Joint Session AOFP and AOASM: Traumatic rain Injury ...– 1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force

Joint Session ACOFP and AOASM: Traumatic Brain Injury

Presentation

P. Gunnar Brolinson, DO, FAOASM

ACOFP FULL DISCLOSURE FOR CME ACTIVITIES

Please check where applicable and sign below. Provide additional pages as necessary. Name of CME Activity: 2015 AOA/ACOFP Osteopathic Medical Conference & Exposition (OMED)

Dates and Location of CME Activity: October 17 - October 21, 2015 Orange County Convention Center Orlando, Florida

Topic: Joint Session ACOFP and AOASM: Traumatic Brain Injury Sunday, October 18, 2015 9:30-10:00am

Name of Speaker/Moderator: P. Gunnar Brolinson, DO, FAOASM

DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 12 MONTHS OF DATE OF THIS FORM

A. Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing

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Organization With Which Relationship Exists Clinical Area Involved

1. NCAA – DOD CARE Consortium 1. Concussion

2. NIH 1R01NS094410-01A1 Biomechanical Basis of Pediatric mTBI due to Sports Related Concussion 2. Concussion

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Signature: Date: 9/15/2015

P. Gunnar Brolinson, DO, FAOASM

Please fax this form to ACOFP at 866-328-1835, or e-mail to [email protected] as soon as possible. Deadline: Wednesday, September 23, 2015

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Diagnosis and Management of Concussion:

Consensus and Controversies

P. Gunnar Brolinson, DO, FAOASM, FAAFP, FACOFP

Discipline Chair, Sports Medicine

Director, Primary Care Sports Med Fellowship

Team Physician, Virginia Tech

Team Physician, US Ski Team

Funding and Disclaimer

DOT: National Highway Traffic Safety Administration

Toyota Central Research and Development Labs, Inc

NIH: R01HD048638

NIH: 1R01NS094410-01A1 NCAA-DoD Care Consortium

I do not have any relevant financial relationships to be discussed, directly or

indirectly, referred to or illustrated with or without recognition within this

presentation.

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Introduction• The human brain possesses functional

complexity far beyond that of any other

organ or body part

• When injured, it is this complexity that

creates tremendous clinical challenges

for both diagnosis and treatment

• Recognizing concussion and

differentiating it from other diagnoses

can be a daunting task, but one of

critical clinical importance

• Returning the athlete to play safely is

critically important for the sports

medicine clinician

No health topic in recent memory has captured the

public’s attention as much as the debate on sports

related traumatic brain injury.

The deal calls for the NFL to pay $765 million to fund medical exams, concussion-related compensation, medical research for retired NFL players

and their families, and litigation expenses, according to a court document filed in U.S. District Court in Philadelphia.

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Concussions misunderstood and feared by most Americans

sponsorUPMC, 10/05/2015

The national survey of 2,012 Americans age 18 and over was conducted in April by Harris Poll on behalf of UPMC. The survey further showed that, despite a lack of knowledge and understanding, there is a high level of concern and even fear across the country.A fear of concussions may be impacting parents’ decisions to let their kids play contact sports

This survey was conducted online within the United States by Harris Poll on behalf of UPMC between April 16 to 23, 2015 among 2,012 U.S. adults age 18 or older, 948 of whom are parents. For complete survey methodology, including weighting variables, please contact Deana Percassi, Harris Poll, 585-214-7212.

Fears about concussion…

• 9 in 10 (89 percent) adults believe concussions are a moderate to severe health concern

• About 1 in 3 (32 percent) of parents live in fear that their child will get a concussion

• 1 in 4 (25 percent) of parents do not let their kids play some contact sports because of fear of concussion

• 2 in 5 (41 percent) adults feel that getting a concussion is a “living nightmare”


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Fears about concussion

• Many Americans (57 percent) have personal experience with concussions

• About 1 in 4 (26 percent) adults did not see a health care professional when someone in their family had one

– The vast majority of adults can’t correctly define a concussion

– Roughly 9 in 10 (87 percent) Americans do not know the definition of a concussion

– 2 in 5 (37 percent) adults admit that they are confused about what a concussion truly is

• There are varying degrees of knowledge – when it comes to understanding the symptoms of concussion

– Slightly fewer than 3 in 5 adults can correctly identify immediate symptoms of a concussion: • headache (58 percent), dizziness/motion sensitivity (58 percent), and cognitive difficulty (55 percent)

– Far fewer – roughly 1 in 3 or less – understand that the following also are symptoms: • fatigue (34 percent) and changes in mood (13 percent)


Fears about concussion• The majority of Americans do not realize that concussions are treatable

– Barely 1 in 4 (29 percent) of Americans believe that all concussions can be treated

– 79 percent of adults incorrectly believe or are unsure that there is no real way to cure a concussion; the symptoms can only be lessened

– About 4 in 5 (81 percent) Americans aren’t comfortable that they would know the steps to manage or treat a concussion if they sustained one

– Less than 1 in 5 (16 percent) adults believe there are no best practices to treat concussions

• The majority of Americans (83 percent) feel that major progress has been made in the past 10 years in assessing and treating concussions

– Only 1 in 2 (49 percent) adults know that a person does not need to stay awake for 24 hours after sustaining a concussion

– 8 in 10 (83 percent) adults believe people generally do not take concussions seriously enough


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What is a Concussion?

• Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic

biomechanical forces

• Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be

utilized in defining the nature of a concussive head injury include:

– 1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with

an impulsive force transmitted to the head

– 2. Concussion typically results in the rapid onset of short lived impairment of neurologic function that

resolves spontaneously

– 3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a

functional disturbance rather than a structural injury

– 4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of

consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course;

however, it is important to note that, in a small percentage of cases, post-concussive symptoms may be

prolonged

– 5. No abnormality on standard structural neuroimaging studies is seen in concussion

Consensus Statement on Concussion in Sport; 3rd International Conference on Concussion in SportMcCrory, P, et al. Clin J Sport Med 2009;19:185–200

What is a concussion?

• Not all athletes have the same threshold for

concussion

– But every athlete, whether previously

concussed or not, walks on to the field

of play with some inherent risk of being

concussed

• If different athletes receive the same type

and magnitude of mechanical force applied

to their brains, some will be concussed while

others will not

• Athlete’s past concussion experience,

concurrent diagnoses, physiologic state, and

family history may play roles

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Incidence of Concussion• 1.6 to 3.8 million traumatic brain

injuries/year

– 300,000 sport-related concussions

• Concussions represent an estimated:

– Up to 9% of all high school athletic

injuries

– 3-6% of interscholastic football

athletes

– 4-8% of collegiate athletes

– 7.7% of National Football League

(NFL) athletes

• 53% of concussed high school athletes

go unreported

McCrea et al, 2004

Diagnosing Concussion

• Diagnostic challenge is the fact that every concussion is unique

• Difficult to establish a single ‘‘gold standard’’ test for concussion

– Some signs and symptoms of concussion may not be present immediately, but may evolve over several hours to days after a concussive episode

• Concussion remains a clinical diagnosis based on a constellation of signs and symptoms and requires a high index of suspicion

Kutcher, J.S. and J.T. Eckner. Curr. Sports Med. Rep.,2010; 9(1): 8-15

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• “If an athlete shows concussion-like signs and reports symptoms after a contact to the head, the athlete has, at the very least, sustained a mild concussion and should be treated for a concussion.” National Athletic Trainers Association (NATA) Position Statement 2004

Halsted, M and K Walter. Pediatrics, 2010; 126 (3): 597-615.Guskiewicz, K.M. et al. J of Ath Train 2004;


• Student-athletes suspected by their coach, athletic trainer, or team physician of sustaining a concussion or brain injury in a practice or game shall be removed from the activity at that time

• A student-athlete who has been removed from play, evaluated, and suspected to have a concussion or brain injury shall not return to play that same day nor until• (i) evaluated by an appropriate licensed health care provider as

determined by the Board of Education and

• (ii) in receipt of written clearance to return to play from such licensed health care provider

VHSL legislation. 2010

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May 2012

See Montgomery County Public Schools Concussion Policy for more details

Standardized Assessment of Concussion

• Any decrease from the

baseline score on a

SAC found to be 95%

sensitive and 76%

specific for a concussion

Halsted, M and K Walter. Pediatrics, 2010; 126 (3): 597-615McCrory, P, et al. Clin J Sport Med 2009;19:185–200

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Neuropsychological Testing

• ANAM (Automated

Neuropsychological

Assessment Metrics)

• CogState

• HeadMinder

• ImPACT

• Pencil-and-paper testing

http://impacttest.com/

Gender Differences

• Data demonstrates a higher incidence for women than men

– Soccer, basketball and ice hockey

• Several studies in 2009-10, concluded that female soccer players performed worse than males on post-concussive neurocognitive testing

• Women also were shown to report more post-concussive symptoms

• The explanation of this trend is unknown and may include biomechanical, hormonal, and cultural factors

Colvin AC, et al. Am. J. Sports Med. 2009; 37:1699-1704Preiss-Farzanegan SJ, et al. PMR. 2009; 1:245-53Blinman TA, et al. J. Pediatr. Surg. 2009; 44:1223-8Halsted, M and K Walter. Pediatrics, 2010; 126 (3): 597-615Broglio, SP, et al. Journal of Athletic Training 2009;44(4):342–349

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Concussion Biomechanics

• Heading a soccer ball can result in head accelerations

– From 16 to 20g lasting 25 ms

• The average collegiate football impact– From 21 and 32g lasting 14-15 ms

• Impacts to the top of the head yielded the greatest linear acceleration and impact force magnitude

– Improper tackling techniques

• Offensive and Defensive line players sustained the lowest-magnitude impacts but the highest number of impacts during games and practices

Rowson, S et al. Presented at Rocky Mountain Bioengineering Symposium & International ISA Biomedical Sciences Instrumentation Symposium 17-19 April 2009, Milwaukee, Wisconsin, www.isa.orgHalsted, M and K Walter. Pediatrics, 2010; 126 (3): 597-615Broglio, SP, et al. Journal of Athletic Training 2009;44(4):342–349

Concussion Biomechanics

• Over 200,000 head impacts recorded at Virginia Tech

– Games (30%)

– Practice (70%)

– Twelve years of data collection: 2003-2015

• Clinically diagnosed concussive impacts recorded for instrumented players

• Unbiased exposure data

– Previous football work

over-sampled injury data

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Example MTBI Event

Peak G = 136 G

Example MTBI Event

Clinically diagnosed concussion

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Another Example MTBI Event

Peak G = 139 G

Another Example MTBI Event

Clinically diagnosed concussion

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Children

• The developing brain has a unique set of

physiologic variables that are changing continuously

as children grow

• It is unclear how ongoing brain development affects

a child’s susceptibility to concussion

• Nonetheless, we are more careful when making

return-to-play decisions in children because of the

uncertainty of dealing with a developing brain

– Patient’s baseline cognitive function**

– Potential unreliability of pediatric patients in

reporting subjective symptoms

• Input of parents, teachers, and coaches, may be

helpful, to provide additional clarity as to the history

Kutcher, J.S. and J.T. Eckner. Curr. Sports Med. Rep.,2010; 9(1): 16-20Halsted, M and K Walter. Pediatrics, 2010; 126 (3): 597-615

6 to 13 years old 3,500,000 Players

High School 1,300,000 Players

College 100,000 Players

NFL 2,000 Players

5,000,000 Football Players in US

Majority of football players are between 6 and 13 years old

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0 20 40 60 80 100

0

50

100

150

200

250

300

350

400

Peak Resultant Linear Acceleration (g)

Num

ber

of Im

pacts

Youth Linear Acceleration Distribution

Median = 15 g

95th Percentile = 40 g

Peak = 100 g

21 impacts over 50 g6 impacts over 80 g

0 2000 4000 6000 8000

0

50

100

150

200

250

300

350

400

Peak Resultant Angular Acceleration (rad/s2)

Num

be

r o

f Im

pa

cts

Youth Rotational Acceleration Distribution

Median = 670 rad/s2

95th Percentile = 2342 rad/s2

Peak = 7694 rad/s2

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What kinds of impacts do we see in practice?

What kinds of impacts do we see in games?

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What kinds of impacts do we see in games?

Pop Warner Football

• June 2012– Pop Warner issued new rules that put restrictions on the

amount of contact players can have in practice.

– Jon Butler, the executive director of Pop Warner, said that research would continue to drive the organization’s rules changes as it tries to limit concussions.

– has more than 285,000 children ages 5 to 15 in its leagues.

– it has produced more than two-thirds of the players now in the National Football League.

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Pop Warner Football

• Rules Changes for 2012 Season– contact will not be allowed for

two-thirds of each practice• 9 hours total practice time each

week so can have full contact 3 hours

– no drills that involve full-speed, head-on blocking and tackling that begins with players lined up more than three yards apart

– No intentional head to head contact

Identifying High-Risk Head ImpactsYear 1

Majority of high head acceleration impacts occurred during practice

Pop Warner instituted new rules to limit contact in practices

Year 2

Compared teams that adopted new rules with teams that didn’t

Observed nearly a 50% reduction in head impact exposure

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Football Age Group Comparisons

6 to 13 years old3,500,000 Players

High School1,300,000 Players

College100,000 Players

NFL2,000 Players

1000

565

107

Impacts

per

Season

19

18

15

50th %

Accel.

(g)

68

56

40

95th %

Accel.

(g)

Concussion Pharmacology

• Common recommendation that NSAIDs or aspirin be

avoided immediately after a suspected head injury for

fear of potentiating the risk of intracranial bleeding

• Pharmacotherapy may be considered for those athletes

with more prolonged symptoms such as difficulty

concentrating, headache, sleep disturbances, and

depressionThe specific therapy is based on the symptoms you are treating

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Cognitive Rest• Athletes with concussion often have difficulty

– Attending school

– Focusing on schoolwork and taking tests

– Especially in math, science, and foreign-language classes

– Reading, even for leisure, commonly worsens symptoms

• Rest may include

– A temporary leave of absence from school

– Shortening of the athlete’s school day

– Reduction of workloads in school

– Allowance of more time for the athlete to complete assignments or take tests

• Other activities that require concentration and attention, including playing

video games, using a computer, and viewing television, should also be

discouraged

A Review of Return to Play Issues and Sports-Related ConcussionDoolan, Brolinson, et al Annals of Biomedical Engineering, Vol. 40, No. 1, January 2012 pp. 106–113

Cognitive Rest…what you might

not know about…• A recent poll of concussed

high school athletes found them engaging in the following activities during “recovery”:

– Snowboarding

– Running a 5 km race

– Playing touch football

– Prolonged use of electronic visual interfaces

• Texting, emailing, You Tube, watching movies

Art Maerlender: Personal Communication

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Physical Rest

• Broad restrictions of physical activity should be recommended– Including the sport or

activity that resulted in the concussion

– Any weight training

– Cardiovascular training

– Physical education classes

A Review of Return to Play Issues and Sports-Related ConcussionDoolan, Brolinson, et al Annals of Biomedical Engineering, Vol. 40, No. 1, January 2012 pp. 106–113

Risk of Recurrence• Significantly increased risk of sustaining a repeat concussion when an

athlete is still recovering from a previous concussive injury

– A second impact, often of less or even minimal force, then produces signs and symptoms that can be much more severe

– In extreme cases, it is likely that this same scenario produces the ‘‘second impact syndrome’’

• Pediatric and Adolescent athletes seem to be a greatest risk

• Guskiewicz et al. showed that high school football players who suffered a concussion were three times more likely to sustain a second concussion during the same season

• Delaney, et al. showed that athletes who experienced concussion with a loss of consciousness were six times more likely to sustain another concussion than those who had been concussed but never lost consciousness

Guskiewicz K, et al. Am. J. Sports Med. 2000; 28:643-50Delaney J,et al. Clin. J. Sport Med. 2000; 10:9-14

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Mood Disorders

• Anxiety and depression are well recognized to occur after traumatic brain injury

– Active disagreement as to the degree of causative effect

– Retired football players reporting a history of 3+ previous concussions were 3X more likely to be diagnosed with depression

• No study has been published that suggests patients with a preexisting mood disorder such as depression or generalized anxiety are at a higher baseline risk of being concussed


Guskiewicz et al. Neurosurgery. 2005;57: 719-24

Concussion Associated Brain

Dysfunction

• Retired football players reporting

a history of 3+ previous

concussions were 5X more likely

to be diagnosed with mild

cognitive impairment

• Increased prevalence of

Alzheimer’s Disease in

retired football players

Guskiewicz et al. Neurosurgery. 2005;57:719-24

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Migraine Headaches

• It is possible that migraine headache is a risk factor for concussion

• It also is possible that concussion leads to the development of migraine headaches

– Or that migraine headaches are being misdiagnosed as concussions

• Athletes with migraines may have more severe and prolonged concussion courses after injury


Review of all of the evidence based scientific

literature related to athletes with multiple

concussions and return to play…

• There isn’t any…

• “Studies of management of concussion were so poor…”

• So what do we do?

• Rely on “Expert Opinion” based on clinical practice, the relevant available medical and scientific literature and currently available diagnostic testing.

Schneider KJ, Iverson GL, Emery CA, et al. The effects of rest and treatment following sport-related concussion: a systematic review of the literature. Br J Sports Med. 2013;47:304–307.

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Return To Play

• Return-to-play decisions are made with the risks of possible

symptom exacerbation and prolongation of recovery,

subsequent concussion, or catastrophic injury in mind

McCrory, P, et al. Clin J Sport Med 2009;19:185–200

A Review of Return to Play Issues and Sports-Related Concussion Doolan, Brolinson, et al Annals of Biomedical Engineering, Vol. 40, No. 1, January 2012 pp. 106–113

Return to Play

• Athletes at a variety of levels of participation will have a series of baseline physiologic parameters that can aid clinicians as they begin the step wise rehabilitative protocol.

• A variety of speed, power and agility data are usually collected.

• Our experience is that athletes can usually begin the progression at about 75% of their typical maximum effort and gradually progress

• This provides objective data to initiate the protocol as well as gauge the athlete’s progress.

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RTP…Other Considerations• Age

– discussed above…generally more conservative

• Must rely more on input from parents and coaches

• Social Pressure– Teammates, coaches and parents

• Multiple Concussions– No specific number has been established to mandate season ending injury or retirement.

– Worrisome group

• Decreased time between concussions

• More prolonged recovery from each subsequent concussion

• Concussions resulting from progressively decreased biomechanical forces

• Persistent Headache– Must differentiate “post concussive” from “cervicogenic” or “cranial” dysfunction

– Consider PT/OMT to address cervical and upper thoracic dysfunction

• With these last two groups may need to consider full neuropsych evaluation as well as other

testing as indicated

Other Considerations• Do “supplements” help?

– Maybe….– There are studies underway.

• Role Of DHA (theory)– Docosahexaenoic acid – The major Omega 3 fatty acid– DHA indirectly protects neurons from axonal injury

and cell death by reducing the inflammation caused by brain trauma

– DHA directly protects neurons against apoptosis or cell death

– DHA may counter head injury-induced cognitive impairments including memory via its role in synaptic transmission

• Dosage– 2 grams daily (1 gm BID)

Bailes et al; J of Neurotrauma 27: 1617-1624 (Sept 2010) DHA reduces traumatic axonal injury in a rodent head injury modelYurko-Mauro et al: Alzheimers and Dementia (2010) Beneficial effects of DHA in age related cognitive decline

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Does “Advanced Imaging” help? Maybe….

• Functional MRI– Measures neuronal

glucose uptake while the patient performs a “task” in the magnet

– Can see changes in brain activation patterns for “acutely injured” patients vs controls

Does “Advanced Imaging” help? Maybe….

• Diffusion Tensor Imaging– can identify structural changes in the

white matter of the brain that

correlates to cognitive deficits even in

patients with mild traumatic brain

injury.

– When white matter is damaged, other

areas of the brain may appear healthy

but they are actually "unplugged" and

cannot function optimally.

Kraus, Little, Susmaras et al; Brain: Oct 2012

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Future Diagnostic Considerations

• Biomarkers– term often used to refer to a protein measured in blood whose

concentration reflects the severity or presence of some disease

state.

– Troponin is a biomarker used to diagnose acute myocardial

infarction (AMI) in Emergency Rooms

Banyan Biomarker Panel for TBI

52

Glial Fibrillary Acidic Protein Ubiquitin Carboxyl-Terminal Esterase L1

• Structural protein of the intermediate

filament of Astroglia 50 kDa

• Highly enriched in the nervous

system.

• 1% of total brain protein

• Small compact 24 kDa protein

• Expressed at a high level in neurons

• 5% of total brain protein

GFAP UCH-L1

GFAP dimer

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TBI study

53

Acad Emerg Med. May 2008

Levels of Serum GFAP Are Associated With Severity Of Injury In Patients With Mild And

Moderate Traumatic Brain InjurySUMMARY:

GFAP was systematically assessed in human serum

following mild and moderate TBI.

GFAP levels were significantly elevated in this

population using ELISA analysis, including those

with mild TBI.

GFAP was able to discriminate TBI patients from

uninjured controls and serum levels were able to

distinguish orthopedic and motor vehicle controls

form TBI patients

Mild and moderate TBI study (GFAP)

54

Annals of Emergency Medicine

May 29, 2011

Elevated Levels of Serum Glial Fibrillary Acidic Protein Breakdown Products in

Mild and Moderate Traumatic Brain Injury Are Associated With Intracranial

Lesions and Neurosurgical Intervention

SUMMARY:

GFAP-BDP is detectable in serum within an

hour of injury

It is associated with measures of injury severity,

including the GCS score, CT lesions, and

neurosurgical intervention.

Further study is required to validate these

findings before clinical application.

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Mild and moderate TBI Study (UCHL-1)

55

Journal of Neurotrauma

July, 2011

Serum levels of UCHL-1 distinguishes mild and moderate traumatic brain

injury from trauma controls and is associated with lesions on computed

tomography.

SUMMARY:

UCHL-1 was detected in the serum of mild and

moderate TBI (MMTBI) patients within an hour of

injury

What about repetitive “sub concussive” impacts?

• Millions of individuals have played contact sports for many years without obvious functionally significant adverse effects, and without developing progressive neurodegenerative disorders.

• Nevertheless, we are concerned that repetitive head impacts may have an adverse effect on some athletes.

– It is reasonable to speculate that individual differences such as polymorphisms in genes modulating response to neurotrauma39 (e.g., APOE, BDNF, ANKK1) or other host factors may play a role

– it is tempting to hypothesize that risk of chronic traumatic encephalopathy or other long term effects of contact sports may represent a gene–environment interaction between repetitive mild neurotrauma and genetic vulnerability to heightened injury response or attenuated neural repair.

McAllister TW, Flashman LA, Maerlender AC, Greenwald RM, Beckwith JG, Tosteson TD, Crisco JJ, Brolinson PG, Duma SM, Duhaime AC, Grove MR and Turco JH. “Cognitive Effects of One Season of Head Impacts in a Cohort of Collegiate Contact Sport”. Neuro. 2012 May 29;78(22):1777-84.

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HS Football and Risk of

Neurodegenerative Disease• To assess whether high school football played between

1946 and 1956, when headgear was less protective than today, was associated with development of neurodegenerative diseases later in life.

• Compared 438 FB players to 140 non FB players from HS in Rochester, MN

• High school students who played American football from 1946 to 1956 did not have an increased risk of later developing dementia, PD, or ALS compared with non–football-playing high school males, despite poorer equipment and less regard for concussions compared with today and no rules prohibiting head-first tackling (spearing).

• These results should be somewhat reassuring to high school players from 50 years ago, they should give no reassurance to today’s players.

High School Football and Risk of Neurodegeneration: A Community-Based Study; Savica, Parisi et al; Mayo Clin Proc. 2012;87(4):335-340

Post Concussion Syndrome• This Dx is a function of the

length of symptom persistence– 3 months duration of at least 3

symptoms

• Retired NFL players who were diagnosed with post-concussion related depression

– 87% continued to have lifelong symptoms

• Medications that address symptoms may be considered in the treatment of PCS

– Dosing should begin low and titrated upward slowly

Jotwani, V et al. Curr. Sports Med. Rep.; 2010; 9 (1): 21-26Halsted, M and K Walter. Pediatrics, 2010; 126 (3): 597-615

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Summary of Gunnar’s clinical

treatment Pearls for PCS• Remember that dx and tx is a “team

event”– Psychologists, neurologists, PM&R, PT’s

and ATC’s can all be involved

• You are treating “symptoms”

• For mild insomnia with head/neck pain– Flexeril 10mg at hs

– Elavil 10-25mg at hs

• For headache– NSAIDs

– Topamax 25-50mg BID

• For depression with diffuse “body pain”– Effexor and Cymbalta (SNRI’s)

– Tricyclics

– SSRI’s don’t seem to work well

• For “fogginess”– Omega 3 supplements

– Antioxidants• Alpha Lipoic Acid 100mg QD

• B Complex

– Amantadine• 100-200mg BID

• Remember to include physical therapy and neurocognitive rehab as appropriate

• In general avoid narcotics

Placebo-Controlled Trial of Amantadine for Severe Traumatic Brain Injury; Gianco et al; N Engl J Med 2012; 366:819-826March 1, 2012DOI: 10.1056/NEJMoa1102609

What is Chronic Traumatic

Encephalopathy???• Dementia Pugilistica…

– “Punch Drunk Syndrome”

– Dr. Harrison Martland 1928

– CTE with Post Traumatic Encephalopathy

• Accumulation of Tau Protein in neurologic tissue– Genetically determined?

– Head trauma triggered?

– “Over-production” vs “Inadequate Clearance”?

– A progressive neurodegenerative syndrome

• A composite syndrome of mood disorders – associated neuropshychiatric and cognitive

impairments

• Is NOT Alzheimer’s Disease– Not associated with cerebral atrophy

• Relationship to Lou Gehrig's Disease?

• Definitive Diagnosis by direct tissue analysis post mortum

BU Center for the Study of Traumatic Encephalopathy

Brain tissue from 18-year-old multi-sport athlete

http://www.nejm.org/toc/nejm/366/9/

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What is Post Traumatic Encephalopathy?

• A clinicopathologic syndrome that follows focal

or diffuse brain trauma

– Associated with gross or microspcopic

destruction of brain tissue

– Lacerations, contusions, hemorrhages, etc

• Not neurodegenerative and not progressive

• Can co-exist with CTE

Clinical Considerations for Athletes

with Multiple Concussions• To date, no specific number of concussions has been established to

mandate season ending injury or retirement.

• Experts understand that repetitive concussions can be associated with significant and prolonged neurocognitive deficits – decreased time between concussions

– increased recovery time

– concussions resulting from decreased biomechanical forces

• Clinicians may wish to consider a full neuropsychological evaluation and the use of advanced diagnostics and imaging techniques in these athletes.


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with Multiple Concussions• When to remove an athlete from the competitive season or

recommend permanent retirement from competition?– Must be managed in on individualized basis and multiple factors taken

into account

– Utilize the sports medicine team and appropriate diagnostic modalities• “One opinion is no opinion”

“The current literature is unclear and contradictory regarding specific therapeutic approaches. Sports clinicians are left to develop an approach to management of concussion that is based on currently available best practices that have little scientific evidence to support them.”

P.G. Brolinson; management of sport related concussion review and commentary; Clin J Sport Med Journal Club issue 24(1) -Jan 2014.


with Multiple Concussions

Remove for Season• Prolonged post concussive

symptoms

• 3 “simple” concussions in a single season

• 2 or more “complex” concussions in a single season

• decreased academic and athletic performance

• clinically relevant imaging abnormality.

Career Ending• Pathologic abnormality such as Chiari

malformation

• Intracranial hemorrhage

• Clinically relevant imaging abnormality

• Diminished academic performance or cognitive abilities

• Persistent prolonged post-concussion syndrome

• Decreased threshold for concussion

• 3 or more “complex” concussions during career

• Persistent neuropsychiatic symptoms


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Star Football Helmet Ranking System

• STAR is first system to account for ALL impacts over the course of a season– 1000 impacts– Four directions– Six severity levels

• Weighted values based on exposure– Higher weights for lower

severity given the higher number of lower impacts

Development of the STAR evaluation system for football helmets: integrating player head impact exposure and risk of concussion. Rowson S, et al. Ann Biomed Eng. 2011 Aug;39(8):2130-40. Epub 2011 May 7.

STAR Testing Process

For each model, 3

new helmets are

tested twice at the

20 STAR matrix

(2x20x3 = 120)

The two peak

accelerations

for each testing

configuration

are averaged.

A STAR value

for each helmet

is determined

from the average

accelerations for

that helmet.

The overall STAR

value is determined

by averaging the

three Individual

STAR values.

Statistical significance between helmet models is

determined using the average and variance in the three

individual STAR values.

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2014 STAR FB Helmet Ratings

For complete results and summary PDF visit: http://www.beam.vt.edu/helmet/helmets_football.php

• Collins et al. (2006)

• Studied over 2000 high school players

• Riddell Revolution reduced risk of concussion by 31% (p = 0.027)

• Virginia Tech Clinical Data (2005 - 2010)

• Studied over 250 college football players

• Riddell Revolution reduced risk of concussion by 85% compared to Riddell VSR4 (p = 0.03)

• STAR Evaluation System

– Developed from data on over 100,000 head impacts

– Predicts Riddell Revolution reduces risk of concussion by 54% compared to Riddell VSR4

Clinical Validation of STAR

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Clinical Validation of STAR

Riddell Revolution

STAR Value

0.362

Riddell VSR4

STAR Value

0.791

3 different studies show differences between helmets

in ability to reduce concussion risk with Revolution

Collins

31%

STAR

54%

VT

85%

>

Lab and clinical agreement on ability to reduce

concussion risk

Journal of Neurosurgery 2014

Data compiled from 8 collegiate football teams

1833 players over 6 years

Exposure controlled

Clinical Evidence

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Consider Two Helmets

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 50 100 150 200 250 300 350

Pro

babi

lity

of M

TBI

Linear Acceleration (g)

Which helmet would you choose?

Helmet A

Helmet BFor Identical Impacts:

Helmet A90 g1% risk of concussion

Helmet B200 g59% risk of concussion

Football Helmet Evolution

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Legislating Risk

• Former British prime minister Harold Macmillan said, "To be alive at all involves some risk."

• Yet, some lawmakers on this side of the Atlantic want to remove all risks for high school athletes through restrictive legislation, with concussions being the flavor of the month.

• The Federal Government has also gotten involved in the concussion debate and the Government Accountability Office (GAO) published its report on the testimony given before the committee on education and labor of the House of Representatives on May 20th 2010.

• Texas (2007), Washington and Oregon (2009) passed the first concussion-specific laws addressing scholastic sports.

• Washington’s law was named after Zackery Lystedt, a teenager who in 2006 sustained a serious brain injury while playing football.

• One problem with this legislation are the costs of implementing such a program which would include athletic trainers present at all practices and games as well as physician coverage for games.

Erik Simpson and Brent CranePosted 04/26/2011 08:21:41 PM | USA Today

Legislating Risk

• Since 2009 44 Sates and DC have enacted youth sports TBI laws aimed at increasing awareness or reducing risk of repeat injury or both.

• These laws represent a uniform but not scientifically proven consensus about the minimum time a young athlete should refrain from reentering contact sports activities.

• Also exhibit divergence regarding the health care professional best qualified to make the RTP decision.

• Existing youth TBI laws are not designed to reduce initial TBIs. Continued research and evaluation of existing laws will be needed to develop a more comprehensive risk reduction program.

Harvey, H; American Journal of Public Health: May 16, 2013

http://content.usatoday.com/topics/topic/Harold+Macmillan

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VHSL• The established policies shall require:

– An annual review of concussion information provided by the school division to both student-athletes and parents/guardians.

– After reviewing the short and long term health effects of concussions, each student-athlete and the student-athlete’s parent or guardian shall sign a statement acknowledging receipt of such information, in a manner approved by the Board of Education

– Student-athletes suspected by their coach, athletic trainer, or team physician of sustaining a concussion or brain injury in a practice or game shall be removed from the activity at that time. A student-athlete who has been removed from play, evaluated, and suspected to have a concussion or brain injury shall not return to play that same day nor until (i) evaluated by an appropriate licensed health care provider as determined by the Board of Education and (ii) in receipt of written clearance to return to play from such licensed health care provider

• It is strongly encouraged that the language included in any policy adopted by a school/school division for 2010-2011 reference practice as well as contest situations

• VHSL strongly recommends that all coaches, student-athletes and parents / guardians of athletes take the NFHS “Concussions in Sports – What You Need to Know” Course http://www.nfhslearn.com/electiveDetail.aspx?courseID=15000

NCAA• “Institutions shall have a concussion management plan on file such that a

student-athlete who exhibits signs, symptoms or behaviors consistent with a concussion shall be removed from practice or competition and evaluated by an athletics healthcare provider with experience in the evaluation and management of concussion. Student-athletes diagnosed with a concussion shall not return to activity for the remainder of that day. Medical clearance shall be determined by the team physician or their designee according to the concussion management plan.

• In addition, student-athletes must sign a statement in which they accept the responsibility for reporting their injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions. During the review and signing process student-athletes should be presented with educational material on concussions.”

-- NCAA Memorandum

April, 2010

www.ncaa.org/health-safety

http://www.nfhslearn.com/electiveDetail.aspx?courseID=15000

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Summary• Data suggest that female athletes may have a higher incidence of concussion and experience

more severe concussive symptoms

• We are just now beginning to research and understand risk and clinical implications for concussion in youth sports

• The presence of preexisting mood or learning disorders can confound pre-injury baseline testing as well as concussion diagnosis and management

• Multiple concussions are associated with increased risk of:– Mood disorders (anxiety and depression

– Cognitive dysfunction

• Migraine headache and concussion have similar presentations– Athletes who have migraines also may be at a higher risk of being concussed but not know if this is a “cause and effect”

relationship

• The genetics of concussion remain a mystery, and the role of factors such as the ApoE promoter gene are being investigated

• Brain Biomarkers and Advanced Imaging Technologies are an emerging area of research for enhancing our clinical diagnostic capability

• There are some data to suggest that concussion risk may increase as an athlete fatigues or if he or she continues to participate in the sport after sustaining an initial mild traumatic injury

• Regarding helmets…more padding is more better!

Prevention• Education and recognition remain the most important components

• Proper tackling technique (“Heads Up” “See what you hit”)

• Various mouth guards have been studied, none have conclusively

demonstrated that they reduce the risk of concussion

• Helmets in sports have been shown in laboratory studies to reduce impact

forces to the head

– Soccer headgear studies are inconclusive regarding the ability to

protect from concussion

• Headgear seems to protect against soft-tissue injuries, such as

lacerations, contusions, and abrasions, and is more likely to be

worn by female soccer players

• However, reduction in concussion incidence has not been

consistently seen

• Newer football helmet technology in high school and collegiate athletes,

which demonstrated a decrease in relative risk and a decrease in absolute

risk for sustaining a concussion

– STAR Football Helmet Ranking system

McCrory, P, et al. Clin J Sport Med 2009;19:185–200

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Recommendations

• Educate student-athletes annually

• Educate coaches and staff annually

– http://www.cdc.gov/concussion/HeadsUp/online_training.html

– http://www.nfhslearn.com/electiveDetail.aspx?courseID=15000

• Educate parents annually

• Develop an Action Plan

• Preventive action

– Educate

– Proper Coaching

– Neck strengthening

– Baseline concussion symptom score (at PPE)

– Baseline neuropsych testing of some type (at PPE)

– Baseline balance testing (at PPE)

• Reduce the number of hits and severity in practice and games (rules enforcement)

• Returning athletes to play safely is complex and based on a number of clinical and diagnostic variables and is best done utilizing a “team approach”

All Data and Reports Online

http://www.vcom.vt.edu/sportsmed/

http://www.cdc.gov/concussion/HeadsUp/online_training.html

http://www.nfhslearn.com/electiveDetail.aspx?courseID=15000

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All Data and Reports Online

www.SBES.vt.edu

Documents

Joint Session AOFP and AOASM: Traumatic rain Injury ...– 1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force