Head Injuries. Michael J. Sampson, DO FAOASM Associate Dean for Clinical Integration Associate Professor Family/Sports Medicine GA-PCOM Copyright 2017

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2 CONCUSSION LEARNING OBJECTIVES On comple9on of lecture, par9cipants are expected to be able to: - - Describe for each of the following the cause(s), anatomical basis, clinical presenta9on, treatment, progression, and poten9al complica9ons: Concussion, Post- concussion syndrome, Diffuse Axonal Injury - Dis9nguish the cri9cal neurological evalua9on components for dis9nguishing a concussion from a more serious trauma (Subdural/Epidural/Subarachnoid Hematoma) - Calculate Glasgow coma scale for head injury - List Return to play parameters (RTP) (physical and cogni9ve rest, exer9on challenge (physical and cogni9ve) List the Neuropsych Tests men9oned List the basic treatments for countering Immunoexcitotoxicity (pharmacotherapeu9cs) List the three theore9cal components of concussion - Describe: Return to Learn, Return to Play, Cogni9ve Rest, Cogni9ve Reserve, Tau Protein in Concussion - Be familiar with the components that make up the SCAT 3 - List the symptoms and morbidity/mortality of Post- Concussion Syndrome and CTE - List/describe the PATHOGENESIS of Concussion and CTE (Metabolic/Excitotoxic/Immunologic) 2

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4 Our Three Goals for Today:! What is a Concussion?! Why should you care about Concussions?! What should you do about a Concussion?! 4

5 What is a Concussion?! True or False? FALSE! As long as you have less than three concussions, you can return to contact sports.! FALSE! If you feel better 30 seconds after you get hit, you don t have a concussion.! FALSE! You can ALWAYS tell when a friend has a concussion.! So what is a concussion?! 5

6 A Concussion! Is a Serious Injury to the Brain! Is caused by a Bump, Blow, or Jolt to the Head or body! Can Happen Anytime You re Hit & Even if You Haven t Been Knocked Out! 6

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8 What is a Concussion?! 8

9 What is a Concussion?! 9

10 Demo: Spot the Injury 10

11 Spot the Injury! #1 #2 11

12 Spot the Injury! #1 #2 12

13 Spot the Injury! 13

14 You ll know it when you see it Or will you?

15 Concussion Symptoms! 15

16 You might Feel like you want to Throw Up 16

17 You might Feel Dizzy & Have Trouble Balancing 17

18 You might Have Double or Fuzzy Vision 18

19 You might Become Sensitive to Light 19

20 You might Become Sensitive to Noise 20

21 You might Have a Headache 21

22 You might Feel Sluggish, Tired, Foggy, or Confused 22

23 You might Forget things or even where you are 23

24 You might Feel like you might Throw Up! Feel Dizzy or have trouble Balancing! Have Double or Fuzzy Vision! Become sensitive to Light and Noise! Have a Headache! Feel Sluggish, Tired, Foggy, and Confused! Forget things or even where you are! And if the brain doesn t have time to heal, symptoms may last for months or even years! 24

25 Post Concussion Syndrome (PCS) Symptoms may include: Chronic headaches Fa9gue Sleep difficul9es Personality changes (e.g. increased irritability, emo9onality) Sensi9vity to light or noise Dizziness when standing quickly Sidney Crosby Deficits in short- term memory, problem solving and general academic func9oning

26 Post- Concussion Symptom Groups More emotional Sadness Nervousness Irritability Headaches Visual Problems Dizziness Noise/Light Sensitivity Nausea Attention Problems Memory dysfunction Fogginess Fatigue Cognitive slowing N=327, High School and University Athletes Within 7 Days of Concussion Difficulty falling asleep Sleeping less than usual (Pardini, Lovell, Collins, et al. 2004)

27 DisrupJon of Neuro transmikers can have profound neurocognijve and psychological effects

28 Our Three Goals for Today:! What is a Concussion? Why should you care about Concussions? What should you do about a Concussion? 28

29 Nathan Stiles 29

30 Nathan Stiles 30

31 Second Impact Syndrome! Happens when a second concussion happens before the first has healed! Massive brain swelling causes permanent damage! Extremely rare!! Leads to paralysis in many cases, and death in half of all cases! 31

32 Junior Seau 32

33 Junior Seau 33

34 Why Should You Care About Concussions?! Chronic Traumatic Encephalopathy CTE! 34

35 Why Should You Care About Concussions?! 35

36 PATHOGENESIS of Concussion, PTSD and CTE Metabolic Excitotoxic Immunologic

Concussion Metabolic Mismatch 500 (Giza & Hovda, 2001) 400 Calcium % of normal Glutamate 300 200 100 50 0 K+

37 Concussion Metabolic Mismatch 500 (Giza & Hovda, 2001) 400 Calcium % of normal Glutamate K+ Glucose minutes hours days Cerebral Blood Flow UCLA Brain Injury Research Center 37

Concussion - Acute Cellular InflammaJon Transient Release of high levels of ROS/RNS lipid peroxidation products Prostaglandins nitric oxide All can then activate microglia Activation of Microglia

38 Concussion - Acute Cellular InflammaJon Transient Release of high levels of ROS/RNS lipid peroxidation products Prostaglandins nitric oxide All can then activate microglia Activation of Microglia Macrophage will stimulate Immune mediated Inflammation Genetic upregulation of chemokines tumor necrosis factor alpha (TNFα) NFK-B Typically Acute Inflammation response will abate and healing will occur Blaylock & Maroon Surgical Neurology International Accepted April 2011

39 Gene Atkins 39

40 Demo: Memory Test 40

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42 Demo: Memory Test 42

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44 Why Should You Care About Concussions?! 44

46 Why Should You Care About Concussions?! KEY DIFFERENCE! Concussion = Injured brain tissue! If you rest, you ll recover the vast majority of the time.!!!cte = Diseased brain tissue! 46

47 2012 Zurich Interna9onal Consensus Conference on Concussion in Sport Introduc9on of SCAT3 Discussion on Neuropsych Tes9ng/validity Risk Reduc9on Strategies (rules change/equipment, etc) CTE evidence and clinical outcomes Children should return to learn before return to sport Post concussive pa9ent >10 days (mul9disciplinary approach- cogni9ve, ves9bular, physical and psychological therapy) along with physical/cogni9ve rest

48 Our Three Goals for Today:! What is a Concussion? Why should you care about Concussions? What should you do about a Concussion? 48

49 What Should You Do About a Concussion? 49

50 Cindy Parlow Cone 50

51 Cindy Parlow Cone I think once you know better, you do better.! 51

52 Stand Up for Yourself! Rest now, so you ll recover faster! Who would you talk to?! What might you say?! 52

53 When should I quit Doc??? Most experts would agree that an athlete in the following scenarios is one who should poten9ally consider discon9nuing ac9vi9es with a high risk of concussion: the athlete who has had numerous concussions, with each concussion seemingly more easily obtained, and with symptoms which are more severe and/or longer las9ng or dispropor9onate to the impact. Concept of Cogni9ve Reserve. any athlete with residual neurocogni9ve problems persis9ng well aner other symptoms have resolved. any athlete with protracted, prolonged symptoms.

54 Ryne Dougherty! 54

55 They Knew Something Was Wrong! Lebida Ryne s teammates heard him complaining of! concussion symptoms, but they did not tell their coaches, trainers, or parents.! 55

56 Ryne Dougherty! Ryne Dougherty got another concussion less than one month later and suffered from second impact syndrome.! 56

57 Standing Up for Friends! It s hard to take yourself out of the game, but helping an injured friend is your responsibility.! 57

58 Standing Up for Friends! Helping an injured friend is your responsibility! Who would you talk to?! What might you say?! 58

59 Our Three Goals for Today:! What is a Concussion? Why should you care about Concussions? What should you do about a Concussion? 59

60 When it comes to concussions, remember: 1. Leave the game or practice! 2. Talk to a coach, parent, or trainer! 3. Get checked out on sidelines! 4. Go to a doctor before returning! 5. Give your brain time to recover by mental and physical rest! 6. It is up to you to make sure your friends get help too! Play Hard, Play Smart! 60

61 On Field Assessment What s Really Going On!

62 Neuropsychological Assessment While not the key to concussion management, it is certainly an important component & comprehensive tes9ng beyond cogni9on is cri9cal cogni9ve recovery is the long- term goal. Should not be performed while pa9ent is symptoma9c, unless pa9ent compliance is a concern. Much stronger tool with pre- injury, baseline tes9ng and serial follow- up but some computerized plarorms allow for reliable interpreta9on even without baseline tes9ng. Mostly helpful in complex concussion evalua9on & management. Several commercial systems are currently in use.

63 Web- based Computerized Assessments HeadMinder - Concussion Resolu9on Index htp:// CogState - CogSport htp://cogstate.com/index.php? sec9onid=4738&pageid=5344 ImPACT htp://

64 Structural Neuroimaging Not much help in concussions these are func9onal injuries and structural findings are rare: Should be used when 1) neurologic findings exist on exam 2) worsening symptoms 3) prolonged disturbance of conscious state CT scans beyond ruling out a cerebral hemorrhage, not very useful any longer MRI current standard of care, par9cularly with gradient echo, perfusion & diffusion- weigh9ng to evaluate for acute structural injury

Advanced Neuroimaging of TBI with High DefiniJon Fiber Tracking (HDFT) David

Novel computa9onal technology to map brain connec9vity 2.

65 Advanced Neuroimaging of TBI with High DefiniJon Fiber Tracking (HDFT) David Okonkwo 1 (MD, PhD) & Walter Schneider 1,2,3 (PhD) 1 Neurosurgery, 2 Radiology, University Pitsburgh Medical Center. 3 Psychology, University of Pitsburgh Bottom Line 1. Novel computa9onal technology to map brain connec9vity 2. Provides a poten9al anatomical diagnosis of mild TBI 3. Has poten9al to transform clinical care and pa9ent educa9on 4. Could be deployed on the DoD/VA 3T MRI scanners Visual Abstract

The Future is NOW Ideal for FEM brain model

66 The Future is NOW Ideal for FEM brain model valida9on SIMon inves9ga9on with 2 nd Genera9on Original HITS system with 6 sensors measured 3 linear and 2 rotational accelerations New HITS system with 12 sensors Will measure 3 linear and 3 rotational accelerations

Other Considera9ons Pharmacologic Therapy Currently there is no evidence- based pharmacological therapy available for trea9ng concussion.

67 Other Considera9ons Pharmacologic Therapy Currently there is no evidence- based pharmacological therapy available for trea9ng concussion. With limited understanding of the pathophysiology, it is extremely difficult to treat concussions pharmacologically. Pharmacotherapy may be used to manage specific issues (anxiety, sleep disorders, depression, etc.). Resveratrol, Fish Oil

68 Concussion Preven9on. Strong neck and shoulder girdle musculature. Tighten neck muscles and the mass of the head approximates the mass of the body. Stay well hydrated. Gene9cs??? Good technique. Tackling, heading the ball, etc

69 Physical Rest/Cogni9ve Rest Physical rest basically means no exer9onal ac9vity for a period of 9me Cogni9ve rest means no TV, video games, tex9ng, reading, etc. REST the brain! This is the hardest thing to have a young pa9ent/ athlete do. Remember, return to learn before return to play but the brain needs to rest as well. 69

70 Return To Play Once a pa9ent is symptom free, they need to follow return to play guidelines before returning to full par9cipa9on Exer9onal exercise (if no symptoms, advance to sport specific drills. If symptom free, return to play) Exer9onal exercise (if develops symptoms, hold out for another day, then do exer9onal exercise. Con9nue to progress un9l symptom free with ac9vi9es) If con9nues to have symptoms >7 days, mul9disciplinary approach is warranted for treatment 70

71 This just in 71

72 Interna9onal Concussion Conference 72

73 Sportsosteopathy Cologne, Germany

74 Learning More about Concussions! Play Smart A free online video for student-athletes! h7p:// Heads Up Info from the CDC! 74

75 To know what you know and to know what you don t know that is knowledge. Confuscious

76 Dr. Gunnar Brolinson Dr. Ed Kornoelje Virginia Tech Sports Medicine Sports Legacy Ins9tute Dr. Joe Maroon UPMC WWE Youth Sports Safety Alliance Credits

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77 Thank You to Our Sponsors Build a beker field. interna9onal.com And Thank You! 77

CCYFL Concussion Information Sheet

CCYFL Concussion Information Sheet Why am I getting this information sheet? You are receiving this information sheet about concussions because of California state law AB 2007, (effective January 1, 2017),