the complicated nature of the concussion. For years, people conceptualized a concussion as a bruise on the brain. It is nothing like that. A concussion is a chemical and metabolic event. In the overwhelming majority of cases of concussion, there is no bleeding and no permanent structural damage. Therefore, it is reasonable to expect a full or near-full recovery. Up until fairly recently, I don’t think most individuals understood the wide range of potential impediments to prevent recovery or extend it significantly. Research has now identified a number of “recovery trajectories” that impact recovery on multiple levels. While there is general agreement on several of these recovery trajectories, the number of recovery trajectories varies. Some individuals identify certain trajectories as physical and therefore not necessarily a part of the concussion. However, if an individual has physical pain or a physical injury, we know that it will impact their neurocognitive functioning. I use the following recovery trajectories: Cervical; Oculomotor; Vestibular; Cognitive/Fatigue; Anxiety/Mood; Post-Traumatic Migraine; Sleep Disruption; and Comorbid and/or Pre-Injury Medical Factors. Each of these trajectories have a unique set of characteristics that impact the speed and length of a recovery from a concussion. In addition, research has identified numerous prescribed interventions to assist in resolving each of the issues related to these multiple trajectories. By utilizing these research-based interventions for these recovery trajectories, we are able to assist our patients return to premorbid levels of functioning much more quickly than even 10 years ago.
Q: What have I left out? Can you think of any unifying theories or approaches that would help our readers think about concussion more accurately?
A: Actually, I can. I can strongly recommend a research-based article and supporting website that helps put concussion and its complexities in greater focus. A journal called Frontiers of Neurology published an article that I think is exceptional at meeting this goal. This conceptualization of concussion puts the complex nature in focus. This research was originally published in April 2018. The actual citation is Kenzie ES, Parks EL, Bigler ED, Wright DW, Lim MM, Chesnutt JC, Hawryluk GWJ, Gordon W and Wakeland W (2018) The Dynamics of Concussion: Mapping Pathophysiology, Persistence, and Recovery With Causal-Loop Diagramming. Front. Neurol. 9:203. doi: 10.3389/fneur.2018.00203. The website which effectively illustrates the issues and levels of complexity can be found at https://psu-sysc.kumu.io/dynamics-of-concussion. I believe that it is beyond the scope of this interview to go into great depth about the article and website presentation. Nonetheless, I strongly encourage individuals interested in understanding concussion to get the article and visit the website.
