MildTrauma+cBrainInjuryandConcussion

MarkE.Gormley,Jr.,M.D.Gille=eChildren’sSpecialtyHealthcare

St.Paul,Minnesota

Concussiondebateevolving•  Footballdeaths

–  1919–53–  1968–36–  Now–5/yr

•  NFL$765millionse=lement•  Recogni+on•  Treatment•  ?Preven+on•  Haveathletesoutpacedevolu+on?•  Hasprotec+veandimprovedequipmentincreasedrisk•  Debatecurrentlydominatedbytreatment(?Influenceof$$$)•  Treatmentevolvingtoo

NYHSfootballplayerdiesa^ermildheadinjury10/11

•  Highschoollinemanhithardandfallstoground

•  Rollsoverandsitsuponown•  Complainsofsevereheadache•  Collapseswhenhestands•  DiesinambulanceonthewaytoED

Concussion

•  Immediateandtransientimpairmentofneurologicfunc+oncausedbytraumatothebrain

•  “dinged”•  “bellrung”•  Notusuallyseenonneuro-imaging(CTorMRI)

MNYouthSportsConcussionLaw

•  9/1/11MNconcussionlaw•  AllyouthsportscoachesmusttakeandpassCDConlineconcussioncourse

•  Anyplayerwithconcussionsymptomsmustleaveac+vityandnotreturnun+lclearedbya“medicalprofessional”

•  Noenforcementorpuni+vemeasures•  Focusesonrecogni+onandtreatment,notpreven+on

The long-term effects of multiple concussions may be severe and not immediately evident in the short-term.

DerekBoogaard DaveDuerson

ChronicTrauma+cEncephalopathy(CTE)

•  Accumula+onofscarringproteinsinthebrainthatleadstoearlycogni+vedeteriora+on,evenifnosymptomsexistedinearlyadulthood

•  ?Relatedtorepe++veconcussions•  DaveDuerson,ex-NFLplayerwhocommi=edsuicideduetocogni+vechanges,CTEonautopsy

•  DerekBoogaard,NHLplayerwithCTEonautopsya^erdrugoverdose

•  NFLse=ledwithplayersfor$765million

Tauaccumula+oninrepe++veconcussions

(A–C)Wholemount50-μm-thickcoronalsec+onsimmunostainedfortau(AT8)fromcase1(A),case2(B),case3(C)(counterstainedwithcresylviolet)showingextremelydensedeposi+onoftauproteinintheamygdalawithincreasingseverityfromle^toright.(D–F)Microscopically,thereisamoderatedensityofNFTsandastrocy+ctanglesincase1(D),thedensityisincreasedincase2(E),andextremelymarkedincase3(F),originalmagnifica+onx350.ChronicTrauma+cEncephalopathyinAthletes:ProgressiveTauopathyfollowingRepe++veHeadInjuryJNeuropatholExpNeurol.JNeuropatholExpNeurol;68(7):709-735.

CTE

•  Tauopathy•  Demen+apugulis+ca(punchdrunk)•  Preferen+alinvolvementofsuperficialcor+callayers

•  Irregularpatchydistribu+oninfrontalandtemporalcor+ces

•  Li=lebeta-amyloiddepositscommoninAlzheimer’s

MichaelLipton,et.al.,AlbertEinsteinCollegeofMedicine,

RadiologicalSocietyofNA,11/11

•  38soccerplayers(ave.age:30.8)•  Askedabout“heading”frequency•  Assesseddiffusiontensorimaging(DTI)MRI•  Assessedcogni+vefunc+on•  HigherrateofheadingshowedDTIwhitema=erpathologyandworsecogni+vetes+ng

Mostfrequentsymptoms

•  headaches40%•  dizziness14%•  memoryproblems13%•  weakness10%•  foggy•  crying

MildTBIsymptoms

•  schoolproblems•  poorabstract,organiza+onal,

judgementskills•  depression•  headaches•  +cs•  anxiety•  neckpain•  dizziness•  diplopia•  photophobia

DiagnosingmildTBI

•  reportsofsymptomsc/wmildTBI•  PETscan(CT,MRI,usuallyofli=lehelp)•  evalua+onsbytherapist(OT,speech,psychology)

•  fMRImaybehelpful•  ImPACT

ClinicalProtocolforImPACT

-  Baseline-  Concussion-  ImPACTtes+ngwithin24-72hours-  Repeattes+ngin5-10days-  Repeattes+ngasneeded-  Usenorma+vedatawhenbaselinetes+ngnotavailable

Post-ConcussionSymptomScale

Module4(SymbolMatching)

-  Ini+ally,thesubjectispresentedwithascreenthatdisplays9commonsymbols.

-  Thenthesymbolsdisappearfromthetopgrid.

N=410

. p.<.00001

N.S.

p.<.0001

p.<.03

Significant difference between

groups out to at least 8 days post-injury

Collins MW, Lovell MR, Maroon et al. Medicine and Science in Sports Exercise, 34:5;2002

ImPACT©MEMORYCOMPOSITEControlvs.ConcussedAthletes

*Lower score indicates poorer performance

InjuredBrainCells

•  Vulnerabletorepeatinjuriesindaysandweekspost-concussion

•  Repeatinjuriescancauseextensiveneuronalloss

•  Shouldini+allyrestlikeskeletalinjuries

“Cogni+veRest”

•  Limitacademicandphysicalac+vi+es–noreading,videogames,vigorousac+vi+es–TVOK

•  Symptomsmayincreasewithincreasedac+vi+es•  Cogni+vedeficitsmaypersista^erothersymptomsresolve

•  Graduallyincreaseac+vi+esassymptomsimprove–stagedreturn

“Cogni+veRest”

•  Shouldnotkeepoutofschoolformorethan1weekifsymptomfree.

•  Ifsymptomssevere,mayneedtorestlonger•  Ifsymptomsseveremorethan4weeks,mayneedto“workthrough”it

•  Returntoac+vi+esshouldbelessthan2weeksifsymptomsresolvequickly

ReturntoAc+vityReturntoPhysicalAc<vityPlan�Nophysicalac<vityun+l_________thisincludesnoprac+ce/games,nogym,norecess,noexercise,&nostrenuousac+vity.�StartStage1ac<vitybeginning___________.Yourtargetheartrateis____________.�StartStage2ac<vitybeginning___________.Yourtargetheartrateis_____________.�StartStage3ac<vitybeginning___________.Yourtargetheartrateis_____________.�StartStage4ac<vitybeginning___________.Yourtargetheartrateis_____________.�StartStage5-fullcontactprac<ce/playbeginning_________.Yourtargetheartrateis_____________.�RepeatImPACTtes<ng___________.

Cogni+verestMoser,etalJofPed,2012

•  Retrospec+vereview•  49athletespost-concussion•  Allprescribed1weekofrest•  Assessedif+mebetweenonsetofconcussionandstartofrestperiodeffectsoutcomes

•  Allgroupsimprovedevenifreststarted1monthpostconcussion

Cogni+verestMajerske,etal,2013

•  Retrospec+velylookedat95studentathletes•  Dividedinto5groupsaccordingtoimmediatepost-concussiveac+vitylevel

•  Strongcorrela+onbetweenhigh-intensitylevelanddelayedneurocogni+verecovery

•  Moderateac+vitygroupsdidbest

StrictRestBeneficial?Thomas,etal,Pediatrics‘15

•  Randomizedcontrolledtrial•  88pa+ents11-22y/oseenw/in24hrsofconcussion

•  Treatmentgroupgot5daysofstrictrest•  Controlgroupgot1-2daysofrest•  Measuredsymptoms,balance,neurocognfxn•  Symptomsbe+erincontrolgroup•  Nodifferenceinbalanceorneurocogni+vefxn

Cervico-ves+bulartherapySchneider,etal

BrJofSportsMed,2013•  Blindedrandomizedcontroltrial•  31athleteswithprolongedsymptomsofdizzinessandheadacheorneckpain

•  1grouptreatedwithves+bularandsensorimotortherapy(treatmentgroup)

•  1grouptreatedwithrestwithgradualresump+onofac+vi+es(controlgroup)

•  Blindedphysiciandeterminedreturntosport•  1of14(7%)ofcontrolgroupand11of15(15%)oftreatmentgroupreturnedtosportby8wks

Athleteswithchronicsymptoms

GyroS+mchair

Resump+onofac+vi+esperSilverberg,etal

JHeadTraumaRehabil2013•  Reviewar+cle•  Bedrestshouldn’tbelongerthan3days•  Beginpreinjuryac+vi+esastolerated•  Delayingcontactac+vi+esreducesoverlap•  Risksfromac+vi+esthatcausesymptomsunknown,severesxmayindicateharm

•  Resumeac+vi+essub-sxlevelatfirst•  Workthroughsxiflongerthan1month

Deme+ainHSfootballplayersSavica,etal

MayoClinicProceedings‘12

•  438highschoolfootballplayers1946-56RochesterMN

•  140maleband,gleeclub,andchoirstudents‘46-56

•  Nodifferenceindemen+a,Parkinson’s,ALS

Summary

•  Restfor1weekhelpspreventoverlapinjuries•  Shouldbegintoreturntomoderateac+vi+esatsub-symptomlevelastolerated

•  Noac+vi+esorhighintensityac+vi+esmaybeharmful

•  Mayneedtoworkthroughac+vityinducedsymptomsifpresentlongerthan1month

•  Ves+bulartherapymayhelpwithlong-termsx

Summary

•  Longtermconsequencesofconcussions+llnotfullyunderstood.

•  Long-termproblemsmayonlybesignificantwithmul+pleconcussionsovermanyyears,i.e.professionalathletes

•  Secondimpactsyndromerarebutconsequencessevere

•  Erronthesideofcau+on