New Frontiers in Sports Concussion

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1 New Frontiers in Sports Concussion Sports Medicine and Performance Summit 22 October2016 William Haug, Jr., MD, CAQSM Advanced Orthopedics Altru Health System

2 Disclosures No Disclosures to report

7 Objectives Guidelines and classification Investigation and emerging research Return to Play

8 It s not dangerous to play with a concussion, said Kelby Jasmon, a senior twoway player for his high school in Springfield, Ill., who has had three concussions. You ve got to sacrifice for the sake of the team. The only way I come out is on a stretcher. September 15, 2007, NY Times

10 National Football League August 2013 Ex-players agree to $765 million settlement Frontline

11 Ivy League Moves to Eliminate Tackling at Football Practices So Many Sports, So Little Time: Texas High School Athletes Opt Out Of Football Pop Warner Youth Football League Settles First Concussion-Related Lawsuit (Joseph Churnach)

13 Suicide Mortality Among Retired National Football League Players Who Played 5 or More Seasons CDC May 2016 Suicide among this cohort of professional football players was significantly less than would be expected in comparison with the United States population (SMR = 0.47; 95% CI, ). There were no significant differences in suicide mortality between speed and non speed position players. Published online before print May 5, 2016, doi: / Am J Sports Med May 5,

14 General Principles Head injuries may be undetected underreported untreated

15 Effects of Head Injury Cerebral Concussion Cerebral Contusion Epidural Hematoma Subdural Hematoma

16 Cerebral Concussion The most common consequence of head injury in sports

17 Vienna Group Definition (2001) Sports concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.

18 How many Concussions occur each A. 1.6 million to 3.8 million B. 500,00 to 900,000 C. 2.4 Billion to 5 Billion D. Less than 500,000 year?

19 American Medical Society for Sports Medicine position statement: concussion in sport DIAGNOSIS OF CONCUSSION: Concussion remains a clinical diagnosis ideally made by a healthcare provider familiar with the athlete and knowledgeable in the recognition and evaluation of concussion Use of graded symptom checklists and standardized assessment tools provide a helpful structure for the evaluation of concussion. SIDELINE EVALUATION AND MANAGEMENT: Any athlete suspected of having a concussion should be stopped from playing and assessed by a licensed healthcare provider trained in the evaluation and management of concussions Imaging is reserved for athletes where intracerebral bleeding is suspected. There is no same day RTP for an athlete diagnosed with a concussion.

20 American Medical Society for Sports Medicine position statement: NEUROPSYCHOLOGICAL TESTING: concussion in sport Neuropsychological (NP) tests are an objective measure of brain behavior relationships RETURN TO CLASS: Students will require cognitive rest and may require academic RETURN TO PLAY: Concussion symptoms should be resolved before returning to exercise. A RTP progression involves a gradual, step-wise increase in physical demands, sports-specific activities and the risk for contact

21 American Academy of Pediatrics Position Statement on Concussions Coaches and Athletic Trainers should be trained in the identification of concussions, and refer any student athlete suspected of sustaining a concussion to a licensed physician, such as a pediatrician, neurologist, primary care sports medicine specialist, or neurosurgeon with expanded knowledge and experience in pediatric concussion management for evaluation. Pediatricians and other physicians can be an important resource in educating coaches, athletic trainers, and other adults that work with young athletes in recognizing the signs of concussion injuries and when to seek medical attention for their athletes. A team approach consisting of the child or adolescent athlete s pediatrician and medical team, the school team, and the family team to assist the student in his or her return to learning is ideal.

22 AMERICAN ACADEMY OF NEUROLOGY POSITION STATEMENT ON SPORTS CONCUSSION Recommendations Any athlete who is suspected to have suffered a concussion should be removed from participation until he or she is evaluated by a physician with training in the evaluation and management of sports concussions No athlete should be allowed to participate in sports if he or she is still experiencing symptoms from a concussion. Following a concussion, a neurologist or physician with proper training should be consulted prior to clearing the athlete for return to participation. A certified athletic trainer should be present at all sporting events, including practices, where athletes are at risk for concussion.

23 Concussion Video 1

24 Journal of Pediatrics 144,000 ED visits annually in pediatric population to age of 21 69% males 30% sports related 33% had no follow-up Most undergo CT Dec 2010

University of Ottowa JAMA March 2016 5-18 years of age 3,000 children Persistent post concussive

25 University of Ottowa JAMA March years of age 3,000 children Persistent post concussive symptoms Low, medium or high clinical risk score 2016 Mar 8;315(10): doi: /jama

26 Concussion Rates by Sport in Twin Cities area Minnesota Department of Health 2014

27 Boston University Center for the study of Traumatic Encephalopathy Brandi Chastain 1999 World Cup

28 John Grimsley Former Linebacker for the Houston Oilers and Miami Dolphins, who died in February 2008 at the age of 43. Confirmed CTE Immunostained for tau protein

29 65 year old control study

30 Chronic Traumatic Encephalopathy

31 Early evidence of CTE in the youngest case to date, a deceased 18-year-old boy who suffered multiple concussions in high school football.

32 Complex Physiology Abnormal energy metabolism Low cerebral blood flow Mitochondrial function decreases Increased glucose use Magnesium decreases Increased lactate ATP decreases Neurosurgery 75 S24-S

concussions impart a cumulative effect, producing

33 Athletes suffering 3 concussions are at a 3 fold greater risk of suffering a repeat concussion Repeat concussions impart a cumulative effect, producing symptoms of increasing severity and duration Consequences

34 Effects of Repeated Concussions Post Concussive Syndrome Dementia Pugilistica Second Impact Syndrome (SIS) Post-traumatic Seizures Traumatic Encephalopathy Chris Nowinski

35 Case Study by Kevin Guskiewicz, PhD, ATC 2005 University of North Carolina: 20-year-old Division I football defensive end Concussion #1: August 14, 2004 Concussion #2: October 16, 2004

36 Accelerometry Instrumentation Head Impact Telemetry System (HITS) Sensors embedded in the padding of helmet Measures and records blows to the head: Impact location Impact magnitude Impact duration Linear and angular acceleration components Exact times of impacts

37 Concussion #1: August 14, 2004 Clinical Findings At the time of injury player reported experiencing 16 of 18 concussion symptoms on the Graded Symptom Checklist (GSC). SAC and BESS performed on the sideline revealed moderate deficits. Follow-up computerized neuropsychological (NP) and postural stability (PS) testing revealed moderate deficits through post injury day 3.

38 Symptoms resolved over the course of 5 days, and he was returned to restricted participation, followed by full participation at post injury days 6 and 7 respectively.

39 ImPACT Data: Concussion #1 All 4 significant impacts 2 in morning session (79.18 & g) 2 in evening session (64.51 & g)

40 Concussion #2: October 16, 2004 Clinical Findings Reported 13 of 18 concussion symptoms at the time of injury. Symptoms lingered for 10 days, with drowsiness, fatigue, and dizziness being the most persistent symptoms. Sideline SAC and BESS scores were again moderately depressed, however, serial assessments of NP tests were significantly depressed during the initial 4 days post injury.

41 An MRI was not conducted as part of the Treatment. However, the player was evaluated by the team physician daily to detect signs of any neurological deterioration. Player withheld for 15 days before being permitted to return to full participation.

42 ImPACT Data: Concussion #2 6 total impacts Between g to g (mean = g)

43 Concussion Video 2

44 Conclusions Raises several intriguing questions with respect to sportrelated concussion: 1) was there a cumulative effect on the initial injury day, since there were two significant impacts during the morning practice? 2) could the threshold for injury be lowered because of these repetitive loads to the brain? Acute cumulative effect of sub-concussive impacts 3) was the delayed symptom recovery and depressed NP scores following the repeat concussion a result of a more chronic cumulative effect, or simply a result of the increased magnitude (102 g)?

47 Concussion Classification Schemes Cantu (1986) Colorado (1991) AAN (1996) Vienna (2001) Prague (2004) Zurich (2008) Zurich (2012)

48 Fourth International Conference on Concussion in Sport, Zurich 2012

49 Zurich Meeting 2008 Recommended injury grading scales be abandoned Severity determined in retrospect

50 A true concussion involves loss of consciousness A. True B. False

51 Loss of Consciousness Limited in assessing the severity of a sports concussion Its presence does not necessarily classify the concussion as complex Only 10% sport related concussion have LOC longer than 1-2 seconds

52 Significance of Amnesia Presence or duration may be associated with slower recovery, but not all studies confirm this

53 Zurich Classification 2008 Simple Complex

54 How long does it take for concussion symptoms to develop? A. Symptoms develop immediately B. It can take hours for symptoms to develop. C. It can take days for symptoms to develop. D. The onset of symptoms varies depending on the person and injury. Symptoms may appear immediately or within hours or days of the event.

55 Simple Concussion Progressively resolves without complication over 7 10 days

56 Complex Concussion Persistent symptoms or sequelae (concussive convulsions, prolonged loss of consciousness or cognitive impairment ) May include multiple concussions over time (with progressively less force)

57 Balance Headaches Cognition Confusion Amnesia Loss of Consciousness Motor Typical Symptoms

58 Which tool is NOT used on the sideline for diagnosis of concussions? A. SCAT3 B. King-Devick C. MACE D. CAPP E. BESS

59 Sport Concussion Assessment Tool A standardized approach to assessment and management of concussion Produced as a result of Prague conference in 2004 (SCAT)

60 Sport Concussion Assessment Tool (SCAT3) Signs Memory Symptom Score Cognitive Assessment Neurologic Screening Return to play

62 M-BESS Modified Balance Error Scoring System (M-BESS) Cleats, equipment vs. control subjects in regular athletic shoes, etc.. BMJ Open Sport Exerc Med 2016;2:e doi: /bmjsem

63 MACE 2010 Jul;175(7): Military Medicine

64 Treatment Plan Note for school, physical education, sport, work Modify activity, school work, etc. Physical Therapy FU in 1 week Visual treatment program +/- Neuropsych testing +/- Imaging +/- Amitriptyline for sleep +/- NSAIDs, Tylenol

65 INVESTIGATIONAL ISSUES Neuropsychological Testing Blood test Neuroimaging

66 Neuropsychological Testing A variety of tests that measure reaction time, memory, and concentration (e.g., King-Devick, ImPACT, AxonSports, and Headminder Concussion Resolution Index) Baseline tests are obtained preseason to provide a basis for comparison in the event an athlete suffers a concussion Tests are of no value when the athlete is symptomatic because it will not affect the return to play decision Has not been proven to reduce morbidity or mortality Should not be used as the sole basis for management decisions

67 King-Devick Based on measurement of the speed of rapid number naming (reading aloud single-digit numbers from 3 test cards) Captures impairment of eye movements, attention, language, and other correlates of suboptimal brain function Neurology; Prepublished online February 2, 2011; K.M. Galetta, J. Barrett, M. Allen, et al.

68 Glial fibrillary acidic protein (GFAP) Protein in cytoskeleton of astroglia brain cells C terminal hydrolase L1 protein studied as well Prospective cohort study CTHL1 was higher initially GFAP elevated up to a week following the head injury Not a stand alone test JAMA Neurol. 2016;73(5): doi: /jamaneurol

69 When should an MRI or CT ordered? A. On all concussions B. Concussions that have symptoms > 7days C. When ruling out more severe head and brain injuries, such as skull fractures, cervical spine injuries, intracranial hemorrhages, as well as cerebral swelling that would require surgical intervention D. In patients with > 4 symptoms

MR Spectroscopy DOI:http://dx.doi.org/10.

70 MR Spectroscopy DOI: First published online: 23 August 2010

71 Resting State Functional MRI Found that the corpus callosum may be primary site of injury after head injury Exp Brain Res Apr; 202(2):

72 Diffusion Tensor Imaging

73 Diffusion Tensor MRI White matter integrity and cognition in chronic traumatic brain injury: a diffusion tensor imaging study, Brain Oct;130(Pt 10): Epub 2007 Sep 14

PET Scan (Positron Emission Tomography) Marvin Bergsneider, MD, University of California Medical Center, UCLA Brain Injury Research Center, Los Angeles.

74 PET Scan (Positron Emission Tomography) Marvin Bergsneider, MD, University of California Medical Center, UCLA Brain Injury Research Center, Los Angeles. Brain Briefings, Society for Neuroscience. Feb 2001 UCLA April 2015 FDDNP 2-(1-{6-[(2-[F-18]fluoroethyl)(methyl)amino]-2-napthyl}ethylidene) malonitrile

75 When should an athlete return to play A. After athlete has been cleared by a medical professional and completed the league's return-to-play protocol. B. After his or her guardian gives him permission. C. After athlete can tell the coach his or her name. D. There's no need to hold a player out. Let s go back to how many fingers?

76 Prague Return to Play Criteria Asymptomatic at rest Asymptomatic physical and cognitive exertion Intact neurocognitive function

77 National Athletic Trainers Association (NATA) Position Statement on management of concussions ATC should spearhead the development of a detailed written plan outlining the concussion-management strategy and share it with administrators and coaches. The plan should include a baseline evaluation of athletes, including a neurologic history with symptoms and physical examination and objective measures of neurocognitive performance and motor control. Once the concussion diagnosis has been made, the patient should be immediately removed from further participation for at least 24 hours. Follow-up testing, using the same protocol as the baseline examination, can aid in determining when to start the return to physical activity after the patient is cleared by a physician or designate. Lastly, although most concussions resolve in a relatively short time frame, patients who are young, who have had multiple concussions, or who have premorbid factors may require additional attention.

78 Return to Play Protocol 1. No activity, complete rest. NO return to play that day. 2. Light aerobic exercise 3. Sport specific exercise (skating in hockey, running in soccer), progressive addition of resistance training 4. Non-contact training drills. 5. Full contact training. 6. Game play.

79 Discontinuing the Season Number of lifetime concussions Duration and severity of symptoms Decreasing force Life goals Ongoing cognitive or emotional issues Time of year/season

80 Any referral is appropriate Symptoms longer than four to seven days Worsening symptoms Interference with ADL Difficulty returning to prior academic or athletic standards despite lack of symptoms Referrals

81 Prevention Education and coaching Enforcement of existing rules Eliminate dangerous activities Promotion of sportsmanship and mutual respect

82 Cantu RC: Is Helmet Design the Answer to Concussion in Sports? Active Voice Bulletin ACSM, September 2010

83 The only way I come out is on a stretcher.

84 Thank you!

Disclosures 7/22/2015 MANAGEMENT OF SPORTS RELATED CONCUSSION. Brad Herskowitz MD Neurologist Baptist Hospital

Disclosures 7/22/2015 MANAGEMENT OF SPORTS RELATED CONCUSSION. Brad Herskowitz MD Neurologist Baptist Hospital MANAGEMENT OF SPORTS RELATED CONCUSSION Brad Herskowitz MD Neurologist Baptist Hospital Disclosures I have no relevant financial conflicts of interest. I will not discuss off label or unapproved usage.