Concussion: the science behind the movie

Concussion (the movie): the science behind the actingJames MacDonald MD, MPHDivision of Sports MedicineNationwide Childrens Hospital@sportingjimjames.macdonald@nationwidechildrens.org

As we sit down to the Super Bowl..

I will need an outline and transitionsPunctuate overall story with specific studiesAnd review LOE association vs. causation

Draw in one C Emery youth hockey study or talk about P Kriz new youth hockey studyThere is real research in sports medicine!!!!

ResourcesMayo Clinic Study/CSMR CTE/AAP Tackling position statement/Zurich Consensus StatementConcussion Policy and LawMy own talks in S Africa on Pedi concussions and NFL and concussions

Potential guest list: Debbie Moore, Donna Smith, Mike Arace, Jamie Caridi? KitJohn Smith/Gail

Emphasize Frontline documentary on League of Denial as opposed to the movie..1Disclosures

MomsTeam Institute, 501(c)(3) BODWolters KluwerCJSM Associate EditorUpToDate Author

MomsTeam is non profit 403c volunteer positionWolters kluwer are paid2COIs???

Photos of me as youth football player?Attending to downed football player3

BiasNot pro-football, not anti-football

Pro-safetyPro-sciencePro-Active KidsPro-sportsWe all have themFor a contentious subject matter like this, I think it helps to be transparent From the get go

I think the NFL has a problem on its hands, Im not so sure youth football does4Im not a doctor but I play one in the movies

Ask for show of hands how many people have seen this?Include quotation:

Two cases does not meet the standard of proof..Three cases is the scientific burden of evidence. We have four.

Thought there would be a bigger buzznow Will Smith not only not in Oscar hunt, he is skipping the cremony#OscarsSoWhite5The Movie: An OverviewConcussions (movie) isnt about concussionsIts about the NFL not about kidsSafe for kids PG-13CTE--discovered by Dr. Omalu?CTE is not yet fully understoodLeague of Denial PBS FrontLinehttp://www.pbs.org/wgbh/pages/frontline/oral-history/league-of-denial/

Six things concussion the movie wont tell you but experts willhttp://www.marketwatch.com/story/six-things-concussion-wont-tell-you-but-concussion-experts-will-2016-01-11?mod=mw_share_twitter

Its about Omalus life story, and its about CTEthe development of a case series

Its about CTE in adults6

Ban on youth football until age 18, the age of consent7What well coverConcussionsShort vs. long-term riskswhat we know 2016Current research/knowledgeChronic Traumatic Encephalopathy (CTE)Are our kids at risk?Youth Footballwhat is the evidence of its dangersDirections where this is heading?Should we ban football

So we are focusing on pediatric sports-related concussions, and youth football8Concussions -- epidemiology3.8 million pediatric SRCs /yr1 50% of HS football players dont report/season2Rates in HS sports3:Football 6.4/10000 AEsBoys Ice Hockey 5.4/10000 AEsBoys LAX 4.0/10000 AEsGirls LAX 3.5/10000 AEsGirls Soccer 3.4/10000 AEsBoys Soccer 1.9/10000 AEsAlmost 9% of HS sports injuries4Youth sports data are lacking1.9% of Youth Soccer injuries

2015 Concussion Total Sports MedicineJan-JunJul-DecTotalNew Patients4216891110Follow Up81010541864Grand Total1231174329741AJSM 20122CJSM 20043AJSM 20124Pediatrics 2010

On left are National #sAnnual incidence of pediatric/adolescent concussions in USAThought to be an underestimate

Unclear if rate is going up recognition most definitely is

I will report on the 50% of HS football playersAJSM Comstock formerly of CIRP here and published while she was at NCH

Sports are second only to MVAs as causes of youth Traumatic Brain Injury

Under HS less well known, European study: Most injuries in youth (7 to 12) soccer are to legs and arms; 1.9% were concussions, Czech-Swiss study finds. http://ow.ly/XTCAM

On right us, and this does not include PM & R, Neuro, ERThis is almost 1000 more visits per year than in 2011

Thanks to Leslie Mccann9Concussionswhat are they?Complex pathophysiologic process affecting brainCaused by Impulsive force direct or indirectResulting in new neurological sign/symptom2016: Concussionclinical diagnosisObjective gold standard still lacking

SignsLOCAmnesiaAtaxiaSymptomsLots!!!!CognitiveAffectivePosturalSleepDiagnosis

Zurich Consensus Statement CJSM 2013Zurich consensus statement and definition in KD articleNot my intention to go too deep into this10SCAT-2 (3)1

ProspectiveSRCs in College AthletesSCAT 2 (0 100)Baseline & Post-concussionDecline > 3.5 Sens = 0.96Spec = 0.81LR+ = 5.1

1CJSM 2013 4th Intl Concussion Consensus Statement2Putukian et al., CJSM 2015Incorporates balance testing, symptom score, cognitive testing like months of the year backwards, memoryTakes 15 to 20 minutes to complete sideline????

100 point scale, decline of 3.5 pos LR of 5.1 is OK, doesnt do a great job of moving you from your pre-test to post-test probability

When in doubt sit them out, youll be sitting a lot of healthy people11Objective BiomarkersBlood S100B, amyloid, tau, NSE, glial fibrillary acidic protein, neurofilament polypeptide, SNTF, APOE 4Video oculography - eye tracking, portablePupillometry peak velocity, latencyVisual/auditory evoked potentialObjective balance portable force plate (Biodex Biosway), accelerometers, app (Sway)Cranial accelerometry skull movement caused by cerebral blood flow reactivityCerebrovascular reactivity Doppler USFunctional Near Infrared Spectroscopy (fNIRS) cerebral oxygenation as function of cognitive workloadHit sensors for helmeted (HIT, Gforce) and unhelmeted (Gforce, Triax), patch (X2)Injury risk curves dependent on accuracy of concussion diagnosis and biomechanical measure

Objective Measures of Concussion -- 2016Christina Master MD, CHOPCourtesy Christina Masternovel MRI sequences (such as diffusion tensor imaging and eye tracking) for evaluation of concussion. Additionally, we have an interest in and plan to continue evaluating biomarkers for MTBI.Look at Renos email if necessary

12Concussions (cont.)HS Football players1 75% Sx free in 3 days 65% RTS in 9 daysYounger take longer80% RTS in 21 daysReturn to SportReturn to LearnReturn to Drive1 Jrnl Athl Training 2007This is not so much a primer on diagnosis and management of concussions as it is an investigation of short and long term risk of concussionsWeve become much better at managementWe struggle with diagnosis and interventions

This is where I take some data out of Comstock paper re HS how often times they recover quickly

J Athl Training Comstock13RCT (N = 88, Age = 11 22)Strict rest 5 dUsual care No difference in neurocog or balance measuresIntervention group had more daily post concussive symptoms & slower resolutionPros cohort (N = 335; Age = 8 23)Patient self-report of cognitive activityDivided into quartilesMean duration of symptoms 43dAssociated with slower recoveryInitial PCSS levelCognitive activity

How much cognitive rest?Brown et al. Pediatrics 2014Thomas et al. Pediatrics 2015Usual care: Because human data on postinjury exertion are limited, expert consensus recommends 24 48 hours of rest before beginning a stepwise return to activityIm a Co-I Ginger Yang at our CIRP more objectively measure cognitive activityBeen some back and forth in the recent medical literature http://www.momsteam.com/strict-rest-after-concussion-does-not-improve-recovery-new-study-findsBrown Pediatrics: http://pediatrics.aappublications.org/content/early/2014/01/01/peds.2013-2125.abstracthttp://pediatrics.aappublications.org/content/early/2014/01/01/peds.2013-2125.abstract

Thomas study Usual care 1 2 d rest followed by stepwise return to activityMost notable outcome not expected!

14Physical Activitypost-concussionPublished Ahead of Print 2/2/16AJSM (N = 364; Age = 15)Cohort study LOE 2Post-concussion symptom durationFemale, initial PCSS score associated with lengthPhysical activity level post injury no associationAges 13 18HIGHER levels of physical activity associated with SHORTER symptom duration

And while its clearer that post concussion should avoid head impact, our understanding of what physical activity may be allowed post concussion is evolving

Among the variables included in the model, initial PCSS score and female sex were independently associated with symptom duration, while physical activity level after the injury was not. For participants aged between 13 and 18 years, however, higher levels of physical activity after the injury were associated with a shorter symptom duration.15CTEwhat is it?Clinical CharacteristicsNo prospective, longitudinal studies demonstrating theseMood/ImpulsivitySuicidal IdeationCognitive impairment HeadachesMotor (Parkinsonian)Diagnosis Post mortem autopsyFound inFootball/rugby/wrestling/rodeo/circus clownsNot found in those with no exposure to head impacts

PathologicalTauopathyamyloid inconsistent feature

Levels of Evidence (LOE)Case Reports/Case SeriesRetrospectiveVI, VIIBiases:Referral/recall/selection/ samplingCorrelation not causationNeurology 2013Univ. of Wisconsing Library LOE GuideLOE: http://researchguides.ebling.library.wisc.edu/c.php?g=293229&p=1953406Neurology (Jrnl)N = 36 RetrospectiveNext of KinPathologic confirmation

Just yesterday Kenny Stabler the snake being found post mortem to have

Pathology: CSMR slides/Castellani etc.

Clinical presentation of chronic traumatic encephalopathy: The main clinical features of CTE involve three aspects: mood/impulsivity, suicide, and dementia.Neurology. 2013; 81(13):1122-9(ISSN: 1526-632X)SternRA; DaneshvarDH; BaughCM; SeichepineDR; MontenigroPH; RileyDO; FrittsNG; StammJM; RobbinsCA; McHaleL; SimkinI; SteinTD; AlvarezVE; GoldsteinLE; BudsonAE; KowallNW; NowinskiCJ; CantuRC; McKeeAC

OBJECTIVE: The goal of this study was to examine the clinical presentation of chronic traumatic encephalopathy (CTE) in neuropathologically confirmed cases.METHODS: Thirty-six adult male subjects were selected from all cases of neuropathologically confirmed CTE at the Boston University Center for the Study of Traumatic Encephalopathy brain bank. Subjects were all athletes, had no comorbid neurodegenerative or motor neuron disease, and had next-of-kin informants to provide retrospective reports of the subjects' histories and clinical presentations. These interviews were conducted blind to the subjects' neuropathologic findings.RESULTS: A triad of cognitive, behavioral, and mood impairments was common overall, with cognitive deficits reported for almost all subjects. Three subjects were asymptomatic at the time of death. Consistent with earlier case reports of boxers, 2 relatively distinct clinical presentations emerged, with one group whose initial features developed at a younger age and involved behavioral and/or mood disturbance (n = 22), and another group whose initial presentation developed at an older age and involved cognitive impairment (n = 11).CONCLUSIONS: This suggests there are 2 major clinical presentations of CTE, one a behavior/mood variant and the other a cognitive variant.16

Boston UniversityAnn McKee Boston Universitydoing a lot of the pathological work17CTEpractice & research gaps

Castellani, Laboratory Investiation 2015This is where I add Castellanis/AMSSM commentary info?18Causes for Concern?Frank Gifford

Tyler Sash

Despite Low quality evidence, case series, there are lots of cases popping up, including in the youngJust this a.m. front page news in Ny Times Kenny the snake stabler

Tyler sash Penn collegiate player as wellhttp://espn.go.com/nfl/story/_/id/13610110/tyler-sash-former-new-york-giants-iowa-hawkeyes-football-player-dies-27

Tyler sash: http://www.nytimes.com/2016/01/27/sports/football/former-giants-safety-tyler-sash-found-to-have-cte.html?_r=0

Talk about this seriously, talk about direction thisneeds to go to fully define it

Gifford 80+Sash 27

19Cause for Concern?Cumulative Head Impacts (Subconcussive blows)?HS/College 1000 head impacts/seasonYouth (age 6) 100 head impacts/seasonCan generate impacts equivalent to collegiate athletesAnimal ModelsChanges in White matterConcussion Dose/Response ModelPRECAUTIONARY PRINCIPLE

By some estimates, high school and college football players sustain 1,000 or more impacts to the head during a typical season. Youth players, some as young as 6, can accumulate 100 head impacts a season. (the difference between practice and games)

AAP tackling statement helps out here a bit20Animal ModelsMouse model2 3 mo oldWeight drop rmTBI (7 injuries/9 d)Cognitive deficits w/o structural injuryInjured (N = 32)vs. sham injured (N = 21)Assessors blindedOutcomesTests of balance, spatial memory (e.g. Morris water maze), exploratory behaviorPost-mortem brain examrmTBI mice3 monthsIncreased exploratory behaviorImpaired balanceWorse spatial memoryIncreased astrocytosis and microgliosisNo volume changesJ Neurosurg 20142 studies by Mannix and Meehan (allude to my relationship)Bill Meehan came from boston childrens about 2 years ago and gave a talk on this on going research

Compared with sham-injured mice, mice subjected to rmTBI showed increased exploratory behavior and had impaired balance and worse spatial memory that persisted up to 3 months after injury. Long-term behavioral deficits were associated with chronic increased astrocytosis and microgliosis but no volume changes.21Corpus Callosum White Matter sDETECT studyNFL players [(N = 40), Age 40 65]Age at first exposure (AFE) to Repetitive Head Impacts (RHI)2 groups: < Age 12 Age 12Magnetic resonance diffusion tensor imaging (DTI)Dependent measures fractional anisotropy, axial/radial diffusivityWhole CC and five subregionsSignificant changes in several dependent measures in earlier AFE group

Journal of Neurotrauma 2015Looked at whether age at first exposure to tackling, head impacts, might relate to later life corpus callosum changes

Part of the ongoing DETECT study diagnose and evaulate traum enceph with clinical tests22Dose Response ModelNCAA Athletes (N = 100 male/88 female; diff. schools)Self-reported concussion history 4 groups0 concussions1 previous concussion2 previous concussions 3 previous concussionsCNT testing (visual/verbal memory, simple/choice RT)Performance decrements beginning at 2 concussionsFemales > malesT Covassin et al. J Neurol Neurosurg Psychiatry. 2010T covassinhttp://www.ncbi.nlm.nih.gov/pubmed/20522868

OBJECTIVE:The purpose of this study was to examine, using a dose-response model, sex differences in computerised neurocognitive performance among athletes with a history of multiple concussions.DESIGN:Retrospective with randomly selected concussion cases from four levels/numbers of previous concussion.SETTING:Multicentre analysis of NCAA student-athletes.PARTICIPANTS:Subjects included a total of 100 male and 88 female NCAA athletes.INTERVENTION:Sex and four mutually exclusive groups of self-reported concussion history: (1) no history of concussion, (2) one previous concussion, (3) two previous concussions, (4) three or more previous concussions.MAIN OUTCOME MEASUREMENTS:Neurocognitive performance as measured by a computerised neurocognitive test battery (Immediate Postconcussion Assessment Cognitive Testing (ImPACT)).RESULTS:A dose-response gradient was found for two or more previous concussions and decreased neurocognitive performance. Females with a history of two and three or more concussions performed better than males with a history of two (p=0.001) and three or more concussions (p=0.012) on verbal memory. Females performed better than males with a history of three or more concussions (p=0.021) on visual memory. Finally, there was a significant difference for sex on both motor processing speed and reaction-time composite scores. Specifically, males performed worse than females on both processing speed (p=0.029) and reaction time (p=0.04).CONCLUSION:The current study provided partial support for a dose-response model of concussion and neurocognitive performance decrements beginning at two or more previous concussions. Sex differences should be considered when examining the effects of concussion history on computerised neurocognitive performance.

Women in general: higher rates of symptoms, less persistent cognitive deficits, for gender matched sports get concussed more frequently23Countervailing Evidence

No increased neurodegen ds in NFL playersRates of suicide and all cause mortality etc. also less than general populationMayo Clinic Study REP (2010 11) rochester epidemiology projectHS students (1946 1956)Median f/u 50.2yAll differences non significant(AD, PD, ALS)

despite poorer equipment and less regard for concussions compared with today and no rules prohibitinghead-first tackling (spearing).

Though statistically HS and college FB players are getting bigger

Balancing this out:http://www.newswise.com/articles/view/646558/?sc=dwhr&xy=10013227Players are getting bigger

24

Youth football:the scope of the sport

CJSM 2013Three main governing bodies for youth football in USA, American Youth Football, USA football, Pop WarnerWith slightly different rules including safety rules

Tie in what alison says, or allude to her research if my talk comes before hersPop Warner, USA Football, American Youth Football

Tiny Mite division of Pop Warner includes 5 year olds ( > 35 lbs)26Helmets:Well fitted, reconditionedMouth Guards? NoNeck Strengthening? Qualified yesRule changes in games/enforcement?MaybePractice changes?PromisingMaking Football Safer

Collins et al. Jrnl of Primary Prevention 2014(N = 6704)Adjusted for gender/sport1 # increase neck strength : OR = 0.95ATCs on site: 70% of U.S. high schools have some access to an AT, 37% with full time access

Moms Team: http://www.momsteam.com/team-of-experts/athletic-trainer-AT-every-school-should-have-oneAs much as 85% of all HS athletes have access (because of big vs. small schools)

Data on concussion rates in schools with ATCsLimits on contactAddressing tacklinghelmetless tackling drillsNeck strengtheningEquipmentImproving Identification & RecognitionATCsNeck strengtheningComstock/Lisa KSchmidt, Guskiewciz cervical musclehttp://www.ncbi.nlm.nih.gov/pubmed/24928761

Collins, comstock, cantu, lisa k:Journal of primary prevention2 phase study, validating a hand held tension scale, inexpensiveWith a dynamometer; HS athletes, girls/boys, lax/bball/soccer, 25 states)And then looking at large #s of kids to see among other thingsIf anthropometric meausures of neck can be associated with Lower incidence of concussionJrnl of primary prevention: neck strengtheningEach 1# increase in neck strength is associated with a 5% decrease in concussion risk27Snake OilCan a dietary supplement treat or prevent concussion?Chocolate milk!Omega-3 fatty acids!Turmeric!As amazing as the marketing claims are, the science doesnt support the use of any dietary supplements for the prevention (or treatment) of concussions. --Director of FDAs Division of Dietary SupplementsNot just for Sarah PalinSnake oil stuff for concussionschocolate milk, fish oil, etc.

http://www.statnews.com/2016/01/11/chocolate-milk-concussion/Counterpoint what we can do with BSChocolate milk for instance (c baugh tweets) and its big business

For DOMS yes!For concussion no!

Fish oil, omega, etc., etc.

? DOD acupuncture TBI/OMT mTBI28Tackling in footballTackling is most common activity at time of injuryMajority of concussions result from tackling/being tackledIncidence of concussion lower in practice than gamesBut there are many more practicesIn youth (not HS/College) measured head impact forces are higher in practicesRecommendationsDecreasing # of contact practices decreases overall number of head impacts over the course of a seasonEmphasis on proper tackling technique/enforcing rules?Delay onset of tackling until a certain age?Importance of having ATCs present at schools

Pediatrics 2015AAP Policy Paper on TacklingTalk a little bit about head impact exposureCouncil on sports medicine and fitnessDrs. Meehan and Landry

Injuries (total) kids age 7 13Football 1.5/10000 AEsBaseball 1.7/10000 AEsBoys Soccer 1.7/10000 Aes

Overall AAP did not recommend a ban on tackling or football in general, decisions to participate should individualized for families, more study needed and made overall recommendation to reduce

29Helmetless tackling???!!NCAA D1 Athletes25 cases/25 controlsImpact sensorsIntervention:5 min 2x week preseason, 1x week in season, helmetless tackling drillsOutcome: 28% less head impacts

JATA 2015

A reasonable time to discuss C Nowinski precautionary principleSimilarity to smoking cigs

Avg. HS and college athletes

These drills involved multiple supervised repetition of executing proper tackling into an upright pad or teammate holding a padded shied at 50-75% effort. The athletes within the control group were separated from the intervention group and performed a placebo drill, which consisted of noncontact football skills.

http://www.sciencedaily.com/releases/2015/12/151223141443.htmhttp://well.blogs.nytimes.com/2016/01/06/how-training-without-helmets-could-reduce-head-injuries/?_r=0http://www.sportsmedres.org/2016/01/helmetless-tackling-promotes-better-tackling-behaviors.html#more

Getting a lot of press,promisingBut need to extrapolate to other divisions, hs and youth football

High school and college football athletes can experience more than 1000 head impacts in a single season. Multiple head impacts have been associated with brain injuries such as concussions and chronic traumatic encephalopathy.

30Concussion reporting HS Football Players with possible concussionsDo they report?MA & OH HS FB at seasons end[(N = 692), (Age = 16.0 +/- 1.2)]104 players with 155 concussionsOnly 56% reporting rate (2004 47%)1st string 49.3%Non 1st string 73.3% (P < 0.05)

Freshman 78.9%Sophomores 62.5%Juniors 51.6%Seniors 42.3% (P < 0.05)

Presented at AAP 2015

Reporting/educationNCH and Boston ChildrensPresented at AAP and now in BJSMThe importance of reporting, the importance of culturereporting rates tend to go down over time

Manuscript BJSM just submittedJoint project boston childrens and NCH invaluable support of OHSAA and Debbie Moore

McCrea similar study 2004 Milwaukee 47%--after 10 years of education, laws, etc.

Response rate was 47%

Not much improvement with education, something we find in public health a lotWe think that a culture of reporting, players and coaches having each others backs, is important31Putting concussions in perspective

https://www.insidehighered.com/news/2016/01/14/ncaa-establishes-best-practices-mental-health-college-athletes?utm_content=buffer6931f&utm_medium=social&utm_source=twitter&utm_campaign=IHEbuffer

New NCAA statement32

Doug Casa, Korey Stringer Institute[N = 243 (1990 2010)]Relative RisksAJSM 2013N = 243 from 1990 2010.

We reviewed the 243 football fatalities reported to the National Center for Catastrophic Sports Injury Research from July 1990 through June 2010.

Courtesy Doug Case KsI

The risk of catastrophic injury is comparable to gymnastics and lower than ice hockey33Relative Risk2694 children/teens died from guns 20101638 children < 12 died in MVAs 2013217 Football Season Fatalities, 20153Indirect: 10 (Mean = 7/last decade)4 head2 spinal cord1 organDirect: 7 (Mean = 3/last decade)SCD = 6EHS = 3Sickling crisis = 11 childrens defense fund2 CDCKorey Stringer instituteDoug Casa info50% of pediatric concussions not assoc with sportshttp://www.newswise.com/articles/view/646523/?sc=dwhr&xy=10013227

All these deaths matterand we need more numbers in the numerator tracking youth and in the denominatorgathering the data and doing better about determining true rates

34First, Lets Kill All the Lawyers the BardCrystal Dixon, et al v. Pop Warner Little Scholars, Inc... about the failure to coach the injured plaintiff in proper tackling technique and whether there was a conscious disregard for his safety based on the evidence presented.Lawmakers in MDBill to suspend coaches who return players suspected of concussions on to playing field

http://concussionpolicyandthelaw.com/2016/01/11/pop-warner-little-scholars-inc-sacked-in-waiverrelease-decision-of-interest/?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+ConcussionPolicyTheLaw+%28Concussion+Policy+%26+the+Law%29

And examples like this

http://www.athletictrainers.myindustrytracker.com/en/article/83027?utm_source=Mandrill-athletictrainers&utm_medium=newsletter&utm_campaign=Athletictrainers-2283-s-en-01021635Social Media & Hornets NestsGun safetyHands UpConcussions/CTEVaccinesPaleo DietBike HelmetsCross-FitOpen Access

Hot topicsSavaged

http://www.medscape.com/viewarticle/853336?src=wnl_edit_tpal&uac=26291AN

This is where I would plug the importance of social mediaLurkers, learners, leaders

If youre going to be a leader you may take some heat

36Weve been talking about this a long time

Football has become soft like our country has become softFootballhttp://www.newyorker.com/magazine/2016/02/01/friday-night-lights-outTeddy Roosevelt and ban of football

President obama has said if he has sons they wouldnt play football

Add in Donald Trump: crummy NFL football http://www.cbssports.com/nfl/eye-on-football/25445047/donald-trump-blasts-soft-nfl-for-being-boring-with-crummy-games

Tom Trojian Article: http://www.philly.com/philly/blogs/thinktank/On-concussions-separate-hype-from-science.html

Something in human natureeasier to destroy things, tear them down than build them upMaybe this is where I have the TR slide

Football developed organically, serves the health of lots of individuals, and Im not so sure is that dangerousCertainly we dont have the evidence now to ban it based on long term risk to our kids

n contrast to recent battles in the now 110-year war over football,Brookes piece in Huffington Post: http://www.huffingtonpost.com/brooke-de-lench/why-im-not-a-football-apo_b_8855362.htmlDanny Kannels tweet

Put this in historical context and emphasize the topicality, the topical movie, we will talk about concussions more than CTE, and we will focus on youth football including and up to high school, less so about the pros

http://www.forbes.com/sites/robertglatter/2015/12/23/the-reasons-not-to-ban-contact-sports-in-children-an-answer-to-the-concussion-movie/#2715e4857a0b2bd44345aff4

Guided risk taking/benefits of sport and structure and discipline

37You dont need a weatherman to know which way the wind blowsSurvey by the Sports and Fitness Industry Association and the Physical Activity Council: 2012 participation in organized football by players aged 6 - 14 was 4.9 percent below that in 2008.National Federation of State High School Assns: Participation in high school football was down 2.3 percent in 2012-2013 compared to the 2008-2009 season.WSJ 2013

http://www.washingtonpost.com/news/sports/wp/2015/08/19/injury-concerns-and-nfls-amplified-concussion-talk-not-scaring-americas-kids-away-from-football/As Bob Dylan said, You dont need a weatherman to know which way the wind blowsIt may be already affecting youth sports participation: wall street journal articleBig data like google: many factors, but concussion fear may be driving exit from football38The concussion crisis: If it bleeds, it leadsScientific Evidence Disseminated = Balance

The big business of concussion (look for article in gmail)at the risk of getting lambasted, attacked, science still must progress

Think about Venn Diagram Concussion perfect storm: business, litigation, risk, non quantifiable, biologically plausible (precautionary principle)

Risk we swallow the camel and we strain at the gnatSt Paul

The risk of concussions is equivalent in girls soccerdo we ban this? Cheerleading likewise has high rates

Here is where I have the slide on the intersections ofLiability/concussion, Inc/risk assessment/science

39NCH: Doing Something About ItStuart EA, Rodenberg RE, Dotson ML, et al. Reliability Measures of the Balance Error Scoring System as Administered by Certified Athletic Trainers. Heyer G, Fischer A, Wilson J, et al. Orthostatic Intolerance & Autonomic Dysfunction in Youth With Persistent Postconcussion Symptoms: A Head-Upright Tilt Table Study. MacDonald J, Wilson J, Young J, et al. Evaluation of a Simple Test of Reaction Time in Baseline Concussion Testing.MacDonald J, Duerson D. Reliability of a Computerized Neurocognitive Test in Baseline Concussion Testing of High School Athletes.High light our divisionLots of folks ginger yang, geoff heyer, gary smithED, PM&R, Sports MedJust in last year

Include our NCH resourcesBesides the stuff referenced in this talk.And several manuscripts in the works40@PediacastiTunesPediaCastPediaCast CME

2/3/16Pic of Dr. Mike and Eric B make a plugPediacast on ConcussionPublishes Feb 3just published Wed Feb 3subscribe on iTunes41Back to the movie orReading the tea leavesDont let kids play football.

.football is safer than its ever been.

The different overall takes

Julian Bailes (Alec Baldwin): Other editorial Donna sent mehttp://www.nytimes.com/2015/12/22/opinion/parents-stop-obsessing-over-concussions.html?mabReward=CTMhttp://profootballtalk.nbcsports.com/2015/12/08/dr-julian-bailes-sees-little-risk-of-cte-from-youth-football/

Bennet Omalu: The Opinion Pages|OP-ED CONTRIBUTORDont Let Kids Play FootballByBENNET OMALUDEC. 7, 2015

42Which is the pediatric public health crisis of our times?

DO WE TRADE IN FOOTBALL PADS FOR iPADS???

MGH doctor: if as a species we were as sensitive to head injury as we are currently worried about,We wouldnt have evolved

I think the greatest reasonable concern has to do with the idea of intentional head contact: body checking, heading soccer ball,Use of helmet in football allowing head to be a weapon.

Bring in yeates editorial: balance out the childhool obesity epidemic with risk for head traumaIt is less than scd or getting hit by lightning.Talk about perceptions of risk: how poor we are at it?about prevention/unclear long term risk/potential immediate catastrophic outcomeDo we stop kids boxing (AAP against it) and the school districts are cutting everything?

43ConclusionsConcussions and exposure to contact sports associated with CTE but NO cause/effect yetFar too early to draw definitive conclusions about what this means for youth footballPrecautionary principle lets work on making football saferPut in the balance the benefits of youth sportTheres more to the concussion crisis than scienceWe have A LOT more science to doConclusions cont.Consensus to limit overall head impact exposureMaintain integrity of gameAvoid unintended consequenceMost initiatives related to lessening frequency of contacte.g. helmetless hitting drillsThis ought not to be the end of youth contact sports (e.g. football)Having a concussion wont destroy your life

e.g. risk compensation with helmet or increased risk of injury from delay of introducing contact

There is consensus that lessening the frequency of contactand thus head impact exposure) is likely to be beneficial to brain health45ResourcesSCAT 3CJSM 2013; 23: 89 117 http://bjsm.bmj.com/content/47/5/259.full.pdfAAP Tackling Statement (see references)Concussion Policy & Law Bloghttp://concussionpolicyandthelaw.com/NCH Sports Medhttp://www.nationwidechildrens.org/sports-medicine-concussion-clinicCDC Heads Uphttp://www.cdc.gov/headsup/youthsports/training/

http://www.slate.com/articles/sports/sports_nut/2015/12/the_truth_about_will_smith_s_concussion_and_bennet_omalu.html

46ReferencesMcCrory P, Meeuwisse W, Aubry M. Consensus Statement on Concussion in Sport Held in Zurich, November 2012. Clin J Sport Med. 2013; 23: 89 117.Stamm JM, Koerte IK, Muehlmann M, et al. Age at first exposure to football is associated with altered corpus callosum white matter microstructure in former professional football players. J Neurotrauma. 2015; 32: 1768 1776.Meehan WP, Landry GL. Tackling in Youth Football; AAP Council on Sports Medicine & Fitness Policy Statement. Pediatrics. 2015; 136: e1419 e1430.Castellani RJ. Chronic Traumatic Encephalopathy: A Paradigm in Search of Evidence? Laboratory Investigation. 2015; 95: 576 584.Putukian M, Echemendia R, Dettwiler-Danspeckgruber A, et al. Prospective Clinical Assessment using SCAT-2 Testing in the Evaluation of Sport-Related Concussions in College Athletes. 2015; 25: 36 42.Gessel LM, Fields SK, Collins CL, et al. Concussions Among United States High School & Collegiate Athletes. J Athl Training. 2007; 42: 495 503.Savica R, Parisi JE, Wold LE. High School Football & Risk of Neurodegeneration: A Community-Based Study. Mayo Clin Proc. 2012; 87: 335 340.Meehan W, Mannix R, Zafonte R, Pascual-Leone A. Chronic Traumatic Encephalopathy and athletes. Neurology. 85: 1504 1511.Consensus Statement on Concussion in Sportthe 4th International Conference on Concussion in Sport Held in Zurich, November 2012

47