The Role of Sports in Long-Term Brain Health

Transcription

1 July 21, 2017 Bronson Sports Medicine Symposium The Role of Sports in Long-Term Brain Health Jeffrey Kutcher, MD, FAAN National Director, The Sports Neurology Clinic Team

2 Disclosures National Director, The Sports Neurology Clinic Team Neurologist, US Ski & Snowboard Team Director, NBA Concussion Program Consultant, NHLPA Consultant, NFLPA Consultant, ElMindA, Ltd. Book royalties: Oxford University Press WMU

3 The Role of Sports on Brain Health

4 CISG 5 th International Consensus protocol mentioned:: 2017 = = 7

5 The Patient s Perspective 1. Concussion: days to weeks 2. Post Concussion Syndrome: months to years 3. Long-term brain health: lifetime Birth Sports Career Death

6 TSNC Approach to Athlete Brain Health Baseline Neuro Testing PPE Sports

7 Baseline Testing Great concept to measure brain function prior to an injury easy to do? Results should be useful to the provider managing the concussion Testing should augment the neurologic history and exam

8 Neurologic history: Recurrent symptoms Relevant comorbidities Brain trauma history Family history The Neuro PPE Neurologic physical exam: Screening neurologic exam Focused concussion exam Supplementary tests

9 The Neuro PPE

10 TSNC Approach to Athlete Brain Health Baseline Neuro Testing PPE Concussion Sports

11 Concussion: Clinical Axiom #1 Not all brain pathology causes a clinical syndrome

12 A Tale of Two Thresholds FORCE INJURY CONCUSSION INJURY THRESHOLD SYMPTOM THRESHOLD

13 Concussion: Clinical Axiom #2 Not every neurological clinical effect seen after a hit is due to concussion

14 Concussion: Clinical Axiom #3 Even if concussed, some symptoms may still be from something else

15 Mechanism Matters

16 Concussion diagnostic certainty Definite Mechanism Clinical Effect Probable Treat as Concussed Possible Situational Adapted from: Kutcher and Giza. Continuum, 2014

17 Concussion as a Projection INJURY INJURY

18 TSNC Approach to Athlete Brain Health Neuro PPE Concussion Sports

19 Concussion Management 1 Kutcher and Giza. Continuum, 2014

20 RTP Process: Defining Relative Rest

21 Concussion Management 1 2 Kutcher and Giza. Continuum, 2014

22 RTP Process: When to start graduated exertion

23 Concussion Management Kutcher and Giza. Continuum, 2014

24 RTP Process: How to progress through stages

25 RTP Process: B.R.A.I.N Bike - simple cardiovascular exertion Run - add simple movement, intervals Agility - add complex athletic movements In Red- add cognitive load of sport No restrictions Allow enough time after each challenge for symptom development and evaluation

26 What About Contact? Consider the sport and position Is there a difference between practice and game play? Find safe, monitored, ways to add contact at the end of RTP process patient initiated planned reactive simulated game play

27 TSNC Approach to Athlete Brain Health PCS Neuro PPE Concussion Sports

28 INJURY Concussion vs. PCS TIME

29 Post Concussion Syndrome Take a history, make a list Unplugged Syndrome Migraine Mood Sleep Neck ADHD etc

30 The Approach to PCS

31 Dynamic Evaluation

32 Dynamic Evaluation

33 Post Concussion Syndrome POST-CONCUSSION Migraine SYNDROME Sleep Anxiety Unplugged Syndrome ADHD Neck

34 Post Concussion Syndrome Identify lodestone vs. keystone problems

35 Post Concussion Syndrome Physical exertion Cognitive exertion Environment exposure Anxiety POST-CONCUSSION Migraine SYNDROME Sleep Psycho-therapy Medication Magnesium/Riboflavin Medication Neck therapy Headache hygiene Unplugged Syndrome Neck Medication Accommodations Medication CPAP Sleep hygiene ADHD Cranio-sacral Traditional PT Electro stim Accupuncture

36 Patient Plan: July 13, 2016 Areas of focus 1. Neck: physical therapy for cervical endurance and strengthening, range of motion, proprioceptive training, and scapular/upper thoracic strengthening. 2. Jaw: continue work on TMJ with emphasis on stabilization over mobilization. 3. Spine: continue myofacial release of cervical and thoracic spine. 4. Exertion Rehabilitation/Return to Sport: FOUNDATION To be done together as a unit HOCKEY ENVIRONMENT CONTACT CARDIO Simple skating drills 4-5 days/wk mins Average HR = No stationary bike MOVEMENT Agility drills that stress head movement 6 days/wk 10 mins/day on days with skating 20 mins/day on days without skating EYE TRACKING Agility drills that stress eye tracking 6 days/wk 10 mins/day on days with skating 20 mins/day on days without skating Gradually add complexity on the ice Two person simple passing drills Add live goalie Add players and increase game play scenarios Short battle drills Anticipated half-speed checking ¾ speed patient initiated contact Anticipated ¾ speed checking RTP When at estimated 80% fitness When tolerating non-contact game play

37 Patient Plan: July 13, 2016 Examples of Agility Drills that stress HEAD MOVEMENT: Drills that require changes of directions and which require the patient to look from forward to back or from side to side to locate where they need to go during the drills. You can also add into the drills verbal or visual cues, forcing the patient to make quick decisions. Such as: 1. STAR Drill 2. Box Drill 3. L-Drill 4. Wave Cone Drills Examples of Agility Drills that stress EYE TRACKING: Drills that require following a moving object with the eyes. Such as: 1. Bosu Balancing with Stick Handling 2. Bosu Balancing with Ball Toss (multiple size balls thrown to both hands and to random locations at intervals) 3. Agility Ladder with Ball Toss ( Different foot work drill with ball tosses incorporated into the drill) 4. Hurdle Drills with Ball Toss ( Different foot work drill with ball tosses incorporated into the drill)

38 TSNC Approach to Athlete Brain Health PCS Neuro PPE Concussion Sports

39 Annual Neuro PPE and Long-Term Brain Health Neuro PPE Screen for patient phenotypes Monitor chronic symptoms Monitor for brain dysfunction Assess sports health quotient Discuss annual dose of force Discuss future exposure risk Re-educate and plan Sports

40 Chronic Traumatic Encephalopathy Tau protein deposition, like Alzheimer s Disease, but in different locations Presumed to be from repeated contact Unclear clinical effects NORMAL CTE

41 CTE vs. TES VS. CTE: Pathological finding Tissue diagnosis Traumatic Encephalopathy Syndrome

42 TSNC Approach to Athlete Brain Health PCS Neuro PPE Concussion Sports

43 The Role of Sports on Brain Health

44 The Role of Sports on Brain Health

45 Healthy People 2020

46 Obesity in Children and Adolescents

47 Brain Benefits of Exercise

48 Physical Activity Guidelines

49 Brain Benefits of Exercise Exercise and the animal brain: Facilitates synaptic plasticity in the hippocampus Proliferation of neural progenitor cells Promotes survival of new cells Widespread growth of blood vessels Improves nutrient and energy supply Facilitates knowledge acquisition and retention voluntary does better than forced

50 Brain Benefits of Exercise

51 Brain Benefits of Exercise Exercise and growth factors: Brain Derived Neurotrophic Factors (BDNF) Essential for hippocampal function Learning Modulation of depression Insulin-Like Growth Factor-1 (IGF-1) Essential role in hippocampus-dependent learning/plasticity Converges with BDNF effects Modulation of depression Increased centrally and in the periphery Vascular Endothelial-Derived Growth Factors (VEGF) Vascular remodeling in brain

52 Brain Benefits of Exercise Exercise and depression: Clearly established in human studies Aerobic and resistance training Benefits similar to anti-depressants Dose dependent Mechanistic theories Hippocampus neurogenesis and growth factor expression Hypothalamic-pituitary-adrenal axis regulation Altered dorsal raphe serotonin neurons

53 Brain Benefits of Exercise Exercise and neurodegenerative disease: prospective epidemiological studies: 16 prospective studies 163,797 non-demented participants Pooled relative risks: highest physical activity vs. lowest showed inverse relationship to risk of dementia Hamer and Chida, 2009, Psychological Medicine

54 Thank you for your time! BRIGHTON KALAMAZOO