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Controversies in Concussion: Where are we now?

New Trends and Best Practices in the Management of ConcussionBILL MOREAU, DC, DACBSP®, FACSM

© 2016 ALL RIGHTS RESERVED

DisclaimersAll opinions, viewpoints and recommendations contained in this presentation represent those of the author alone and do not represent the opinions, viewpoints or recommendations of any organization with which the author may be affiliated, including, without limitation, the USOC.

• I receive payment for presentations including air travel

• I serve as a VICIS council member

• I am a paid consultant to the Allegheny Health Network

• I am the CEO of Fortis CuraTM and DConlineTM

Bill Moreau DC DACBSP FACSM

United States Olympic Committee, Managing Director of Sports Medicine

Chief Medical Officer Team USA - Rio 2016 Summer Olympic Games, 2015 Toronto Pan American Games

Medical Director Team USA – 2014 Sochi Winter Olympics, 2012 London Olympic Games

Professor – Southern California University of Health Sciences Associate Professor – University of Western States NFL International Think Tank on Concussion University of Washington Sports Health and Safety Institute

External Advisory Board Member

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Acknowledgements

•Karen Moreau•Dustin Nabhan DC DACBSP•USOC Sports Medicine Team•The People We Care For!•The ACBSP Certificants•COCSA•FCLB

Presentation Outcomes Look at new EBM trends in concussion evaluation and

management using “prevention” and the ACBSP Position Statement on Concussion as a framework.

Creating a framework of changing the discussion for the inclusion of the “qualified DC” to be included in State Concussion Return to Play

Describe the importance of having a conceptual framework for managing patients with TBI.

Identify important concepts in the assessment of an individual with TBI.

Q/A if time allows

Where We are Headed –HANG ON!!

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Concussion Is Still Big News Concussion

Old Problem New Awareness

Concussion Literature in 2016:

• Google Scholar ~ 13,300 results in 0.06 sec

• PubMed = 312 manuscripts

• Journal of Chiropractic Medicine2015

Berlin 2016: The 5th International Consensus Conference on Concussion in Sport

International experts on concussion gather every four years to collaborate on the next best steps for the evaluation and management of concussion.

For the first time - Two USA DCs were invited this year! Bill Moreau DC DACBSP FACSM

Dustin Nabhan DC DACBSP

For the first time three poster presentations from DCs were included! Defining the elite: normative values for SCAT major components in healthy elite

athletes. Moreau W, Walden T and Nabhan D.

Defining the Paralympic athlete: normative values for scat major components in healthy Paralympic athletes. Moreau W, Walden T and Nabhan D.

Concussed elite athletes have better tandem gait performance. Nabhan D, Walden T and Moreau W.

If we accept the best predictor of future injury is a history of prior injury, does it make sense that preventing concussion is a key to preventing concussion?

Is reducing or preventing concussion even possible?

Proposed Prevention Prerequisites

Prevention

Access to Care

Policies

Technique and

Mechanism

Social Pressure

Knowledge

Attitude

Has Sport Injury and Illness Prevention Research Delivered? A Vigorous Debate. Paper presented at: IOC World Conference on Prevention of Injury & Illness in Sport. April 10, 2014; Monaco. 

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attitude

Adherence to GuidelinesGuidelines aim to improve the quality of medical care and reduce treatment variation. The extent that guidelines are adhered to in the field of traumatic brain injury (TBI) is unknown. Systematic review objectives(1) quantify adherence to guidelines in adult patients with TBI, (2) examine factors influencing adherence, and (3) study associations of adherence to clinical guidelines and outcome.22 retrospective and prospective observational cohort studies, reported in 25 publications, were included, describing adherence to 13 guideline recommendations. Guideline adherence varied considerably between studies (range 18%-100%) and was higher in guideline recommendations based on strong evidence compared to those based on lower evidence, and lower in recommendations of relatively more invasive procedures such as craniotomy. A number of patient-related factors, including age, Glasgow Coma Scale and intracranial pathology, were associated with greater guideline adherence. Guideline adherence to Brain Trauma Foundation guidelines seemed to be associated with lower mortality. Guideline adherence in TBI is suboptimal and wide variation exists between studies. Further research specifying hospital and management characteristics that explain variation in guideline adherence is warranted.

Adherence to guidelines in adult patients with traumatic brain injury: A living systematic review. Cnossen MC, et al. Journal of Neurotrauma. October 2015

Sport Concussion Knowledge and Clinical Practices of DC’s w/ SP MED CAQ

The study described the knowledge base and clinical practices regarding concussion by sports-certified doctors of chiropractic.A survey was distributed to the 312 attendees of the 2014 ACBSP Sports Sciences Symposium. Results measured by frequency analysis and descriptive statistics for all surveys.All (N = 76) 100% respondents believe that the evaluation of concussion should be performed by a health care provider with training in concussion, the respondents actively assess and manage concussion in adults (96%), adolescents (95%), and children (75%), a majority (79%) believe that the Sideline Concussion Assessment Tool–3 represents a current standard of care for the sideline evaluation of the athlete who possibly has sustained a sport concussion. Most agreed or strongly agreed that manual therapies may be appropriate in certain circumstances in adults (80%) and minors (80%).Most respondents strongly believe that the evaluation of concussion should be performed by a health care provider with specific training in concussion, assess and manage sport concussion in their practice, and many of them endorse the use of the Sideline Concussion Assessment Tool–3 as a sideline assessment tool.

Sport Concussion Knowledge and Clinical Practices: A Survey of Doctors of Chiropractic With Sports Certification. William J. Moreau, Dustin C. Nabhan, Taylor Walden. Journal of Chiropractic Medicine, Vol. 14, Issue 3, p169–175 November 18 2015

Sport Concussion Knowledge and Clinical Practices of DC’s w/ SP MED CAQManual medicine was considered either somewhat or very important by (91%)In the adult (80%) and minor populations (80%), most respondents agreed or strongly agreed that manual medicine may be appropriate in certain circumstances at the time of injury. There was near consensus, as 92% agreed or strongly agreed in the opinion that informed consent is a best practice before performing manual therapy regardless of patient age and 93% agreed or strongly agreed that a written release should be obtained before performing manual medicine on a minor. There was less agreement on the timing of manual therapy after the injury, with 74% agreeing that a focal neurologic deficit at the time of injury is a contraindication of manual therapy, 87% agreeing or strongly agreeing that the serial examinations should be static before proceeding with manual medicine, 82% agreeing or strongly agreeing that vital signs should be within normal limits and stable before manual medicine, and only 38% agreeing or strongly agreeing that a 2-hour waiting period should be implemented before manual therapies. There was relatively strong agreement that the lowest force types of manual therapies should be tried first, with 74% agreeing or strongly agreeing to this statement. Many of the respondents felt that manual medicine should be performed in a private setting, with 68% of respondents indicating that they agreed or strongly agreed. The respondents favorably scored manual therapies in the stable concussed patient in terms of efficiency (77%), usefulness (80%), and safety (77%).

Sport Concussion Knowledge and Clinical Practices: A Survey of Doctors of Chiropractic With Sports Certification. William J. Moreau, Dustin C. Nabhan, Taylor Walden. Journal of Chiropractic Medicine, Vol. 14, Issue 3, p169–175 November 18 2015

Current Practice Patterns by Health Care Providers who Manage Concussion Pediatricians, a group in which 31% to 38.6% of providers see at least 1 concussion a

month, largely do not follow any concussion guidelines. (1,2)

A survey of Illinois pediatricians published in 2014 showed that only 14.6% of respondents are “very familiar” with the Consensus Statement on Concussion in Sport. (2)

In a study of 73 emergency medicine physicians, only 23% use recognized concussion management guidelines. (3)

1) Gordon, K.E., Do, M.T., Thompson, W., and McFaull, S. Concussion management by paediatricians: a national survey of Canadian paediatricians. Brain Inj. 2013; 28: 311–3172) Carl, R.L. and Kinsella, S.B. Pediatricians’ knowledge of current sports concussion legislation and guidelines and comfort with sports concussion management: a cross-sectional study. Clin Pediatr (Phila). 2014; 53: 689–6973) Giebel, S., Kothari, R., Koestner, A., Mohney, G., and Baker, R. Factors influencing emergency medicine physicians’ management of sports-related concussions: a community-wide study. J Emerg Med. 2011; 41: 649–654

Current Practice Patterns by Health Care Providers who Manage Concussion A study of fourth-year medical students revealed that concussion management is

frequently left out of the medical school curriculum, with 32% of respondents answering that they either “could not remember if they learned about concussions” or “never learned about concussion” during their undergraduate medical education. (1)

Neurologists are a medical specialty frequently relied on to manage concussion. A recent survey showed that more than half of neurologists surveyed (63%) have not received any informal or formal training on sports neurology.

1) Boggild, M. and Tator, C. Concussion knowledge among medical students and neurology/neurosurgery residents. Can J Neurol Sci. 2012; 39: 361–368.

2) Conidi, F.X., Drogan, O., Giza, C.C., Kutcher, J.S., Alessi, A.G., and Crutchfield, K.E. Sports neurology topics in neurologic practice: a survey of AAN members. NeurolClin Pract. 2014; 4: 153–160

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Current Practice Patterns by Health Care Providers who Manage Concussion

Athletic trainers, who have been estimated to manage 10 concussions per provider each year, have been studied extensively for their practice patterns. Athletic trainer practice patterns have demonstrated a progression in management strategies, as a 2013 study showed that, since 1999, the use of multimodal concussion management strategies has increased significantly.

In this population, the 2004 National Athletic Trainers Association Position Statement on Concussion in Sport (69.3%) was the concussion management document that most athletic trainers were familiar with, followed by the Consensus Statement on Concussion in Sport (48.6%) and the National Collegiate Athletic Association Concussion Management Plan Legislation.

1) Lynall, R.C., Laudner, K.G., Mihalik, J.P., and Stanek, J.M. Concussion-assessment and -management techniques used by athletic trainers. J Athl Train. 2013; 48: 844–850

2) Ferrara, M.S., McCrea, M., Peterson, C.L., and Guskiewicz, K.M. A survey of practice patterns in concussion assessment and management. J Athl Train. 2001; 36: 145–149

Where Next? Look for these changes in current standards of care within the next two years

1. Exercise as a treatment modality.

2. Multimodal assessments

3. Increased utilization of eye related testing to objectify the presence of concussion.

4. Continued exploration of “manual medicine” for concussion care. Who will write it?

5. Continued controversy regarding the legislative ruling around concussion management.

Access to care

Googling Concussion Care: A Critical Appraisal of Online Concussion Healthcare Providers and Practices in Canada.

Concussion is presently unregulated in Canada. Performed an independent, blinded Google internet search for the terms "concussion" and "concussion clinic“ in Canada. The first 10 -15 concussion healthcare providers per province were identified and a critical appraisal of type of healthcare personnel and services offered was conducted.

Study identified 58 concussion HCPs, 40% listed an on-site medical doctor (M.D.), 47% of concussion healthcare providers advertised access to a concussion clinic, program, or center.

Professionals designated as the leaders among concussion clinics, programs, and centers included a neuropsychologist (15%), sports medicine physician (7%), neurologist (4%), and neurosurgeon (4%). Services offered by providers included baseline testing (67%), physiotherapy (50%), and hyperbaric oxygen therapy (2%).

This study indicates that there are numerous concussion healthcare providers in Canada offering diverse services with clinics operated by professionals with varying levels of training in traumatic brain injury. In some cases, the practices of these concussion clinics do not conform to current expert consensus guidelines.

Googling Concussion Care: A Critical Appraisal of Online Concussion Healthcare Providers and Practices in Canada. Ellis, M et al. Clinical Journal of Sport Medicine., Post Author Corrections: February 10, 2016

Telemedical Evaluation of Athletes with Suspected Concussion

Most elite-level athletes have access to providers with concussion expertise, this level of care is uncommon in amateur youth sports. > 7.5 M US children participate in high school sports, the majority without access to athletic trainers. The volume of youth athletes exceeds the number of concussion experts, telemedical concussion evaluations (teleconcussion) may address gaps in care.N=11 consecutive collegiate football players with suspected concussion were assessed using the Standardized Assessment of Concussion (SAC), King-Devick Test (KD), and modified Balance Error Scoring System (mBESS). A remote neurologist assessed subjects w/ another provider performed a simultaneous F2F assessment. A remove-from-play determination was made. The remote and F2F providers were blinded to each other’s exam findings and remove-from-play decision. The teleconcussion and F2F SAC were in agreement 100% of the time. Remote and face-to-face KD times were within a 3s difference 100% of the time. Remote and F2F mBESS scores were within 3 points 100% of the time. Remove from play decisions were in agreement 100% of the time.Conclusions: This is the first study investigating teleconcusison feasibility for concussion assessments. These data suggest high levels of agreement between remote and a F2F providers regarding exam findings and remove from play decisions.

Feasibility and reliability of remote telemedical evaluation of athletes with suspected concussion: Addressing gaps in care with teleconcussion. VargasB.B., et al. Journal of the Neurological Sciences 357 (2015) e39–e41

Policies and legislation

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Creating a framework of changing the discussion for the inclusion of the “qualified DC” to be included in State Concussion Return to Play

Where are you now? All Inclusive?

This rule is being proposed in order to comply with ORC Section 3707.521 (E) that requires the Board to adopt a rule in order for chiropractic physicians to be authorized to asses and clear athletes for return to practice or competition under ORC Section 3313.539 or 3707.511.

Most all in efforts do not make it to the Governor

Specialty in Sports and sometimes neurology may make it

Could extra training and a State Association “registry” be the path?

State Association Driven Concussion Registry

The State Association Concussion Registry may be built as a first-of-its kind Concussion Credential Registry that will allow any public user to see the credentials in terms of competencies, transfer value, assessment rigor, third-party approval status,

Open and voluntary registry could include all kinds of credentials, but expect pushback and set a drop back position to the DC in your State

Each Registry “concussion credential” would describe the name, competencies, assessments, accreditations, references, value, renewal, etc.

The goals are transparency and clarity, and to help assure those with questions that the DC on the Registry has the education and skill sets to meet the required Standard of Care to more than adequately meet the needs of the athletes, parents, State Athletic Associations, and other rule makers.

Statutory Description of a Health Care Provider Knowledgeable in Concussion Management:

The following is an annotated and abbreviated list of state concussion statutory language. AK: “qualified person who has received training, as verified in writing or electronically by the qualified

person, in the evaluation and management of concussion” CA: “licensed health care provider trained in management of concussions and acting within scope of

practice” CO: “doctors of chiropractic with the U.S. Olympic team” DC: “licensed or certified health care provider” FL: “appropriate health care practitioner trained in DX, evaluation and management of concussions as

defined by the Sports Medicine Advisory Committee of the Florida High School Athletic Association” IA: (chiropractors are legally qualified by chiropractic licensure) IN: “licensed health care provider trained in evaluation, management of concussions & head injuries” MA: “other trained/ licensed health professional allowed by the Dept. of Public Health” MD: “licensed health care provider trained in the evaluation and management of concussions” ME: “licensed health care provider trained in concussion management”

J. Schwatzbauer (FCLB) Personal correspondence April19, 2016

Effects of Legislation on Sports-Related Concussion

Following the lead of Washington state and passage of the Lystedt Law in 2009, all states now have sports concussion laws designed to help protect youth athletes.

Current concussion legislation centers on the following three points: 1) Education of athletes, parents, and coaches; 2) Removal from practice or play for suspected concussion; and 3) Clearance by a health care provider before medically supervised graded return to play.

Sports concussion laws are not designed for primary prevention but instead aid in proper diagnosis and management, thereby preventing the tragedies that may occur from premature return to play.

Laws are living documents and can be amended as more research becomes available. In 2014, less than 5 years later, all 50 states and the District of Columbia had also adopted

youth sports concussion laws. To put this in perspective, only 21 states require bicycle helmets for all children, and only 34 have a primary seat belt law.

Concannon, Leah G. "Effects of legislation on sports-related concussion." Physical Medicine and Rehabilitation Clinics Of North America (2016).

Udall, Rockefeller Introduce Bill to Help Protect Young Athletes from Sports-Related Traumatic Brain InjuriesThe Youth Sports Concussion Act will: Instruct the Consumer Product Safety Commission (CPSC) to review the findings of a

forthcoming National Academy of Sciences (NAS) report on sports-related concussions in youth;

Authorize the CPSC to make recommendations to manufacturers and, if necessary, promulgate new consumer rules for protective equipment based on the findings of the NAS report; and

Allow the Federal Trade Commission (FTC) to impose civil penalties for using false claims to sell protective gear for sports. State attorneys general could also enforce such violations.

http://www.tomudall.senate.gov/?p=press_release&id=1305 22MAY2013

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Technique and mechanisms

Soccer and Heading the BallSoccer has seen a rapid increase in popularity in the United States over the past 3 decades w/ increased concerns regarding the safety of heading the soccer ball. Study evaluated boys’ and girls’ HS soccer SRCs to identify injury SRC mechanisms, when most SRCs occur, detail heading-related soccer concussion mechanisms, and to compare concussion symptom patterns by injury mechanism.627 concussions were sustained during 1.4M athlete exposures Contact with another player was the most common SRC mechanism Heading was the most common soccer-specific activity Contact with another player was the most common mechanism of injury in heading-related

concussions Although heading is the most common activity associated with concussions, the most

frequent mechanism was athlete-athlete contact. Banning heading from youth soccer would likely prevent some concussions, reducing athlete-athlete contact across all phases of play would likely be a more effective way to prevent concussions as well as other injuries.

Comstock R, Currie DW, Pierpoint LA, Grubenhoff JA, Fields SK. An Evidence-Based Discussion of Heading the Ball and Concussions in High School Soccer. JAMA Pediatr. 2015;169(9):830-837.

Protective Equipment - FB Helmets

Generally speaking there has been little to offer in regards to disruptive innovations in football helmets over the last 50 years.

For example, heads are not round so why do we fit helmets by circumference?

Image provided courtesy of VICIS. All Rights Reserved © 2016

Concussion – FB Helmet Design This Football Helmet

Crumples—and That’s Good Thing.

Gruley B and Robison P. (2016, January 11) Seattle startup Vicis tries to crack a tough market. Bloomberg. Retrieved from http://www.bloomberg.com/features/2016-vicis-football-helmet/

It won’t be close on price. While most adult helmets retail for $200 to $400, the Zero1 will sell for $1,500.

VICIS

Gruley B and Robison P. (2016, January 11) Seattle startup Vicis tries to crack a tough market. Bloomberg. Retrieved from http://www.bloomberg.com/features/2016-vicis-football-helmet/

Helmet Fit and ConcussionLooked at the relationship between football helmet fit and concussion severity. (Level 3 evidence)4580 concussions were analyzed. 3.2% w/ SRC and a helmet that did not fit properly, had higher rates of drowsiness, hyperexcitability, phonophobia, more symptoms, and had longer symptom duration. Athletes with helmets lined with an air bladder had greater rates of photophobia, phonophobia, and longer symptom duration compared with foam or gel liners.CONCLUSION: An improperly fitted football helmet is a risk factor for a concussion with more symptoms and of longer duration. Concussions of longer duration are also more common in players with an air bladder-lined helmet. Current high school football rules should mandate supervision and maintenance of helmet fit throughout the season, prior to impact.CLINICAL RELEVANCE: Team physicians, athletic trainers, coaches, and high school officials should ensure proper oversight of helmet fit in high school athletes to decrease concussion severity and duration.

Inadequate Helmet Fit Increases Concussion Severity in American High School Football Players. Greenhill DA et al. Sports Health. 2016 Mar 22.

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Helmet Type and ConcussionHS Football helmets, despite differences construction, should provide comparable SRC protection. There is debate regarding differences in the rates or severity of concussions based on helmet design, manufacturer, age, etc. HS football SRC and helmet data was collected from 2008-2013.2,900 SRC football concussions were reported. SRC rates significantly increased from 2008 through 2013. SRC s/s were similar among players wearing new helmets when compared with reconditioned helmets. SRC s/s, number symptoms, resolution time, and time to RTP were similar for the most common helmet manufacturers and models. Outcome: Overall, for the most common helmets, new and reconditioned football helmets, provide high school football players with similar protection against concussions.

Concussion Characteristics in High School Football by Helmet Age/Recondition Status, Manufacturer, and Model: 2008-2009 Through 2012-2013 Academic Years in the United States. Collins CJ, et al. Am J Sports Med February 23, 2016

Social Pressure

Social Pressure is not Always a Good Thing

More than half of sports medicine clinicians had experienced pressure from coaches and athletes to return athletes to participation prematurely after a concussion.

Clinicians experienced greater pressure from coaches at schools where the sports medicine department reported to the athletic department than at schools where the sports medicine department reported to an independent medical institution.

Female clinicians experienced greater pressure from coaches than male clinicians experienced.

More research is needed to determine how pressure affects clinical practice and whether pressure on clinicians affects return-to-participation decisions.

Pressure on Sports Medicine Clinicians to Prematurely Return Collegiate Athletes to Play After Concussion. Kroshus E et al. J Athletic Training 2015 50_9 944-951

SRC present a substantial public health burden

Athletes failing to report SRC and continue play are at risk of catastrophic neurologic consequences. Understanding why athletes do or do not report SRC is critical for strategies on risk reduction.

Psychosocial theories are useful in framing this problem. The study quantifies the pressure that athletes experience to continue playing after a head impact--from

coaches, teammates, parents, and fans. N=328 male and female athletes from 19 teams competing in seven sports (soccer, lacrosse, basketball, softball, baseball, volleyball, field hockey) at 4 colleges in NE US. Results found >25% had experienced pressure from at least one source to continue playing after a SRC

the previous year. Athletes who experienced pressure were significantly more likely to continue playing in the future than

were athletes who had no pressure, or only pressure from coaches and teammates. Findings underscore the importance of designing interventions that address the system in which athletes

make decisions about concussion reporting, including athletes' parents, rather than focusing solely on modifying the individual's reporting cognitions.

Concussion under-reporting and pressure from coaches, teammates, fans, and parents. Kroshus E, et al. Soc Sci Med. 2015 Jun;134:66-75.

SRC Under Reporting Previous studies found substantial proportions of athletes with undisclosed concussions. Study examined the prevalence and factors associated with nondisclosure of recalled SRC in

former collegiate athletes. N=800 former collegiate athletes used an online questionnaire to recall self-identified sports-

related concussions (SISRCs) while playing in HS, college, or professionally. 26.9% reported at least 1 SISRC. 33.2% reported not disclosing all SISRC. Former football athletes were most likely to report nondisclosure (68.3%) The prevalence of nondisclosure was higher among men than women. The most commonly reported motivations to not report were: did not want to leave the

game/practice (78.9%), did not want to let the team down (71.8%), did not know it was a concussion (70.4%), and did not think it was serious enough (70.4%).

Conclusion: Consistent with previous studies, a substantial proportion of former athletes recalled SISRCs that were not disclosed. Male athletes were less likely to disclose all of their SISRCs than female athletes.

Head Injury and Concussion: Motivations Associated With Nondisclosure of Self-Reported Concussions in Former Collegiate Athletes. Kerr ZY, et al. Am J Sports Med January 2016 44 220-225

Computerized Neurocognitive Assessment Tools

Limited data exist comparing the performance of computerized neurocognitive tests (CNTs) for assessing sport-related concussion.

Across time, the CNTs’ sensitivities were highest in those athletes who became asymptomatic within 1 day before neurocognitive testing but was similar to the tests’ false positive rates when including athletes who became asymptomatic several days earlier. <They are useful for early assessment>

Analyses of group effect sizes, discrimination, and sensitivity and specificity suggested that the CNTs may add incrementally (beyond symptom scores) to the identification of clinical impairment within 24 hr of injury or within a short time period after symptom resolution but do not add significant value over symptom assessment later.

The rapid clinical recovery course from concussion and modest stability probably jointly contribute to limited signal detection capabilities of neurocognitive tests outside a brief post-injury window.

Prospective, Head-to-Head Study of Three Computerized Neurocognitive Assessment Tools (CNTs): Reliability and Validity for the Assessment of Sport-Related Concussion. Nelson LD et al. JINS, 2016, 22, 24–37

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knowledge

Consistent and Prevalent Indicators of ConcussionSummary of Relevant Findings / Prevalent Indicators Observed and documented disorientation or confusion immediately after the event, Impaired balance within 1 day after injury, Slower reaction time within 2 days after injury, and/or Impaired verbal learning and memory within 2 days after injury. At this time, there are no known objective measures to identify the change in brain

function called concussion. Consequently, observed signs, subjective reports, and objective measures of neurologic and cognitive function that may be indicators of the underlying change in brain function are used to identify individuals with a high likelihood of having a concussion.

Concussion Guidelines Step 1: Systematic Review of Prevalent Indicators. Carney N et al. Neurosurgery 75:S3–S15, 2014

The Sensitivity and Specificity of Clinical Measures of Sport Concussion: Three Tests are Better than One A multidimensional assessment of concussed athletes that included a symptom checklist

and computerized measures of cognitive function and balance resulted in a sensitivity of 80% or 100% using predictive discriminant analysis or clinical interpretation guidelines, respectively.

Individual sensitivities of the component measures using PDA ranged from 52.5% to 77.5%, with an overall sensitivity of 80%.

Overall sensitivity of the battery based on clinical interpretation guidelines was 100%, with sensitivity of each individual measure ranging from 55% to 97.5%.

Findings support the use of clinical interpretation of multidimensional assessment procedures in the management of SC.

The sensitivity and specificity of clinical measures of sport concussion: three tests are better than one. Resch JE, et al. BMJ Open Sport Exerc Med 2016;2:1

Neuroprotection - DHA Efforts to investigate whether naturally occurring supplements and compounds that may

possess anti-inflammatory or beneficial neuroprotective effects in the aftermath of a concussion with human studies are lacking.

Long-chain polyunsaturated fatty acids are an important structural component of the neuronal synaptosomal plasma membrane, but they are underrepresented via our dietary intake. Pretraumatic supplementation of docosahexaenoic acid (DHA) has been demonstrated in rodents, DHA supplementation has been shown to be neuroprotective following either focal or diffuse TBI, to reduce the number of damaged axons, to reduce excitotoxicity, and to provide numerous other multimechanistic benefits to the posttraumatic brain.

Well-designed trials will be required to determine whether DHA supplementation in athletes may improve outcomes following SRC.

Sports-related concussions: diagnosis, complications, and current management strategies. Hobbs JG, et al. Neurosurgical Focus Apr 2016 / Vol. 40 / No. 4 / Page E5.

Neuroprotection – Green Tea Green tea is a commonly discussed product that contains many natural compounds that

have been investigated for their potentially neuroprotective antioxidant and anti-inflammatory properties.

One study (Rezai-Zadeh) demonstrated that green tea reduced the amount of tau phosphorylation and beta-amyloid deposition in a mouse model of Alzheimer disease, which may be relevant given the pathological findings in CTE.

Sports-related concussions: diagnosis, complications, and current management strategies. Hobbs JG, et al. Neurosurgical Focus Apr 2016 / Vol. 40 / No. 4 / Page E5.Green tea epigallocatechin-3-gallate (EGCG) reduces b-amyloid mediated cognitive impairment and modulates tau pathology in Alzheimer transgenic mice. Rezai-Zadeh K, et al. Brain Res 1214:177–187, 2008

Neuroprotection – Ethanol Study determined whether acute EOTH administration could attenuate cognitive deficits

associated with traumatic brain injury. Adult male rats received oral administration of ethanol or drinking water 2 h prior to surgery to produce a blood ethanol concentration of 100 mg% and then received bilateral contusion injuries of the medial prefrontal cortex.

7D after surgery, the rats began 10 days of testing for acquisition of spatial localization in the Morris water maze. The rats given ethanol at the time of injury later spent significantly less time searching for the hidden platform than their water-treated counterparts. On a memory probe test, in which the platform was removed from the pool, rats given the ethanol spent more time in the area where the platform had been located indicating that they learned its location better than the lesion/water controls.

Acute ethanol treatment reduced some of the histopathology that typically occurs following severe contusion but did not attenuate post-traumatic formation of edema. These results indicate that acute ethanol intoxication can reduce the severity of cognitive impairments caused by contusive traumatic brain injury and support the contention that there is a dose-response relationship of acute ethanol intoxication in the setting of traumatic brain injury.

Acute ethanol administration reduces the cognitive deficits associated with traumatic brain injury in rats. Janis et al. J Neurotrauma. 1998 Feb;15(2):105-15.

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Morris Water Maze

The apparatus consists of a large circular pool, generally 1.5 to 2 meters in diameter, containing water at around 25°C made opaque by adding milk or another substance that helps to hide the submerged platform. This choice of water temperature at around 13°C below body temperature is sufficiently stressful to motivate the animals to escape, but not so stressful as to inhibit learning. There is a mild stress reaction on day 1 of training, but this habituates over days. If the pool temperature drops to 19°C, performance improves, but when temperature drops to 12°C, it gets worse -reflecting the inverse U-shaped function relating stress to cognitive function.

Neuroprotection – Hypothermia The role of hypothermia in the management of severe traumatic brain injury remains

controversial.

Recent trials not only failed to demonstrate benefit but also revealed a tendency towards clinical harm.

The time may have come to reconsider the role of hypothermia in the management of severe traumatic brain injury.

Reconsidering the role of hypothermia in management of severe traumatic brain injury. Honeybul S. Journal of Clinical Neuroscience Available online 28 February 2016

Neuroprotection – Cannabidiol Cannabidiol is the nonpsychoactive natural component cannabis that has been shown

to be neuroprotective in multiple animal models. The researchers problem was to remember what they were researching… Their primary screen evaluated the ability of Cannabidiol to prevent damage to

hippocampal neurons induced by ammonium acetate and ethanol at clinically relevant concentrations.

Cannabidiol is effective in models of hepatitis encephalopathy (HE), with limitations in terms of safety and oral bioavailability, but has limitations in terms of safety and oral bioavailability.

Developed KLS-13019 which was 50 X more potent and >400X safer than cannabidioland exhibited an in vitro profile consistent with improved oral bioavailability.

Discovery of KLS-13019, a Cannabidiol-Derived Neuroprotective Agent, with Improved Potency, Safety, and Permeability. Kinney WA et al. ACS Med. Chem. Lett., 2016, 7 (4), pp 424–428

Neuroprotection – Cannabidiol (CBD)

Cannabidiol (CBD) is a non-psychotomimetic phytocannabinoid derived from Cannabis sativa.

It has possible therapeutic effects over a broad range of neuropsychiatric disorders. CBD attenuates brain damage associated with neurodegenerative and/or ischemic

conditions. It also has positive effects on attenuating psychotic-, anxiety- and depressive-like behaviors.

CBD affects synaptic plasticity and facilitates neurogenesis. The mechanisms of these effects are still not entirely clear but seem to involve multiple

pharmacological targets.<SN: this is often in Colorado news for families moving to Colorado with children who have

serious seizure disorders>

Cannabidiol, neuroprotection and neuropsychiatric disorders. Campos AC, etal.Pharmacol Res. 2016 Feb 1.

Will eye tracking change the way we diagnose and classify concussion and structural brain injury? Without accurate diagnostics, classification schemes, outcome measures, and even a

definition, the idea of estimating the incidence and impact of brain injury is a daunting one.

Modern era optometrists can detect abnormal eye movements in up to 90% of patients with so-called mild traumatic brain injury or concussion.

The most commonly detected abnormal eye movement associated with brain injury is a vergence problem. Vergence is the ability of the both eyes to focus together on a single point.

“I would argue that eye tracking might ultimately be used to classify – or even define concussion – and limit its scope to traumatic neurologic injury not apparent on CT scanning and resulting in intracranial mass effect, elevated intracranial pressure or disruption of neurologic pathways.”

Will eye tracking change the way we diagnose and classify concussion and structural brain injury? Samadani U. Concussion, Vol. 1, No. 1, Pages 1-3.

Vestibular/Ocular Motor Screening (VOMS)VOMS evaluates vestibular and ocular motor symptom provocation after SRC. The study examined the internal consistency of the VOMS in a large sample of healthy, nonconcussed collegiate athletes. 263 D1 NCAA athletes completed self-reported demographic and medical history at preseason physical examinations and baseline screening. A series of univariate nonparametric tests were used to examine the associations among medical history risk factors and VOMS clinical cutoff scores, with higher scores representing greater symptom provocation. Internal consistency of the VOMS was high. Female athletes and those with a personal history of motion sickness were more likely to have ≥1 VOMS scores above cutoff levels.Conclusion: The VOMS possesses internal consistency and an acceptable false-positive rate among healthy Division I collegiate student-athletes. Female sex and a history of motion sickness were risk factors for VOMS scores above clinical cutoff levels among healthy collegiate student-athletes. Results support a comprehensive baseline evaluation approach that includes an assessment of premorbid vestibular and oculomotor symptoms.

Kontos, Anthony P., et al. "Reliability and associated risk factors for performance on the vestibular/ocular motor screening (VOMS)tool in healthy collegiate athletes." The American Journal of Sports Medicine (2016): 03635465166

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The King-Devick test of rapid number naming for concussion detection: meta analysis and systematic review of the literature

Vision encompasses a large component of the brain’s pathways, yet is not represented in current sideline testing.

The efferent visual pathways are particularly vulnerable to injury in the acute setting of concussion and may be assessed through visual performance measures such as rapid number naming tasks.

The K-D test is a two minute rapid number naming assessment in which an individual reads numbers aloud quickly from test cards or a computer-based application.

The King-Devick test of rapid number naming for concussion detection: meta-analysis and systematic review of the literature. Galetta KM et al. Concussion (2016) 1(2), CNC8 2016 eISSN 2056–3299.

The King-Devick test of rapid number naming for concussion detection: meta analysis and systematic review of the literature

The King-Devick test of rapid number naming for concussion detection: meta-analysis and systematic review of the literature. Galetta KM et al. Concussion (2016) 1(2), CNC8 2016 eISSN 2056–3299.

Major cortical areas involved in control of eye movements and visual processing,

The King-Devick test of rapid number naming for concussion detection: meta analysis and systematic review of the literature This meta-analysis demonstrates that preseason baseline scores are consistent across

published studies, with high degrees of precision. The K-D test detects concussion with high degrees of sensitivity and specificity, with any

worsening of time score from baseline, indicating a five-times greater likelihood of concussion.

Test-retest reliability is high, and vigorous exercise alone is associated with mild learning effects rather than worsening of scores from preseason baseline.

Among youth, collegiate and adult amateur and professional athletes, rapid number naming using the K-D test adds significantly to sideline assessment and contributes a critical dimension of vision to sports-related concussion testing.

The King-Devick test of rapid number naming for concussion detection: meta-analysis and systematic review of the literature. Galetta KM et al. Concussion (2016) 1(2), CNC8 2016 eISSN 2056–3299.

Is Rest an Effective Intervention?

First 24-48 hours: Probably After that: Inconclusive

Can Rest Actually Be Harmful?

Deconditioning Prolonged vestibular

adaptation Chronic fatigue Depression Maintenance of

anxiety/PTSD (supporting avoidance)

After: Silverberg ND. AAPMR 2014 – San Diego

Iatrogenesis (Craton & Leslie 2014)

Rest vs. Exercise for Post concussion Cares

“The cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve and then a graded program of exertion prior to medical clearance and RTP. The current published evidence evaluating the effect of rest following a sports-related concussion is sparse.” ** Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012

How many clinical trials or carefully controlled studies relating to the benefits of rest in the first 2 weeks following sport-related concussion have been published? Zero

After 3-6 days of bed rest, some people complain of headache, restlessness, and difficulty sleeping. Fortney, Schneider, and Greenleaf (2011)

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Evidence Description

A A strong recommendation that the clinicians provide the intervention to eligible patients.Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm.

B A recommendation that clinicians provide (the service) to eligible patients. At least fair evidence was found that the intervention improves health outcomes and concludes that benefits outweigh harm.

C No recommendation for or against the routine provision of the intervention is made.At least fair evidence was found that the intervention can improve health outcomes, but concludes that the balance of benefits and harms is too close to justify a generalrecommendation.

D Recommendation is made against routinely providing the intervention to patients. At least fair evidence was found that the intervention is ineffective or that harms outweigh benefits.

I The conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention. Evidence that the intervention is effective is lacking, or poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Exercise for Post concussion Cares1. Bed R\rest >3d is NOT recommended (Strength=D)2. Gradual resumption of activities should begin as soon as tolerated (=B)3. For contact sports and other activities with high MTBI exposure risk, a delay of at least 1

week will help reduce the risk of overlapping injuries. (=B)4. Medium and long term risks to exacerbate symptoms are unknown. Heavy exertion that

causes pain may be harmful, exercise should be temporarily modulated to reduce symptoms and then return to activity at a slower pace. (=I)

5. After 1 month supervised exercise should be considered as a part of the treatment plan for individuals who remain symptomatic. (=C)

Is rest after concussion "the best medicine?": recommendations for activity resumption following concussion in athletes, civilians, and military service members. Silverberg ND1, Iverson GL. J Head Trauma Rehabil. 2013 Jul-Aug;28(4):250-9.

Rest vs. Exercise for Post concussion Cares Exercise facilitates molecular markers of neuroplasticity and promotes neurogenesis in the

healthy rodent brain and the injured brain. Associated with changes in neurotransmitter systems.

(Chaouloff, 1989; Molteni, Ying, & Gomez-Pinilla, 2002) Improved mood and lower stress / (Callaghan, 2004; Conn, 2010)

Improved sleep quality / (Youngstedt, 2005)

Positive effects on self-esteem / (Ekeland, Heian, Hagen, Abbott, & Nordheim, 2004)

Effective treatment, or adjunctive treatment, for mild forms of anxiety and depression (Daley, 2008; Mead et al., 2009; Rethorst, Wipfli, & Landers, 2009)

Associated with reduced pain and disability in patients with chronic low back pain (Bell & Burnett, 2009; Henchoz & Kai-Lik So, 2008)

Regular long-term aerobic exercise reduces migraine frequency, severity, and duration (Koseoglu, Akboyraz, Soyuer, & Ersoy, 2003; Lockett & Campbell, 1992)

Second Impact Syndrome SIS Premature return to play for the concussed pediatric athlete may result in devastating

neurological injury. Identification of at-risk patients and ideal management of the concussed athlete remain a challenge.

Authors review a case of SIS in which neuroimaging was obtained between the first and second impacts.

A previously healthy 17-year-old high school football player sustained a helmet-to-helmet hit with an opposing player during a punt return.

He felt momentarily dazed, telling a teammate, “I feel dizzy, I can’t really see straight,” but continued playing.

Witnesses reported that he played the remaining 15 minutes of the game with no apparent difficulty.

Second impact syndrome in football: new imaging and insights into a rare and devastating condition. Weinstein E, et al. J Neurosurg Pediatrics 11:331–334, 2013

Second Impact Syndrome SIS Post game, he reported HA, he attributed specifically to the hit, telling a teammate,

“That was the hardest I’ve been hit in my whole life.” Over the next 3 days he resumed typical activities but complained of fatigue and

persistent headache, exacerbated by lateral upward gaze. F/U with PCP three d. later w/ “normal” exam and (-) CT, told to refrain from practice,

which the athlete ignored and he RTP that afternoon. The following day, (5 days after the initial impact) patient continued to complain about

persistent headache and appeared to have difficulty with concentration. At full-dress practice that afternoon, he participated in hitting drills. After a hit during the drill he was slow in getting up and complained of a HA.

Second impact syndrome in football: new imaging and insights into a rare and devastating condition. Weinstein E, et al. J Neurosurg Pediatrics 11:331–334, 2013

Second Impact Syndrome SIS Several plays later he went down to a knee w/ dizziness, HA, “could not feel his legs”. He subsequently became unresponsive, and there was generalized seizure activity and

he was air evacuated to a trauma center. He was intubated at a local emergency department where noncontrast CT of the brain

demonstrated thin bilateral subdural hematomas. Upon presentation he was intubated w/ a GCS of 7, ICP of 25-30 mm Hg (nl=5-15), pupils

were 3mm bil and sluggish, DTR 3+, Bab absent bil., His hospital course was complicated by hypotension, severe metabolic acidosis, renal

failure requiring hemodialysis, sepsis, ventilator-associated pneumonia with empyema requiring thoracotomy, disseminated intravascular coagulation, and cardiac arrest.

Second impact syndrome in football: new imaging and insights into a rare and devastating condition. Weinstein E, et al. J Neurosurg Pediatrics 11:331–334, 2013

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Second Impact Syndrome SISImages obtained after second impact. A: Arrows point to thin bilateral ASDHs.B: Sagittal T1-weighted brain MR image. Arrows point to downward descent of the midline structures. C: Axial T2-weighted MR image. Arrows point to thalamic injury. D: Axial diffusion-weighted MR image. Arrow points to left thalamic injury. Restricted diffusion was proven by calculation of apparent diffusion coefficient (not shown).

Second impact syndrome in football: new imaging and insights into a rare and devastating condition. Weinstein E, et al. J Neurosurg Pediatrics 11:331–334, 2013

Second Impact Syndrome SIS He was transferred to rehabilitation on hospital Day 54, and discharged to home on

hospital Day 98. At the time of discharge he was nonverbal and nonambulatory.

More than 3 years after his injury, our patient is living at home and has regained limited verbal, motor, and cognitive skills.

Second impact syndrome in football: new imaging and insights into a rare and devastating condition. Weinstein E, et al. J Neurosurg Pediatrics 11:331–334, 2013

Second Impact Syndrome SIS The pathophysiology of SIS is poorly understood, but has previously been thought to

reflect loss of cerebral autoregulation and resultant massive brain swelling, frequently with brain herniation.

A number of authors have hypothesized that this disruption of autoregulation results from re-injury to neuronal cells within a vulnerable period of ongoing derangement from previous injury.

Importantly, this case shows that a normal head CT scan does not obviate the need for close clinical follow-up and for the athlete to be cognitively normal and asymptomatic before return to play.

Second impact syndrome in football: new imaging and insights into a rare and devastating condition. Weinstein E, et al. J Neurosurg Pediatrics 11:331–334, 2013