2018 Sports Concussion Conference Abstracts Supplementsociated with concussions among lower level...

2018 Sports Concussion ConferenceAbstracts SupplementProfiling position specific head trauma in professionalAmerican football based on impact magnitude andfrequencyClara Karton Michael D Gilchrist Thomas Blaine Hoshizaki MD

In American football repetitive brain trauma is associated with high riskof neurologic disorders Head contact is integral to the game resulting inhigh frequency of head contacts during a gameseason Low energyimpacts that do not manifest signs recognized as injury still presentmetabolic andor physiologic changes within the brain The purposewas to estimate player position specific brain trauma profiles based onstrain magnitude and impact frequency Head impacts from 32 gamefilms of professional football were documented and categorized basedon event type head location and velocity for 8 positions Inboundvelocity was calculated using Kinovea 0820 software Events werereconstructed using 50th percentile Hybrid III headform unbiasedneckform linear impactor (collisions) and monorail drop tower (falls)Maximum principal strain (MPS) within the cerebrum was calculatedusing UCDBTM Frequency [p lt 00005] and magnitude [p lt 00005]were significantly different between the 8 positions No significant dif-ferences in frequencies between the following quarterback wide re-ceiver and defensive back running back tight end and linebacker andbetween offensive and defensive linemen Approximately 60 ofdocumented impacts were received by linemen and tight end Themagnitudes of impacts experienced by quarterbacks were significantlydifferent to all positions excluding wide receiver and defensive backWide receiver experienced significantly different magnitudes than bothlinemen and differences were found between offensive linemen anddefensive back Approximately 95 of impacts experienced by linemenwere below 17MPS Conversely over 90 of impacts documented forquarterback were above moderate strain magnitudes (gt17) Resultsshow risks of repetitive trauma and injury vary with position someexperience high frequency impacts of low magnitude while others re-ceive lower hit counts of higher magnitudes Findings showed that tightend and running back are particularly risky with relatively high brainstrain magnitudes coupled with high frequency making them susceptibleto high trauma loads

Disclosures Dr Karton has nothing to disclose Dr Gilchrist has nothing todisclose Dr Hoshizaki holds stock andor stock options in Oblique Tech-nologies Dr Hoshizaki has received research support from CCM HockeyCompany

Laboratory and on-field results of athlete head impactmonitoringAdam Bartsch Rajiv Dama Sergey Samorezov Jay L Alberts Ed Benzel

Vincent Miele Alok Shah John Humm Michael McCrea PhD Brian

Stemper

BackgroundAlthough concussion continues to be a major source of acute andchronic injury in automotive athletic and military arenas concussioninjury mechanisms and risk functions are ill-defined To overcome thisknowledge gap we have developed tested and deployed a head impactmonitoring mouthguard (IMM) system The IMM system was firstcalibrated in 731 laboratory tests against Hybrid III and NOCSAEheadforms with Reference kinematic sensors Next during on-field playinvolving n = 54 amateur American athletes in football and boxing therewere tens of thousands of kinematic signatures collected by the IMM Atotal of 890 true positive head impacts were confirmed using a combi-nation of signal processing and NINDSNIH Common Data Elementsmethods [1]

MethodsLaboratory tests were conducted using an American football helmet(n = 451) padded headform (n = 99) or bare head (n = 181) The IMMincluded kinematics sensors along with associated microprocessorbattery and data transmission Peak linear acceleration (PLA) at head-form center of gravity (cg) was compared in each test between Refer-ence and IMM54 athletes in football and boxing aged 11 to 22 wereconsented Impact with cg PLA as low as 7 g were collected duringpracticesgames

ResultsdiscussionLaboratory data fit a linear model close to ideal y = x + 0 R2 = 1 Therewere gt100000 triggering events with 890 true positives ldquoFalsepositivesrdquo contained high frequency data not indicative of head mo-tion The median99th percentile of (PLA) and (PAA) were 2050 gand 1700 rads24600 rads2 There were no diagnosed concussionsOne athlete was removed by athletic training staff after a significanthead impact

ConclusionsIn the future head impact dynamics data must be correlated with sen-sitive and specific assessments of cognitive executive vision and balanceparameters in order to determine the concussion assessment threshold

DisclosuresDr Bartsch has nothing to disclose Dr Dama has nothing to discloseDr Samorezov has nothing to disclose Dr Alberts has received personal com-pensation for activities with Boston Scientific Corporation Dr Benzel hasnothing to disclose Dr Miele has nothing to disclose Dr Shah has nothing todisclose Dr Humm has nothing to disclose Dr McCrea has nothing to discloseDr Stemper has nothing to disclose

In-season variations in head impact exposure among youthfootball playersJillian Urban Mirellie Kelley Mark Espeland PhD Elizabeth Davenport

Christopher T Whitlow Alexander Powers Joseph Maldjian Joel Stitzel

Sport-related head impacts are of increasing concern as early evidencehas demonstrated a relationship between subconcussive head impactexposure (HIE) experienced in contact sports such as football andchanges in pre-to post-season imaging and cognitive measures Cumu-lative HIE is often measured with a single number that amounts to thetotal exposure measured over the season and does not give any in-dication as to how the exposure was accumulated nor how it variesduring the season Therefore the objective of this study was to compareHIE during preseason the first and second halves of the regular seasonand playoffs in a sample of youth football players (n = 119 ages 9ndash13)Athletes were divided into 1 of 4 exposure groups based on quartilescomputed from the distribution of risk-weighted cumulative exposure(RWECP) The mean 95th percentile linear and rotational accelerationsand impacts per session in practices and games were compared across 4exposure groups and time frames using mixed effects models Withingames the sample mean 95th percentile linear and rotational accel-erations ranged from 472 g and 23313 rads2 during preseason to521 g and 25334 rads2 during the second half of regular season Meanimpacts per practice increased from preseason to the second half ofregular season and declined into playoffs among all exposure groupshowever the variation between time frames was not greater than 2impacts per practice Time of season had a significant effect on mean95th percentile linear and rotational acceleration in games (both p =001) but not on practice accelerations or impactssession Mean 95thpercentile accelerations for games showed significant interaction effectsbetween exposure group and season segment (linear p = 005 and ro-tational p = 004) The results of this study improve our understandingof in-season variations in youth football HIE and may inform importantopportunities for future interventions

S1Copyright copy 2018 American Academy of Neurology

Copyright ordf 2018 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Disclosures Dr Urban has nothing to disclose Dr Kelley has nothing to dis-close Dr Espeland has received personal compensation from Schering-PloughBTG INO Therapeutics and Digestive Care Inc as a data safety monitoringboard member for several industry-sponsored trials Dr Davenport has nothingto disclose Dr Whitlow has nothing to disclose Dr Powers has nothing todisclose Dr Maldjian has nothing to disclose Dr Sitizel has nothing to disclose

Head impact analysis in elite football (soccer)Bianca Brigitte Rock Thomas Blaine Hoshizaki MD

IntroductionTrauma related neuropathologies including recent reports involvingchronic traumatic encephalopathy (CTE) in 8 soccer players have beenconcerning Purposeful sub-concussive head impacts known as headersare an integral part of the game The purpose of this study was todescribe dynamic head response and brain tissue strains for front ball-to-head impacts in elite soccer

MethodsVideo analysis thirteen (13) Championrsquos League soccer footage wascompleted to establish reconstruction parameters of head impact eventsAnalysis of 5 (5) front ball-to-head events were reconstructed usinga Hybrid III 50th percentile headform and a pneumatic linear impactorThe University College Dublin Brain Trauma Model was used to cal-culate maximum principal strain (MPS)

Results and discussionRecorded head impact velocities during elite soccer game play were35ndash230 ms Most purposeful head-to-ball impacts occurred on thefront-temporal region of the head (664) at 0ndash15 degrees of cervicalflexion There was an average of 15 unintentional head impacts and 622headers per game 496 of headers occurred at an inbound velocitybelow 10 ms The lowest velocity reconstructed was 47 ms yielding128 g and 604 rads2 for peak resultant linear and rotational accel-erations respectively the MPS for this impact was 009 Neurophysi-ologic changes and functional impairment have been reported in pastresearch on sub-concussive impacts with 5ndash15 strain The mean 011MPS yielded in this study reflects a potential for these changes in elitesoccer athletes

ConclusionThe main objective of this analysis was to identify impact characteristicsand quantify dynamic cerebral response and brain tissue deformation inelite soccer game play Further research must include cervical muscleactivation the level of play and player position inbound ball-to-headvelocities during different game play events and appropriate impactcharacteristics to appropriately characterize risk of injury in the attemptsof mitigating risk of head injury during soccer game play

DisclosuresDr Rock has nothing to disclose Dr Hoshizaki holds stock andorstock options in Oblique Technologies Dr Hoshizaki has received researchsupport from CCM Hockey Company

Football concussion case series using biomechanical andvideo analysisMirellie Kelley Jillian Urban Derek Jones Alexander Powers Christopher T

Whitlow Joseph Maldjian Joel Stitzel

Approximately 11ndash19 million sport-related concussions among ath-letes le18 years of age occur annually in the United States but there islimited understanding of the biomechanics and injury mechanisms as-sociated with concussions among lower level football athletes There-fore the objective of this study was to combine biomechanical headimpact data with video analysis to characterize youth and HS footballconcussion injury mechanisms Head impact data were collected fromathletes participating on 22 youth and 6 HS football teams between2012 and 2017 Video was recorded and head impact data were

collected during all practices and games by instrumenting players withthe Head Impact Telemetry (HIT) System For each clinically di-agnosed concussion a video abstraction form was completed whichincluded questions concerning the context in which the injury occurredLinear acceleration rotational acceleration and impact location wereused to characterize the concussive event and each injured athletersquos headimpact exposure on the day of the concussion A total of 9 (5 HS and 4youth) concussions with biomechanics and video of the event wereincluded in this study The mean [range] linear and rotational accelera-tion of the concussive impacts were 629 [293ndash1184] g and 30567[10468ndash69546] rads2 respectively Concussive impacts were thehighest magnitude impacts for 6 players and in the top quartile of impactsfor 3 players on the day of injury Concussions occurred in both practices(N= 4) and games (N= 5) Themost common injury contact surface washelmet-to-helmet (N = 5) followed by helmet-to-ground (N = 3) andhelmet-to-body (N = 1) All injuries occurred during player-to-playercontact scenarios including tackling (N = 4) blocking (N = 4) andcollision with other players (N = 1) The biomechanics and injurymechanisms of concussions varied among athletes in our studyhowever concussive impacts were among the highest severity foreach player and all concussions occurred as a result of player-to-playercontact

Disclosures Dr Kelley has nothing to disclose Dr Urban has nothingto disclose Dr Jones has nothing to disclose Dr Flood has nothing to discloseDr Powers has nothing to disclose Dr Whitlow has nothing to disclose DrMaldjian has nothing to disclose Dr Stitzel has nothing to disclose

Comparing head impact kinematics simultaneously measuredusing 6 different sensors in a human cadaver modelJames T Eckner MD R Scott Conley Hugh JL Garton Nikki Weiss Lauro

Ojeda Amanda O Esquivel Ryan Kassel Grant Kulik Patrick J Ransford

Steven Broglio PhD James A Ashton-Miller

ObjectiveTo compare head kinematics measurements obtained from 6 differenthead impact sensors utilizing different methods of sensor-to-headfixation

DesignFree-drop impacts (total n = 54) were performed at 35 and 55 msonto to the front back side and top of 2 elderly human cadaverichead-neck specimens a helmeted (Riddell Revolution Speed) malespecimen was dropped onto a NOCSAE testing pad an un-helmetedfemale specimen was dropped onto a framed sample of field turf Thespecimens were instrumented with an intracranial reference sensorsurgically mounted at the approximate head center-of-mass bya rigidly-fixed custom standoff pad an intra-oral test sensor rigidlyfixed to the upper teethhard palate by a custom orthodontic ap-pliance and 4 commercially available head impact sensing systemsX-Patch Vector mouth guard HITS (helmeted condition only) andG-Force Tracker (affixed to helmet interior or head band dependingon helmet status) Peak linear and rotational head accelerations(PLA and PRA) were compared between each sensor and the in-tracranial reference sensor using intraclass correlation coefficients(ICC [2 1])

ResultsAgreement with reference PLA and PRA values differed betweensensors with the greatest agreement observed for the rigidly affixedintraoral sensor (ICC = 0921 PLA ICC = 0810 PRA) Agreementfor PLA and PRA respectively was for X-Patch ICC = 0638 ICC =0155 for Vector mouth guard ICC = 0775 ICC = 0480 for HITSICC = 0662 (PLA only) for G-Force Tracker ICC = 0364 (PLAonly)

S2 Neurology | Volume 91 (Suppl 2) | December 4 2018 NeurologyorgN


DiscussionHead kinematics measurements during free-drop testing differed amongsensors using different approaches of fixation to the head There wasgreater agreement with intracranial reference PLA and PRA values fora rigidly affixed intraoral sensor utilizing an orthodontic appliance thanfor commercially available sensors incorporated into athletic equipmentor otherwise non-rigidly affixed to the head Measurement error at-tributable to non-rigid sensor-head coupling could potentially be re-duced by incorporating an impact sensor into an orthodontic appliancein future research

Disclosures Dr Eckner has nothing to disclose Dr Conley has nothing todisclose Dr Garton has nothing to disclose Dr Weiss has nothing to dis-close Dr Ojeda has nothing to disclose Dr Esquivel has received personalcompensation for consulting serving on a scientific advisory board speakingor other activities with Beaumont Hospital Farmington Hills EmergencyMedicine Department Dr Kassel has nothing to disclose Dr Kulik hasnothing to disclose Dr Ransford has nothing to disclose Dr Broglio hasnothing to disclose Dr Ashton-Miller has received personal compensationfor activities with American Medical Systems Inc and Johnson amp JohnsonInc Dr Ashton-Miller has received research support from American MedicalSystems Inc

Biomechanical comparison of concussions with and withouta loss of consciousness in elite American footballJanie Cournoyer Thomas Blaine Hoshizaki MD

IntroductionLoss of consciousness (LOC) occurs with approximately 8 percent ofconcussions in professional American football and has been associatedwith severity of injury (1 2) However it is unknown how LOC relates toseverity of head impact responses The purpose of this study was tocompare the head accelerations and brain tissue deformation betweencases of concussions with and without LOC in elite American football toinform prevention strategies

MethodsConcussive injuries with and without LOC from helmet-to-helmet andshoulder collisions as well as falls in elite American football werereconstructed in laboratory using hybrid III headform to obtain peaklinear and rotational acceleration and maximum principal strain cu-mulative strain damage at 10 and strain rate metrics in 5 brain regionsassociated with loss of consciousness

ResultsImpact velocity peak linear and rotational acceleration were greaterin the LOC group than the no LOC group The brain tissue de-formation metrics were greater in the LOC group than the no LOCgroup Linear acceleration was most predictive for cases of helmet-to-helmet collisions whereas shoulder collisions were best predictedby rotational acceleration The best overall predictor was impactvelocity

DiscussionconclusionThe presence of a loss of consciousness in concussive impacts is a resultof greater magnitude of brain tissue trauma This was primarily causedby greater impact velocities in head impacts leading to LOC Rulesaiming at mitigating this aspect of the game would decrease the risk ofa loss of consciousness in this sport Each type of events resulted indifferent values of kinematic data and brain tissue deformation whichsuggests that studies evaluating risk of concussions based 1 type of eventcannot be generalized

Disclosures Dr Cournoyer has nothing to disclose Dr Hoshizaki holds stockandor stock options in Oblique Technologies Dr Hoshizaki has received re-search support from CCM Hockey Company

References1 American Academy of Neurology Practice parameter the management of concussion

in sports (summary statement) Report of the Quality Standards SubcommitteeNeurology 199748581ndash585

2 McCrory P Meeuwisse W Dvorak J et al Consensus Statement on concussion insportmdash5th international conference on concussion in sport held in Berlin October2016 Br J Sports Med 201751838ndash847

A common data language for biomechanical devices used inTBI clinical research The National Institute of NeurologicalDisorders and Stroke (NINDS) and Department of Defense(DoD) CDE recommendationsKatelyn Elizabeth Gay Adam Bartsch David Camarillo Carol Taylor-Burds

Muniza Sheikh Joy R Esterlitz Kristen R Joseph MA Carolina

Mendoza-Puccini Patrick Bellgowan

ObjectiveThe NINDS Common Data Element (CDE) project provides datastandards for clinical research in neuroscience NINDSNIH and DoDcollaborated to develop CDE recommendations for BiomechanicalDevices in TBI CDEs increase efficiency of clinical research studies byreducing study start-up time and cost increasing data quality facilitatingdata sharing and aggregation and helping educate new clinicalinvestigators

BackgroundIn January 2017 a working group (WG) of subject matter experts fromacademia industry and the military convened to develop CDE recom-mendations for blast blunt head impact and inertial-loading exposuresmeasured by biomechanical devices These CDEs are available asa subset of the TBI recommendations under the DiseaseInjury RelatedEvents Domain and Biomechanical Devices Sub-Domain on theNINDS CDE website

DesignmethodsTheWG divided into 3 subgroups Head Accelerometry Impact Videoand Blast Exposure to review commonly collected data and analysismethods The Head Accelerometry subgroup focused on data capturedby kinematic sensors in sportsactivities The Impact Video subgroupaddressed the use of video information to confirm device measure-ments The Blast Exposure subgroup compared data from researchsources using blast overpressure sensors Subgroup recommendationswere reviewed internally across the WG before being posted for publicreview

ResultsTheWGrsquos end products are summaries CDE metadata and templatecase report forms Assigned classifications guide researchers inselecting CDEs Supplemental-Highly Recommended (essential forspecified conditions study types or designs) Supplemental (com-monly collected but not required) and Exploratory (reasonable touse but require further validation) Version 10 recommendationswere made available for use through the NINDS CDE website in lateFebruary 2018

ConclusionThese new CDE recommendations will facilitate robust metadataanalysis and data-sharing NINDS encourages use of CDEs for allclinical research in neuroscience NINDS CDEs are a dynamic re-source which is updated periodically based on the current state ofscience

DisclosuresDr Gay has nothing to disclose Dr Bartsch has nothing to discloseDr Camarillo has nothing to disclose Dr Taylor-Burds has nothing to discloseDr Sheikh has nothing to disclose Dr Esterlitz has nothing to disclose DrJoseph has nothing to disclose Dr Mendoza-Puccini has nothing to disclose DrBellgowan has nothing to disclose

S3NeurologyorgN Neurology | Volume 91 (Suppl 2) | December 4 2018


Psychometric proprieties of a color-shape version of theswitch taskVeronik Sicard Alexe Simard Robert Davis Moore Gabriel Lavoie Dave

Ellemberg

The impact of concussions on an individualrsquos cognitive functioning hasbecome a growing health concern over the past several years howeverthe search for sensitive tests persists The task-switching paradigm isknown to be sensitive to various medical conditions including concus-sion Accordingly we developed 2 versions of the color-shape switch taskThree different costs are computed from the raw scores global switchcost which is thought to be a measure of global cognitive control localswitch cost which is believed to be a measure of cognitive flexibility andworking memory cost The aim of this study was to evaluate psycho-metric characteristics of these costs An ANOVA revealed a main effect ofsex on local latency switch cost with females exhibiting longer latenciesthan males p = 005 No main effect of sex was observed on any otherswitch costs Moreover no main effect of experimenter or version of thetask was observed Local switch cost was significantly correlated withtrails 4 and 5 of the Comprehensive Trail Making Test (rs gt 021 ps lt004) No other significant correlation between costs and establishedneuropsychological tests was observed indicating low convergent val-idity The intraclass correlation coefficient estimates ranged from 023 to077 suggesting low-to-moderate 1-week test-retest reliability Resultsindicated a low switch costs convergent validity Moreover results showthat the traditionally computed switch costs are less reliable than theprimary outcomes (ie reaction time and accuracy) Researchers andclinicians should rely on primary variables from the task-switching par-adigm rather than computing the traditional switch costs to increase thepsychometric properties of the tasks which is critical to advances intheoretical models of executive functions and evaluations of clinicalpopulations

Disclosures Dr Sicard has nothing to disclose Dr Simard has nothing todisclose Dr Moore has nothing to disclose Dr Lavoie has nothing to discloseDr Ellemberg has nothing to disclose

Measurement properties of the Dynavision D2 one-minutedrill task in active adolescentsTamara McLeod R Curtis Bay Hannah Gray Richelle Marie Williams

ObjectiveThe purpose of this study was to evaluate test-retest reliability andpractice effects of the Dynavision D2 in active adolescents

BackgroundFollowing sport-related concussion assessment of oculomotor functionand vision is important While clinical tests are recommended comput-erized devices such as the Dynavision D2 are emerging as viable tools forvision assessment As with all concussion assessments understanding test-retest reliability and susceptibility to practice effects is important for ap-propriate interpretation of serial assessments post-injury

DesignmethodsParticipants included 20 female adolescents (age = 166 plusmn 110 yearsmass = 620 plusmn 59 kg height = 1692 plusmn 51 cm) Participants completed 2test sessions 1 week apart using the Dynavision D2 The Dynavision D2includes a one-minute drill task where a single light illuminates andparticipants hit the light as quickly as possible completing 3 drills pertrial Participants completed 3 trials during the first session and 2 duringthe second Independent variables were day (day 1 day 2) and drills(15 drills) Dependent variables were the number of hits per minute(Hitsmin) and average reaction time (AvgRT) Within-day andbetween-day test-retest reliabilities were analyzed using two-way ran-dom effects intraclass correlation coefficients for consistency Practice

effects were analyzed with repeated measures analysis of variance andHelmert contrasts (p = 0=05)

ResultsModerate-to-strong reliability was demonstrated for Hitsmin (within-day 1 [ICC = 074 95 CI 053 087] within-day 2 [ICC = 091 95CI 7797] between-days [ICC = 086 95 CI 6595]) Moderate-to-strong reliability was demonstrated for AvgRT (within-day 1 [ICC =070 95 CI 4886] within-day 2 [ICC = 092 95 CI 7897]between-days [ICC = 085 95 CI 06494]) Practice effects werenoted for HitsMin (p = 0001) and AvgRT (p lt 0001) Helmertcontrasts suggested that the practice effect plateaued at drill 11 for Hitsmin and drill 12 for AvgRT

ConclusionsModerate-to-excellent test-retest reliability was found for the one-minute task drill with better reliability noted on day 2 and between dayscompared to day 1 This task is susceptible to practice effects high-lighting the need for familiarization or practice trials prior to doc-umenting patient scores

DisclosuresDrMcLeod has nothing to disclose Dr Bay has nothing to discloseDr Gray has nothing to disclose Dr Williams has nothing to disclose

Half of purposeful sandbaggers undetected by ImPACTrsquosembedded invalidity indicatorsCourtney Raab Amy Peak

ObjectiveThe primary objective of this study is to determine the ability of em-bedded invalidity indicators (EIIs) within the Immediate Post-concussion Assessment and Cognitive Test (ImPACT) to accuratelyidentify individuals purposefully underperforming (sandbagging) on thebaseline assessment The secondary objective is to determine if any ofthe 5 specific EIIs are more or less likely to identify purposefulsandbaggers

BackgroundSandbagging baseline neuropsychological tests is a growing problemwith significant potential consequences including premature post-concussion clearance

DesignmethodsVolunteers were recruited to complete a baseline ImPACT assessmentParticipants were randomized to either a control group or a coachedsandbagging group Primary outcome measures were the number ofparticipants identified as invalid via any EII as well as mean raw com-posite scores and percentiles for each sub-section within the ImPACTassessment

ResultsSeventy-seven participants (37 control and 40 sandbaggers) completedthe study Only half (50 n = 20) of the purposeful sandbaggers wereidentified via any EII Appropriately no participants in the control groupwere identified as invalid The Working Memory EII correctly identified40 of the purposeful sandbaggers and the Three Letters EII identified35 of purposeful sandbaggers All other EIIs identified 15 of pur-poseful sandbaggers Twenty-six purposeful sandbaggers achieved atleast 1 composite sub-score 1st percentile 27 of those were notidentified via any EII One participant scored le 1st percentile in everycomposite category and was not identified via any EII

ConclusionSandbagging baseline ImPACT assessments without detection likelyoccurs more often than previous literature suggests Half of purposefulsandbaggers were not identified via current EIIs and 3 of 5 EIIs



identified 15 of purposeful sandbaggers Re-evaluation or recalibrationof ImPACTrsquos current EIIs may be appropriate

Disclosures Dr Raab has nothing to disclose Dr Peak has nothing to disclose

Evaluation of multisensory responses (oculomotorvestibular and reaction time) in 3 8 and 15 days after mildtraumatic brain injuryAlex Kiderman PhD Carey Balaban Mikhaylo Szczupak Hillary Snapp

Michael Hoffer

BackgroundDespite the prevalence of mild traumatic brain injury (mTBI concus-sion) in a wide range of occupational sport and military settings ac-curate diagnosis and optimal treatment of concussive injuries aredelayed by several challenging obstacles Ability to measure the multi-sensory functional integrity of numerous neuroanatomical pathwayswith multiple tasks (oculomotor vestibular and reaction time) cancapture impairments of brain function

Methods106 mTBI patients and 300 control subjects were tested in the ves-tibular labs at 2 military hospitals Patients were tested 3 times ataverage 25 85 and 158 days post-injury All patients completeda health history questionnaire a dizziness handicap index (DHI)a functional gait index (FGI) and Trail Making Tests (TMTs) andwere assessed by a battery of tests with video-oculography (I-PortalVOG) comprised of a head mounted high speed eye tracking systemon a rotary chair device (I-Portal Neuro-Otologic Test Center) Theindividuals in the study performed multiple tests including saccadesantisaccade pursuit tracking nystagmus optokinetic vestibular mo-tion and reaction time

ResultsNo single test was sufficiently predictive to have separation betweencontrols and mTBI subjects but results from a computer controlledrotational head impulse test (crHIT) antisaccade and predictive saccadewere highly correlated with mTBI for the first test session Longitudi-nally for example 74 of patients in session 1 56 in session 2 and51 in session 3 had in crHIT gain or absolute asymmetry above 95 ofthe respective controlrsquos distribution

ConclusionThese results suggest that vestibular oculomotor and reaction time testsusing can provide an objective and reliable method of capturing andquantifying abnormal response in patients with mTBI In addition thistype of testing can be used to monitor the recovery process

Disclosures Dr Kiderman has nothing to disclose Dr Balaban has nothing todisclose Dr Szczupak has nothing to disclose Dr Snapp has nothing to discloseDr Hoffer has nothing to disclose

Effects on intracranial cerebral blood flow by history ofconcussionYu Hiramoto Haruo Nakayama Satoshi Iwabuchi

AimDecrease of intracranial cerebral blood flow is an important factor inpathophysiology of concussion Transcranial Doppler (TCD) is simpleand minimally invasive tool that can evaluate intracranial cerebral bloodflow

MethodWe examined University American football players number of 81players In the pre-season (before interpersonal contact) We evaluatedtheir cerebral function with SCAT and evaluated intracranial cerebral

blood flow with TCD by the same examiner Forty-five players fromwhich TCD waveforms could clearly be depicted were targeted Wedivided them into concussion group (7 players with a history of con-cussion) and non-concussion group (38 players without a history ofconcussion) And we examined the score of SCAT and the parameter ofTCD between the 2 groups

ResultThe average score of SCAT was 914 points and there was no differencebetween the 2 groups due to the history of concussion For parameter ofTCD the average of the depth is 649 mm the average of Mean flowvelocity is 374 cms (plusmn92) the average of Peak flow velocity is664 cms (plusmn170) There was no difference between the 2 groups due tothe history of concussion

ConclusionIn this study there was no significant difference in the parameter ofTCD or SCAT due to the presence or absence of concussion history

DisclosuresDr Hiramoto has nothing to disclose Dr Nakayama has nothing todisclose Dr Iwabuchi has nothing to disclose

Concussion history and career status influence sportsconcussion assessment tool (SCAT-3) performance in elitefootball playersBrittani Cookinham Chad Swank

ObjectiveTo determine if concussion history and career status influences baselineSports Concussion Assessment Tool (SCAT-3) performance in elitefootball players

DesignmethodsFifty-seven elite football players (age 2939 plusmn 749 years) categorizedby career status (draft prospects active professional players and retiredprofessional players) underwent SCAT-3 assessments The SCAT-3was administered in accordance to published recommendations14 Toexamine our primary purpose participants were placed into eithera low concussion history (0ndash1 concussions) or multiple concussionhistory (2 + concussions) group A Mann-Whitney U test was used toexamine the differences of concussion history on SCAT-3 totalsymptoms total symptom severity SAC total scores and m-BESSbalance scores To examine our secondary purpose a Kruskal-Wallistest and a post-hoc analysis was used to analyze differences betweencareer status categories

ResultsAt baseline common baseline symptoms were fatigue (456) troublefalling asleep (351) difficulty remembering (333) and irritability(228) 368 reported no symptoms The low concussion (0ndash1)group reported fewer symptoms (U = 60850 p = 0001) less symptomseverity (U = 59800 p = 0001) and produced greater scores on theStandardized Assessment of Concussion (SAC) total scores comparedto the multiple concussion (2+) group (U = 25300 p = 0024) but nodifferences were observed on modified Balance Error Scoring System(m-BESS) scores (U = 50150 p = 0066) on the Mann-Whitney U testThe Kruskal-Wallis Test and post-hoc analysis indicated retired playerswere significantly different from draft prospects and current professionalplayers for total symptom scores (p lt 0001) total symptom severity(p lt 0001) SAC total scores (p = 0030) and m-BESS (p lt 0001)

ConclusionsConcussion history and career status appear to influence performanceon the SCAT-3 in elite football players With this in mind future re-search is recommended to determine normative scores on the SCAT-3for elite football players



Disclosures Dr Cookinham has nothing to disclose Dr Swank has nothing todisclose

Balance performance maintained during dual-task conditionwith a cognitive task across menstrual cycleMeng Ni Joseph Hazzard Jr EdD ATC Pamela Smith

BackgroundDual-task performing a balance task and a cognitive task simulta-neously has been used as sport-related concussion assessment toolHowever the effect of dual task on balance performance remains con-troversial Also the fluctuation of hormone across menstrual cycle onbalance and dual-task performance has not been fully examined

ObjectiveTo examine (1) the effect of dual task on balance performance (2) theinteraction of female sex hormonal level balance and dual-taskperformance

DesignA cohort study

SettingA laboratory of concussion research and services

ParticipantsA group of 49 healthy female college-aged students (age = 216 plusmn 20years)

Main outcome measuresThe Stability Evaluation Test (SET) protocol Balance error scoringsystem (BESS) test and postural sway velocity (degsec) by using VSRSPORT force plate Three auditory mathematics questions were givenfor each condition of the SET test Two single-task conditions wereprovided including balance only and math only Balance test and mathquestions were given simultaneously during the dual-task condition

ResultsThere was no significantly statistically difference in BESS or sway ve-locity between single and dual task However the performance of mathcalculation is better in dual-task comparing to the single task (mathonly) with an 8ndash12 higher rate of accuracy but it didnrsquot reacha statistical significance The rate of accuracy during the dual task didnrsquotvary among menstrual phases

ConclusionsBalance performance was maintained under dual-task conditions andfluctuation of female sex hormones across the menstrual cycle may notaffect working memory and executive function These findings are po-tentially clinically applicable to detecting balance deficits and cognitivealterations in female concussed individuals Future studies are needed toinvestigate the underlying mechanism of balance maintenance and at-tention dividend under dual-task conditions

DisclosuresDr Ni has nothing to disclose Dr Hazzard has nothing to discloseDr Smith has nothing to disclose

The influence of concussion knowledge on reportingintentions in collegiate student-athletesLandon Bryce Lempke ATCMichelleWeber Robert Lynall Julianne Schmidt

BackgroundConcussion education programs have been implemented across sportassociations to improve concussion recognition and reporting inten-tions Despite widespread implementation no studies have examinedthe influence of concussion knowledge on reporting intentions in col-legiate athletes

PurposeTo (1) examine if concussion knowledge is a predictor of concussionreporting intentions and (2) identify concussion knowledge differencesbased on sex age and years of sport eligibility remaining in collegiateathletes

MethodsOne-hundred five collegiate athletes across 3 universities completed anonline reporting intentions survey (consisting of indirect and directreporting intentions) and 2 online concussion knowledge surveys (indirectknowledge agreement and direct knowledge assessment [comprised ofsignssymptoms recognition and general knowledge]) across a four-monthperiod General linear models were used to test whether concussionknowledge outcome scores predicted indirect and direct reporting inten-tions and if concussion knowledge differed within demographic factors

ResultsIndirect knowledge agreement explained 129 of direct reportingintentions variability (R2 = 0129 F3 73 = 361 p = 0017) Knowledgedid not predict indirect reporting intentions (p = 0152) Femalesdemonstrated greater signs and symptoms recognition than males(females 791 plusmn 123 vs males 730 plusmn 135 p = 0017 d = 047)Knowledge outcomes did not differ between sexes (p ge 0117) agegroups (p ge 0491) or years of eligibility remaining (p ge 0393) Neitherage (p ge 0491) nor years of sport eligibility remaining (p ge 0393)affected concussion knowledge outcome measures

ConclusionsConcussion knowledge has limited predictive capabilities for de-termining reporting intentions Although statistically significant con-cussion knowledge sex differences may not be clinically meaningfulClinicians should take caution in relying heavily on knowledge inter-ventions to influence concussion reporting Future studies should ex-amine the role psychosocial factors play in improving concussionreporting

Disclosures Dr Lempke has nothing to disclose Dr Weber has nothing todisclose Dr Lynall has nothing to disclose Dr Schmidt has nothing to disclose

Sports-related concussion knowledge and attitudes ofintramural and club sport athletesDevon Freudenberger Victoria Lucia

IntroductionSports-related concussions have attracted greater public health concernas their incidence rises leading to changes in concussion education andlaws protecting athletes Currently the intramural and club sport pro-grams at Oakland University (OU) (Rochester Michigan) do not havea concussion education program for its athletes Therefore determiningthe knowledge and attitudes these athletes have towards concussions isessential in determining whether a program is needed We hypothesizedthat due to the lack of a concussion education program athletes at OUdo not possess adequate knowledge and harbor unhealthy attitudestowards concussions

MethodsA validated and reliable concussion knowledge and attitudes survey wasidentified modified and distributed to athletes participating in intra-mural and club sports at OUrsquos Recreation Center The responses werescored generating concussion knowledge and attitude scores Data wasanalyzed using t-tests to evaluate significant differences between dif-ferent groups

ResultsOne hundred eight-two of 200 respondents had complete survey data ofwhich 536 were female and 464 male 599 participated in



intramural sports only 264 in club sports only and 137 in bothThe mean overall knowledge and attitude scores were 806 and 748respectively These scores did not vary by sport participation (p = 0685p = 051) Female athletes had significantly higher knowledge than maleathletes (p = 0011) Athletes majoring in health science fields hadsignificantly higher knowledge than athletes in non-health sciencemajors (p = 0006) but similar attitudes (p = 0697)

ConclusionsWhile the results indicate that OU athletes possess some knowledge andgenerally healthy attitudes there is room for improvement that could bemet with a single concussion education program for both intramural andclub sport athletes Despite having significantly higher knowledgehealth science athletes did not display healthier attitudes than non-health science athletes suggesting that knowledge does not alwaysconfer healthier attitudes Therefore a concussion education programshould emphasize improving athlete concussion attitudes

DisclosuresDr Freudenberger has nothing to disclose Dr Lucia has nothing todisclose

Effect of contextualprocedure-based concussion educationon community college student-athlete reporting ofconcussionNancy Chinn EdD Monica Ohkubo Brianna Scott

Various measures have been recommended to facilitate early identi-fication of concussion including concussion education Most com-monly concussion education is provided via lecture video andwritten materials The extent to which these modes of concussioneducation result in greater self-reporting of concussion by student-athletes is unclear This retrospective study compared student-athleteconcussion reporting behaviors of participants who received tradi-tional concussion education with those who also received a contex-tualprocedure-based learning approach Sports medicine charts werereviewed for 2 groups collegiate student-athletes (n = 301) who re-ceived concussion education in the fall semester of 2015 in a classroomsetting that included lecture hand-outs and viewing a video (Tradi-tional Learning Group) and collegiate student-athletes (n = 271) whoreceived traditional education in the fall 2016 semester and addi-tionally received contextualprocedure-based learning approach(ContextualProcedure-based Learning Group) Data was analyzedusing a series of t-tests Percent of concussions identified increased by42 when comparing the fall 2015 Traditional Learning Group to thefall 2016 ContextualProcedure-based Learning Group Self-reportingof concussion by student-athletes increased 69 in the ContextualProcedure-based Learning Group Time to report concussion wassignificantly lower for participants in the ContextualProcedure-basedLearning Group but this result was specific only to male student-athletes This study indicates a contextualprocedural-based learningapproach to concussion education may positively influence reportingand reduce time to report when compared to a more traditionallecture-based approach to concussion education

Disclosures Dr Chinn has nothing to disclose Dr Ohkubo has nothing todisclose Dr Scott has nothing to disclose

The stability of ImPACT baseline test performance overa 3-year period in high school athletesNicholas Erdman AT SamuelWalton MEd Jeremy Eith Lizzie Leitch Joanna

Shutzer Shari Norte Munro Cullum PhD Jacob Resch PhD

PurposeAnnual baseline assessment using computerized neurocognitive testshave been recommended by governing healthcare bodies for the man-agement of sport-related concussion but is supported by limited

evidence The current study examined the stability of ImPACT per-formance across three-successive years in adolescent athletes

MethodThis prospective cohort included 229 (117 male 112 female) high schoolstudent-athletes from 2 private high schools ImPACT was administered ina controlled group setting (1ndash17 participants) at years 1 (T1 n = 229) 2(T2 n = 101) and 3 (T3 n = 47) Repeated measures analyses of variance(ANOVA 4 times 3) were used to examine performance on ImPACTrsquos VerbalMemory (VEM) Visual Memory (VIS) Visual Motor Speed (VMS) andReaction Time (RT) composite scores Paired t-tests were used for post-hoc analyses Two-waymixed intraclass correlation coefficients (ICC [31])with 95 confidence intervals (CI) were calculated between time pointsGroup mean and within-subject differences between each time point forImPACT scoreswere analyzed usingmanufacturer provided reliable changeindices (RCI) All analyses were performed with alpha = 005

ResultsA significant main effect was observed for VMS (F [292] = 2790 p =0001) across time Participants significantly improved on VMS betweenT2 and T1 (t [100] = 415 p = 0001) T3 and T2 (t [46] = 719 p =0001) and T3 and T1 (t [46] = 385 p lt 0 001) Weak (VEM ICC =037 CI = 019 055) to strong (VMS ICC = 083 CI = 074 090)ICCs were observed for ImPACT scores No group mean differencesexceeded the 80 CI for ImPACTrsquos RCI although within-subject dif-ferences for at least 1 score exceeded the 80 CI between T2 and T1(24ndash39) T3 and T2 (26ndash45) and T3 and T1 (32ndash51)

ConclusionsOverall statistically significant improvement was observed for VMShowever the magnitude of the change may not be clinically meaningfulSimilar to previous research reliability of ImPACT scores ranged fromweak to strong Our results support annual baseline assessment of youngathletes for progression of neurocognitive functioning

Disclosures Dr Erdman has nothing to disclose Dr Walton has nothing todisclose Dr Eith has nothing to disclose Dr Leitch has nothing to disclose DrShutzer has nothing to disclose Dr Norte has nothing to disclose Dr Cullum hasnothing to disclose Dr Resch has nothing to disclose

Return to play following a sports concussion The ldquoaddedvaluerdquo of post-exertion assessmentVeronik Sicard Jean-Christophe Lortie Robert DavisMoore Dave Ellemberg

Decision of return to play (RTP) after a concussion is critical given thepotential consequences of premature RTP Athletes should not becleared for full contact activity until they demonstrate normal cognitivefunctioning on both rest and post-exertion assessments Accordinglythis study aimed to examine post-exertion cognitive performance inasymptomatic collegiate athletes who were cleared to return-to-playTwenty-two recently concussed athletes who completed step 4 ofZurichrsquos RTP protocol and 39 teammate controls participated in thestudy They completed a Switch task before and after an acute bout ofmoderate cardiovascular exercise (80ndash85 maximal predicted maxi-mal heart rate for 20-minute) on an ergocycle Based on their perfor-mance on both conditions (Rest Post-exertion) concussed athleteswere categorized into the Pass or Fail group Specifically they wereplaced in the Fail group if their performance was 2 SD lower than thecontrol grouprsquos average score A χ2 test was used to test for equality ofproportions between conditions Although the proportion of athletescategorized in the Fail group was higher in post-exercise (3182) rel-ative to rest (2273) it did not reach statistical significance (χ2 = 020p = 066) Irrespective of condition 45 of concussed athletes werecategorized in the Fail group Of these 10 failed on both conditions13 failed on rest only and 22 failed on post-exercise The currentstudy suggests that 1 out of 2 athletes who successfully completed the



RTP protocol exhibited diminished cognitive functions compared tocontrols The use of a sensitive cognitive test combined with physicalexertion can prevent premature RTP in identifying athletes would haveotherwise received medical clearance

Disclosures Dr Sicard has nothing to disclose Dr Lortie has nothing to dis-close Dr Moore has nothing to disclose Dr Ellemberg has nothing to disclose

Gender differences in transcranial doppler ultrasoundmeasured features and self-reported symptoms after sports-related concussionCorey Thibeault PhD Samuel Thorpe PhD Nicolas Canac Mina Ranjbaran

Michael OrsquoBrien James LeVangie Mateo Scheidt Seth Wilk Robert

Hamilton PhD

The possibility of gender-related differences in concussion severity andrecovery remains a controversial subject With some studies showingthat female subjects suffer a longer period of symptom recovery ascompared to males while other studies have failed to demonstratesignificant differences In this retrospective study we explored thegender-related effects of concussion on both self-reported symptomsand physiologic features (captured with TCD) that were previouslyshown to be related to concussion A total of 75 subjects with a meanage of 162 years (116) consisting of 51 males and 24 females wereassessedmdashat different points post-injurymdashafter suffering a clinicallydiagnosed sports-related concussion Subjects first answered a series ofsymptom related questions based on an integer rating scale The velocityfrom the middle cerebral artery (MCA) was insonated bilaterallythrough transtemporal windows with TCD After a baseline periodsubjects participated in 4 breath-holding challenges The PulsatilityIndex (PI) was computed from the baseline section while the BreathHold Index (BHI) was computed from the challenge sections Over thefirst 10 days post-injury the female subjects had significantly highersymptom scores In addition the length of recovery was longer lasting14 days compared to 9 days before the overall mean symptom scorereturned to baseline The BHI and PI were not significantly differentbetween genders The elevated symptom scores for the female subjectswithout a significant correlation to physiologic measurements is possiblydue to reporting bias The population consisted of high school agedathletes who were motivated to return to play perhaps explaining whythe male population reported lower symptom severity than the femalepopulation However the potential of increased severity in the femalepopulation cannot be overlooked This pilot study illustrates the needfor more focused research on gender differences in concussionpathophysiology

Disclosures Dr Thibeault received personal compensation for activities withNeural Analytics as an employee Dr Thorpe received personal compensation foractivities with Neural Analytics as an employee Dr Canac received personalcompensation for activities with Neural Analytics as an employee Dr Ranjbaranreceived personal compensation for activities with Neural Analytics as an em-ployee Dr OrsquoBrien received personal compensation for activities with NeuralAnalytics as an employee Dr LeVangie received personal compensation foractivities with Neural Analytics as an employee Dr Scheidt received personalcompensation for activities with Neural Analytics as an employee Dr Wilk re-ceived personal compensation for activities with Neural Analytics as the Directorof Research Dr Hamilton received personal compensation for activities withNeural Analytics as the CSO

Gender differences in quantitative EEG volumetric analysisshortly after sport concussion injury in high school athletesHarry G Kerasidis MD P David Ims Stacie Rector

BackgroundStudies have identified gender differences in the incidence severity andrecovery time from sport concussion injury all increased in females Theobjective of this investigation is to explore gender differences in

volumetric QEEG analysis after sport concussion injury in high schoolathletes

MethodsStandard electroencephalograms (EEGs) were analyzed in 40 highschool athletes (20 males) shortly after concussion injury usingsLORETA imaging compared to a normative database (NYUBrainDx) Peak Z-score variation (PZV) and volume of grey matteractivity that fell outside Z = minus25 to 25 (PIGMV for increased activityPRGMV for reduced) were calculated for each of 5 EEG frequencybands

ResultsPZV was increased in the DeltaThetaAlpha in both genders with nostatistical gender difference (MF averages 382316 273272 252272 respectively p ge 005) Beta in females not males Beta-Gamma inmales and females which was significantly increased in females (MFaverages 175288 364502 respectively p lt 001) PZV was de-creased in Beta in males not females (MF averages minus283minus218 p =005) there was a significant difference in reduced beta-gamma activity(MF averages minus111minus049 p = 001) Greater than 1 grey mattervolume of PIGMVwas seen in DeltaThetaAlphaBeta activity with nogender difference (MF averages 20941171 587738 562793409922 p ge 005) There was a significant difference in PIGMV inBeta-Gamma (MF averages 31946004 p = 001) Greater than 1PRGMV in AlphaBeta in both genders and Theta activity in femalesnot males

ConclusionsSlower frequency (Delta Theta and Alpha) abnormal variations showno statistical gender differences In the faster frequency bands (Beta andBeta-Gamma) females demonstrate a larger variation from the normand larger percent grey matter volume affected by increased Beta andBeta-Gamma activity Males not females exhibit a deficiency in Betaactivity after concussion Further research to correlate these electro-physiologic changes with symptom severity and recovery time is needed

Disclosures Dr Kerasidis has received personal compensation for consultingserving on a scientific advisory board speaking or other activities with Pure Re-covery California Stress Therapy Solutions Dr Kerasidis holds stock andor stockoptions in Concussion Management LLC Dr Ims has nothing to disclose DrRector has nothing to disclose

The epidemiology of sport related concussion in BrazilianJiu-JitsuMatthew Spano Mill Etienne MD MPH FAAN

Brazilian Jiu-Jitsu (BJJ) is a rapidly growing grappling sport with a widespectrum of participants This study aimed to analyze the prevalence ofconcussions among BJJ practitioners while determining potential pre-dictive factors A 17-question survey was distributed via email to BJJpractitioners in the United States The survey included questions onpractitioners demographics and the development of a concussion doingBJJ Among those with a concussion during BJJ further information waselucidated on symptoms return to play and the development of a sec-ond concussion A total of 780 survey responses were analyzed rangingin age from 18 to 67 with females representing 118 of respondents252 of practitioners reported a concussion doing BJJ Forty-threepercent of females reported a concussion doing BJJ compared to 229of males (X2 [1 n = 740] = 15129 p = lt 0001) This gender differencedid not exist in the prevalence of concussions before starting BJJ (X2 [1n = 774] = 1930 p = 0381) Logistic regression indicated several factorspredictive for developing a concussion from participating in BJJ in-cluding having a prior concussion (odds-ratio = 1691 p = 0017 95CI 1097 2606) the number of competitions in which an athlete par-ticipated (odds-ratio = 1023 p = 0016 95 CI 1004 1042) and



female gender (odds-ratio = 1863 p = 0048 95 CI 1006 3450)Logistic regression indicated competing more times per year was pre-dictive for developing a second concussion [odds-ratio = 1038 p =0016) After a concussion the median time to return to BJJ was 3 daysThis included 308 of participants returning the day of their concus-sion The present study represents the first epidemiologic research ex-amining concussions in Brazilian Jiu-Jitsu The results underscore theneed for increased education on concussions and return to play guide-lines among BJJ coaches and practitioners

Disclosures Dr Spano has nothing to disclose Dr Etienne has nothing todisclose

Incidence of head injury and concussion among synchronizedskaters Rates risks and behaviorsGretchen Mohney Robert Baker Shelly DiCesaro

Data regarding risk and rates for head injury and concussion specific tothe sport of synchronized skating is absent from literature This studydifferentiated team level-based rate and risk for head injury and con-cussion identified behaviors to include education baseline screeningand protective equipment utilization and the implementation of returnto play protocols An anonymous cross-sectional survey was imple-mented at the 2018 US Synchronized Skating Championships Par-ticipants were female members of a qualifying team ages 13 and olderintermediate participation level and higher The survey response ratewas 42 (5201232) Among the survey respondents 7 (36520)reported head injury in the practice setting and 1 (4520) in thecompetitive setting Among respondents who reported head injury (n =37) 68 (2537) reported a team skill injury with senior level reportingthe highest 22 (1375) rate Among the sample population (n = 520)the odds of sustaining a head injury during a team skill was 213 timesmore likely than during individual skill (OR 213 CI 106 430 p =003) The odds of sustaining a head injury during practice was 959times higher than in competition (OR 959 CI 330 2715 p lt00001) Among the sample population 36 (188520) reported re-ceiving concussion education during the past training year and 8 (44520) reported hitting their head on the ice and returning to skatingwithout seeking medical consultation A χ2 analysis did not reveala significant association between education and return to skating with-out medical consultation X2 (1 n = 520) = 0391 p = 0532 Baselinescreening was reported among 25 (128520) of the survey respond-ents Only 006 (3520) of the survey respondents reported utilizingprotective headgear Among those reporting concussion (n = 26) 92reported receiving a return to sportlearn progression Emphasis onconcussion education and medical provider access should be targeted toteam skill development in the practice setting

Disclosures Dr Mohney has nothing to disclose Dr Baker has nothing todisclose Dr DiCesaro has nothing to disclose

Altered state of consciousness in mild traumatic brain injuryin relation to utilization of servicesSam Meske MS Joseph Hazzard Jr EdD ATC Meng Ni

IntroductionPrevalence of traumatic brain injuries (TBI) in young adults on collegecampuses worldwide is extremely concerning given that this age range iscritical for cognitive and behavioral development Impaired cognitioncan negatively affect academic performance and quality of life while theprevalence of acute andor chronic symptoms impact outcome meas-ures of intellectual efficiency andmental health It has been reported thata greater number of TBI symptoms and altered state of consciousnessare correlated with more academic challenges chronic symptom prev-alence long-term deficits in executive emotional and behavioral func-tions and lower employment outcome

Objective(1) Determine the relationship between altered or loss of consciousnessand utilization of services (2) Compare gender differences in prevalenceof altered state of consciousness and service utilization from TBI

MethodsA campus wide email was sent out with a Qualtrics online survey askingquestions that pertained to the participantsrsquo TBI history state of con-sciousness immediately following the injury symptom prevalence andthe campus services they utilized

ResultsOf 194 respondents included in analysis 366 indicated a loss ofconsciousness and 356 altered consciousness from TBI At the samenotion only 9 of respondents indicated utilizing services In-terestingly frequency of respondentsrsquo who accessed services was lowerfor those who experienced only loss of consciousness or both loss andaltered consciousness and higher for those who experienced only al-tered consciousness or neither (27 86 294 91 respectively)No significant differences were observed between genders for alteredstate of consciousness or services utilized However more men seemedto indicate that they experienced neither change in consciousness(588 compared to 398 of females)

ConclusionsState of consciousness may not be a good predictor of subsequentservice utilization Additionally gender differences do not seem appar-ent when analyzing service utilization or level of consciousness at time ofinjury

Disclosures Dr Meske has nothing to disclose Dr Hazzard has nothing todisclose Dr Ni has nothing to disclose

The influence of concussion on cardio-autonomic functionduring cognition before and after exerciseAdam T Harrison Brett Steven Gunn Jacob James Michael Kay MS Robert

Davis Moore

In an average day of a student-athlete they must endure the cognitivedemand of classes physical stress of practice and then end the daystudying and doing homework for the next day Cardio-autonomicregulation is an integral process linking the neurologic and cardiologicalsystems that responds and adapts to these changing environmentalstressors to maintain overall effective functioning The adaptation of thecardio-autonomic system to environmental stressors is often impaired inpeople who have experienced a concussion The aim of the currentstudy was to assess cardio-autonomic function in a group of athleteswith and without a history of sports-related concussion (SRC) in anexperimental paradigm designed to mimic an average day of a student-athlete Heart-rate variability (HRV) was assessed in a group of ado-lescent athletes with a history of diagnosed concussion (n = 16) andhealthy matched controls (n = 19) (1) at rest (2) during a switch taskparadigm and (3) during a switch task paradigm following a 20-minutebout of aerobic exercise at 70 of their theoretical max heart rateResults of the preliminary investigation revealed that individuals witha history of SRC exhibited alterations in HRV at rest that were exac-erbated by the cognitive load of the switch task However following thebout of aerobic exercise HRV normalized in the individuals with a his-tory of SRC These results continue to demonstrate cardio-autonomicdysregulation following a SRC It also indicates the potential therapeuticbenefit of aerobic exercise in mediating these cardio-autonomicabnormalities

Disclosures Dr Harrison has nothing to disclose Dr Gunn has nothing todisclose Dr Kay has nothing to disclose Dr Moore has nothing to disclose



The clinical utility of using involuntary eye movements toassess concussionKathleen Heeter Thayer Jacob Nicholas Port

Critical decisions are made daily about whether to bench athletes whomight have suffered a concussion or mild traumatic brain injury (mTBI)The low-level damage underlying mTBI has been difficult to measureespecially during competition when assessments are made quickly utiliz-ing primarily subjective symptoms The ideal instrument would be (1)sensitive to low-level diffuse damage (2) easily and rapidly administeredon the sidelines and (3) unaffected by human bias or sandbagged base-lines Based on a body of research documenting the sensitivity of oculo-motor movements (eg saccades and smooth pursuits) to mTBI damagewe have constructed 5 Sideline Eye Trackers and are evaluating theirclinical use for quick objective and accurate assessment of mTBI Currentenrollment of athletes is over 1200 including the entire IU athletic de-partment and several local schools All enrollees complete a 6-minute pre-season baseline oculomotor exam consisting of 2 saccade 2 pursuit and 1ocular following task Balance is simultaneouslymeasured using a portablebalance board Anyone suspected by the team physician of having a con-cussion during the season repeats this exam 3 additional times (1) im-mediately post-injury (minutes) (2) at the time of being cleared forreturn-to-play and (3) as far post-injury as possible (months) To provide2 separate measures of test-retest variability 2 control groups are alsobeing studied (1) within-sport non-concussed matched control groupand (2) non-concussion prone cross-country athletes Athletes withmTBIshow significant deficits in both saccadic and pursuit function compared totheir baseline (p = 00001) Drift in the center of pressure measure(balance) is also significantly affected in many subjects Signal detectiontheory yields a specificity amp sensitivity of greater than 85 of 69 concussedathletes Measuring oculomotor dysfunction in athletes with a 6-minutetask may be a promising tool for the diagnosis and management of mTBI

Disclosures Dr Heeter has nothing to disclose Dr Jacob has nothing to dis-close Dr Port has nothing to disclose

Symptom free return to sport following supervised exerciseand a return to play progressionMatthew T Lorincz MD PhD Melvin Darwin Andrea Almeida MD Andrew

R Sas MD PhD

ObjectiveTo determine if completion of a symptom free return to play pro-gression (RTPP) was associated with a symptom free return to sport Asecondary analysis investigated symptom free return to sports partici-pation following supervised exercise

BackgroundThe current consensus statement on concussion in sport recommendsa graded return-to-sport strategy but there is limited data on the utility ofthis approach

Methods200 sequential clinic patients with physician-diagnosed concussionsustained during sport participation were contacted by phone followingcompletion of care from a University-associated Sports Neurologyclinic A survey about their success in returning to their sport was ad-ministered Standardized data elements were extracted from the medicalrecords and analyzed The study was approved by the university ofMichigan Institutional Review Board

ResultsThe survey was completed on 61 (31) patients Of these 57 (93)returned to sport participation without symptom reoccurrence Ofthose who returned to sport 41 (80) returned to sport without

symptom reoccurrence within 2 weeks of completed clinical care 53(87) completed a RTPP and 49 (92) of those completing a RTPPreturned to sport without symptom reoccurrence Completinga RTPP compared to those not completing a RTPP was significantlyassociated with return to sport participation without symptom reoc-currence (p = 00000001) Of those surveyed 32 (52) underwentsupervised exercise (SE) as part of their clinical care Completing SEas compared to those not undergoing SE was significantly associatedwith return to sport participation without symptom reoccurrence (p =0017)

ConclusionsOur results support recommendations for utilizing graded return-to-sport strategy demonstrating that 92 of those completing a RTPPsuccessfully returned to sport Our data also suggest that completion ofSE was a predictor of symptom free return to sport and can be in-corporated in to return to play decision making

Disclosures Dr Lorincz has nothing to disclose Dr Darwin has nothing todisclose Dr Almeida has nothing to disclose Dr Sas has nothing to disclose

Quantitative pupillary light reflex abnormalities in acuteconcussionMelissa M Cortez DO Asad Raud

BackgroundThe process of concussion diagnosis following a sports injury remainssuboptimal and currently relies on self-reported symptoms andor di-agnostic ldquotask-basedrdquo assessments with subjective and effort-basedlimitations The purpose of this study was to evaluate the use ofpupillometry light reflex (PLR) as a potential objective physiologicmarker in concussion

MethodsSix (6) subjects underwent baseline (pre-concussion) PLR testing usinga Neuroptics DP-2000 Binocular Pupillometer Pupil diameter wasrecorded for 5 seconds following a brief light stimulus in a single eyeThe following values were obtained from the recordings in both thestimulated and consensual eyes maximum diameter minimum di-ameter percent change latency constriction velocity (CV) maximumconstriction velocity (MCV) dilation velocity (DV) T75 and RA5T75 and RA5 represent the time to 75 re-dilation and the re-dilationamplitude from baseline respectively Measurements were taken againwithin 48 hours of concussion in the same participants A paired 2 tailedt-test was used to assess significant changes in these values Bonferronicorrection was applied to account for multiple comparisons

ResultsRA5 a measure of pupillary sympathetic function was significantlyreduced (p = 0004) in the post-concussive state compared to pre-concussion baseline Additionally percent change a measure ofpupillary parasympathetic function was greater post-concussioncompared to baseline though this did not meet significance fol-lowing Bonferroni correction (p = 0007) A similar pattern was seenin the consensual eye though these differences did not meetsignificance

ConclusionsWe demonstrate significant changes in pupillary autonomic functionwithin 48 hours of a concussion These findings support the potentialuse of PLR as a biomarker in athletes following concussion with thepotential to yield important mechanistic information about the acuteconcussive state

DisclosuresDr Cortez has nothing to disclose Dr Raud has nothing to disclose



Psycho-affective health cognition and neurophysiologicalfunction following sports-related concussion in symptomaticand asymptomatic athletesAdam T Harrison Veronik Sicard Robert Davis Moore

The proposed normal recovery window for a concussive-injury is 10ndash14days However a significant portion of athletes who sustain a sports-related concussion (SRC) exhibit symptoms beyond this recoverywindow Little is known about the neuropsychiatric and neurophysio-logic differences within these slow-to-recover athletes that may explainthese prolonged recovery periods The present study aimed to in-vestigate the psycho-affective and neuropsychological profiles ofsymptomatic and asymptomatic athletes who recently experienced anSRC Additionally we compared these concussed athletes with healthycontrols without a history of concussion Accordingly 78 participantswith a history of concussion (26 Symptomatic 26 Asymptomatic) and26 healthy controls completed a neuropsychiatric and neuro-psychological test battery including the Beckrsquos Depression Index (BDIII) Profile of Mood States (POMS) and 2-Back task Additionallyevent-related brain potentials (ERPs) were recorded during an experi-mental oddball paradigm The results suggest that symptomatic athletesreport significantly worse levels of depressive symptoms and negativelyaltered mood compared to both asymptomatic and control athletesAdditionally symptomatic athletes demonstrated poorer performanceon the 2-back test characterized by increased commission errors andslower reaction times Finally ERP analyses revealed that both symp-tomatic and asymptomatic athletes demonstrated reduced allocation ofattentional resources during the oddball task indexed by reduced P3bamplitude However only asymptomatic athletes exhibited prolongedP3 latency indicative of delayed information processing Taken togetherthese results suggest that compared to asymptomatic and healthy ath-letes athletes with persistent concussive-like symptoms not only reportgreater disruptions in affect and mood but also demonstrate impairedcognitive and neurophysiologic function

Disclosures Dr Harrison has nothing to disclose Dr Sicard has nothing todisclose Dr Moore has nothing to disclose

Photophobia symptoms and visual pain thresholds inposttraumatic headache after mild traumatic brain injuryNicholas Jarvis Amaal J Starling MD Todd J Schwedt MD FAAN

BackgroundLight sensitivity can be a disabling symptom in posttraumatic headache(PTH) The objective of this pilot study was to characterize photo-phobia symptoms and visual pain thresholds in PTH compared tohealthy controls (HC)

MethodsIndividuals with PTH attributed to mild traumatic brain injury (mTBI)(N = 18) and HC (N = 20) aged 18ndash65 were prospectively assessedusing the Photosensitivity Assessment Questionnaire (PAQ) StateTrait Anxiety Inventory (STAI) and Beck Depression Inventory (BDI)A progressive light stimulation device was used to quantify visual painthresholds Visual pain thresholds were determined by the intensity oflight at which subjects first noted pain The mean of 3 trials was con-sidered the visual pain threshold Two sample t-test Wilcoxon rank sumtest χ2 test and Fisher exact test was used to compare the 2 groups fortheir demographics clinical characteristics and outcomes measures

ResultsThere were no differences in demographics including age gender orrace The average time since onset of PTH was 507 (736) monthsThose with PTH had 158 (92) headache days per month BDI andSTAI scores were significantly higher in PTH compared to HC

Photophobia was higher in PTH compared to HC 064 (025) vs 024(024) p lt 00001 Visual pain thresholds were lower in PTH (median501 lux quartiles 153 to 3000) compared to HC (median 8635 luxquartiles 5199 to 49065 p = 00002)

ConclusionPhotophobia symptoms are higher and visual pain thresholds are lowerin PTH compared to HC Light sensitivity is a well-known disablingsymptom in PTH and this pilot study provides objective data througha validated photophobia scale and visual pain thresholds to characterizelight sensitivity Additional studies are needed to confirm this data tocompare acute to persistent PTH to compare PTH to other headachedisorders and to determine if photophobia and visual pain thresholdswill improve with intervention

Disclosures Dr Jarvis has nothing to disclose Dr Starling has received per-sonal compensation for consulting serving on a scientific advisory boardspeaking or other activities with Eli Lilly amp Company eNeura Alder andAmgen Dr Schwedt has received personal compensation for consultingserving on a scientific advisory board speaking or other activities with Aller-gan Amgen ATI Avanir Dr Reddyrsquos Nocira Novartis Teva Dr Schwedt hasreceived personal compensation in an editorial capacity for Headache PainMedicine Cephalalgia

Pediatric headache incidence and outcomes after sports-related concussion Findings from the North TexasConcussionRegistry (ConTex)Bert B Vargas MD FAAN Elida Godbey Stephen Bunt Ali Shah Tejani

Munro Cullum PhD

IntroductionHeadache is the most common symptom reported after concussionhowever little is known about the incidence of headache and the clinicalcourse over 3 months in pediatric patients with sports-related concus-sion (SRC) presenting within 30 days of injury

MethodsFour hundred twenty-five patients met inclusion criteria (patients under18 years old limited to SRC within 30 days of injury and who alsocompleted a 3 months follow up evaluation) and were enrolled from any1 of 5 ConTex clinic sites

ResultsMean age was 143 years (range = 7ndash18 SD 22) and mean time sinceinjury at presentation to clinic was 81 days (range = 0ndash30 SD = 67)Only 137 (n = 56) had a history of headache before their concussion965 (n = 410) of patients recalled having headache at time of injuryAt initial presentation 773 (n = 317) reported headache 382 (n =121) mild 486 (n = 154) moderate 132 (n = 42) severe (on a scalefrom 0-6) At 3 months follow up 198 (n = 81) reported headache766 (n = 62) mild 185 (n = 15) moderate 49 (n = 4) severeAmong 264 that were treated with headache abortive medications977 (n = 258) used simple analgesics (NSAIDs or acetaminophen)08 (n = 2) used opioids 102 (n = 27) used triptans and 57 (n =15) used other non-specified treatments 665 of children reportedsymptom resolution within 29 days (range 0ndash90 days mode 17ndash29 n =71 202)

ConclusionsThe incidence of headache at the time of concussion is high andremains high within 30 days after injury the majority of which weremoderate in severity By 3 months only a minority of patients reportheadache the majority of which were mild For 863 of children theirfirst experience with recurrent headache occurred in the context ofSRC Outcomes were generally good at 3 months despite an over-whelming majority of children being treated with non-specific simple



analgesics Most children reported symptom resolution within 29 daysof injury

Disclosures Dr Vargas has received personal compensation for consultingserving on a scientific advisory board speaking or other activities with AmgenAlder Allergan Avanir Pernix Teva Lilly Upsher-Smith Dr Godbey hasnothing to disclose Dr Bunt has nothing to disclose Dr Tejani has nothing todisclose Dr Cullum has nothing to disclose

Comparing the acute presentation of sport-relatedconcussion in the adult and pediatric populationsSandro James Corti MD Nicole Pizzimenti Matthew T McCarthy MD Kate

M Essad MD Jeffrey S Kutcher MD FAAN

IntroductionDespite growing research on concussion there is currently minimalevidence comparing the acute presentation of sport-related concussionbetween adult and pediatric patients

ObjectiveTo assess and compare the injury characteristics symptoms and neu-rologic exam findings in acute sport-related concussion between adultand pediatric patients

MethodsRetrospective cohort study of all patients presenting to an outpatientsports neurology clinic for initial assessment of an acute concussionwithin 7 days of injury between January 2016 and August 2017 Patientswere divided into 2 groups 18 and older (n = 28) and 17 and younger(n = 107) Data assessed included age sex injury date date of visitinjury characteristics Sport Concussion Assessment Tool (SCAT3)symptom scale sleep characteristics comorbid medical diagnoses andneurologic exam findings

ResultsThere were no significant differences between the adult and pediatricpatients in any SCAT3 symptom score neurologic exam categorypertinent elements of past medical history or characteristics of the acuteconcussion including number of head impacts presence of helmet lossof consciousness amnesia or continuation of play The pediatric grouphad significantly higher average hours of sleep (p = 0034) and were lesslikely to wake up refreshed (p = 0024) There were no other significantdifferences in sleep characteristics between the groups

ConclusionsThe initial presentation of acute concussion within 7 days of injury willlikely not differ by age specifically 18 and older vs 17 and youngerThese data suggest no indication for focusing on specific portions of thehistory or neurologic examination based on these age groups

Disclosures Dr Corti has nothing to disclose Dr Pizzimenti has nothing todisclose Dr McCarthy has a research grant funded by Riddell and Elminda DrEssad has nothing to disclose Dr Kutcher has received personal compensationfor consulting serving on a scientific advisory board speaking or other activitieswith ElMindA Ltd National Basketball Association National Hockey LeaguePlayers Association National Football League Players Association Dr Kutcherhas received royalty license fees or contractual rights payments from OxfordUniversity Press

Baseline concussion symptom score differences comparingcollision contact and noncontact sports and comparison ofbetween sexesAndrew Sas MD PhD Katherine Foug Aleah Gillenkirk Michael Popovich

MD Andrea Almedia MD Matthew Lorincz MD

ObjectiveTo determine if baseline concussion symptoms scores in athletes priorto the start of their season vary by sport or sex

BackgroundConcussion is a clinical diagnosis that includes an appropriate clinicalscenario reporting of symptoms through a post concussion symptomscore list and an objective neurologic exam Symptom reporting isconsidered when determining if an athlete has recovered from theirconcussion Recent studies have shown that athletes at baseline canreport symptoms at a rate high enough to meet criteria for post con-cussion syndrome without any history of concussion The number ofsymptoms reported was found to be higher in female athletes than maleathletes but to date there has not been a clear consideration of howthese symptoms compare across different sports played

MethodsRetrospective chart review of baseline pre-participation sport examsfrom 2016 More than 2000 charts were reviewed for age sex sportplayed number of past concussions Baseline concussion symptomchecklist scores were reviewed for number of symptoms reported andseverity of symptoms reported Comparisons were made betweengroups comparing age sex sport played and number of previous con-cussions prior to the start of this season

ResultsFemale athletes in all sports compared reported more baseline symp-toms and more severe symptoms compared to their male counterpartsAthletes of the same sex male or female who participated in collision orcontact sports reported less baseline symptoms than athletes who par-ticipated in noncontact sports

ConclusionContact and collision sport athletes report at baseline less concussionchecklist symptoms than noncontact sport athletes in all age groupscompared This leads to many questions about why certain athletepopulations report less symptoms Symptom reporting could be due tounderlying physical traits in different sports or player psychology dif-ferences between sports

DisclosuresDr Sas has nothing to disclose Dr Foug has nothing to disclose DrGillenkirk has nothing to disclose Dr Popovich has nothing to disclose DrAlmeida has nothing to disclose Dr Lorincz has nothing to disclose

A single season of soccer results in no significantneurophysiological changes in adolescent female athletesKaylin Ryan Katherine Schiller Roozbeh Rezaie Brandon C Baughman

Shalini Narayana

IntroductionSports related mild traumatic brain injury (mTBI) is a serious andincreasing health incident in the United States particularly in youngchildren and adolescents often affecting developing frontal and tem-poral lobes Literature comparing various methods of cognitive assess-ment tools as well as the utility of various non-invasive brain imagingtechnologies in the diagnosis and follow up of mTBI lacks standardizedmethods and requires further investigation We investigated the stabilityof intercortical and intracortical inhibition parameters and their re-lationship to white matter integrity in athletes without mTBI We hy-pothesized that a single season of soccer without a concussion wouldresult in no significant neurophysiologic differences in femaleadolescents

MethodsTen female soccer athletes between the ages of 14ndash17 years wereevaluated pre and post season using neuropsychological testingtranscranial magnetic stimulation (TMS) anatomical MRI and diffu-sion tensor imaging (DTI) One athlete sustained a concussion and wassubsequently removed from analysis



ResultsThere was no significant difference when comparing pre- and post-season measures for neuropsychological testing intercortical (p =0812) or intracortical (p = 0888) inhibition measured by durationof silent periods during TMS motor evoked potential onset (p =0227) or duration (p = 0977) and interhemispheric conductiontimes (p = 0092) In addition no significant difference was foundbetween pre and post assessments of fractional anisotropy forwhite matter tracts of interest posterior limb of internal capsulecortical spinal tracts and genu body and splenium of the corpuscallosum

ConclusionFollowing a season of soccer there was no difference in any neurologicparameters that would elicit concern for the continuation of the sport atthis level We demonstrate that the inter- and intra-cortical inhibitoryparameters derived from TMS are stable therefore TMS and DTI canbe used as reliable measures for further investigation of patients sus-taining mTBI

Disclosures Dr Ryan has nothing to disclose Dr Schiller has nothing to dis-close Dr Rezaie has nothing to disclose Dr Baughman has nothing to discloseDr Narayana has nothing to disclose

Brain-derived neurotrophic factor Biopsychosocialcorrelates and exercise response in mild traumatic braininjuryAliyah Snyder MD Russell Bauer David Fitzgerald MD James Clugston

Floyd Thompson Christopher Giza MD FAAN Talin Babikian Joshua

Yarrow

Recovery from mild traumatic brain injury (mTBI) is a dynamiccomplex process and pre-clinical research highlights brain-derivedneurotrophic factor (BDNF) as an important mediator in functionaland pathophysiologic outcomes Although BDNF appears to also bea significant factor in recovery in humans its role is less understoodOur purpose was (1) to examine the association of serum andplatelet-poor plasma concentrations of BDNF to relevant biopsy-chosocial outcomes of mTBI recovery (ie neurocognitive perfor-mance [attention processing speed memory executive functioning]sleep balance mood and self-reported symptoms) and (2) to assessBDNF response to a single-session of aerobic exercise (40 minutes ofstationary cycling at 65ndash75 maximum heart rate) There were 36participants (ages 18ndash40 19 male 17 female) in 2 groups (1) mTBIparticipants (n = 26) who were 14ndash25 days post-injury were ran-domized to either aerobic or non-aerobic exercise (low intensitystretching) and (2) demographically-matched non-injured partic-ipants (n = 10) who participated in a single session of aerobic exerciseResults indicate that serum BDNF concentration has significant (p =005) inverse relationships with both sleep dysfunction and statelevels of anxiety No significant association between exercise type andserum BDNF was found but there was a small to medium effect size(= 008) for increased plasma BDNF after aerobic exercise in mTBI vsnon-injured participants Overall peripheral BDNF concentrationsare poorly correlated which suggests they reflect different tissuesources Serum BDNF was more sensitive to select biopsychosocialoutcomes particularly sleep quality and anxiety regardless of injurystatus Additionally aerobic exercise may play a role in enhancingplatelet-poor plasma BDNF response in the post-acute period aftermTBI

Disclosures Dr Snyder has nothing to disclose Dr Bauer has nothing todisclose Dr Fitzgerald has nothing to disclose Dr Clugston has nothing todisclose Dr Thompson has nothing to disclose Dr Giza has received researchsupport from NINDS Neural Analytics SBIR grant (NS092209 2016ndash2018)Avanir (research grant 2017ndash2018) NCAA-US Dept of Defense CARE

[research grants 2014-present] Dr Babikian has nothing to disclose DrYarrow has nothing to disclose

Biomarker signatures indicate Aldolase C neurogranin andsynuclein beta are correlated with concussion history in mildTBITimothy VanMeter PhD Nazanin Mirshahi W Frank Peacock Ramon Diaz-

Arrastia MD FAAN Ronel Veksler Frederick Korley Alon Friedman

IntroductionConcussion has been studied with increasing scrutiny in recent yearsincluding evaluation of diagnostic technologies to detect structuraldamage to the brain Previous studies in our laboratories using a numberof TBI biomarkers have demonstrated the potential of blood biomarkersNeurogranin (NRGN) Oligodendrocyte myelin glycoprotein (OMG)and Synuclein beta (SNCB) as indicators of damage after concussionThis study was designed to evaluate the relationship of blood bio-markers with concussion history

MethodsELISA assays were developed to detect Aldolase C (ALDOC) Brainderived neurotrophic factor (BDNF) GFAP Metallothionein-3(MT3) NRGN Neuron specific enolase (NSE) OMG and SNCBSerum concentrations were determined in replicate assays Threecohorts were studied mild TBI patients (HeadSMART n = 139 JohnsHopkins University) healthy controls (n = 52 Baylor College ofMedicine) and semi-professional football players (n = 31 Ben-GurionUniversity) Serum biomarker values were analyzed by Spearmanrsquospairwise correlation to identify associations with prior concussionnumber age and years of play Modeling in logistic regression was usedto assess risk of PCS at 3 months

ResultsPrior concussion number was correlated with NRGN (p = 058) SNCB(p = 042) and ALDOC (p = 064) in players during the active seasonPost-season NRGN (p = 053) and ALDOC (p = 037) remain asso-ciated with concussion number ALDOC and NRGN also correlatedduring the active season (p = 068) and ALDOC levels correlated withOMG (066) BDNF (minus051) and NSE (minus038) In HeadSMART mild-TBI NRGN was correlated with ALDOC (p = 044) and SNCB andBDNF (p = minus033) and OMG and NSE (p = minus033) were weaklycorrelated ALDOC BDNF GFAP andOMGwere associated with ageincluding decreasing ALDOC and NRGN with age Classifier modelsconfirmed the utility of these markers for predicting risk of ongoingsymptoms (PCS) after mTBI

ConclusionBlood levels of NRGN and SNCB are consistently associated withconcussion and have been shown to be useful for mTBI diagnosis Thesemarkers and ALDOC are promising biomarkers for further de-velopment in sports-related concussion

Disclosures Dr Van Meter received personal compensation for activities withImmunArray as Head of Research ampDevelopment for Neurological Diseases DrMirshahi received personal compensation for activities with ImmunArray as anemployee Dr Peacock has nothing to disclose Dr Diaz-Arrastia holds stock andor stock options in Neural Analytics Inc Dr Diaz-Arrastia has received researchsupport from Grant support from ImmunArray INC Grant support fromBrainBox Solutions Inc Dr Veksler has nothing to disclose Dr Korley hasnothing to disclose Dr Friedman has nothing to disclose

Quantitative analysis of neurometabolites in adolescents withpersistent symptoms following concussion using magneticresonance spectroscopyRyan Moonnoh Lee Lezlie Espana Robert Prost Andrew Nencka Kevin

Koch Timothy Bradley Meier PhD



There is great interest in developing physiologic markers of persistentconcussion symptoms (PCS) that can occur following mild traumaticbrain injury (mTBI) Magnetic resonance spectroscopy (MRS) cannon-invasively measure changes in brain metabolism and is directlytranslatable to clinical application Previous studies have shown thatmTBI is associated with decreases in N-acetylaspartate (NAA) thoughmost prior work has focused on adults In this pilot project we hy-pothesized that adolescents with PCS would have decreased NAA infrontal white matter (FWM) and the anterior cingulate cortex (ACC)relative to adolescents without PCS Twenty-two patients (14ndash18 yearsold) with persistent symptoms following sport or recreation-relatedconcussion (PCS+) were recruited from a concussion clinic andassessed at least 4-week post-injury Twenty-one adolescents withvarying concussion history but without PCS served as controls (PCSminus)Exclusion criteria included current or prior moderatesevere TBIneurodevelopmental disorder or psychiatric disorder unrelated to cur-rent injury Participants completed a clinical assessment battery thatincluded self-reported concussion and psychiatric symptoms and neu-rocognitive testing MRS was performed in the ACC and right FWMusing a PRESS sequence on a GE 3T scanner Spectra were analyzedusing LCModel to calculate metabolite levels Independent samplest-tests were used to compare groups with apriorianalyses focused onNAA NAA plus N-acetylaspartylglutamic acid (total NAA) and com-bined glutamate and glutamine (Glx) PCS+ showed significant ele-vations in concussion and psychiatric symptoms as well as decreasedneurocognitive performance compared to controls (p = 005) In ad-dition PCS+ had a significant decrease in total NAA (p = 0012) anda non-significant decrease in NAA (p = 0057) in the FWM whencompared to PCSminus No differences between groups were seen in theACC (p = 01) Our results suggest a relationship between PCS inadolescents and decreased total NAA in frontal white matter Additionalanalyses investigating the relationship between neuro metabolites andclinical measures are underway

DisclosuresDr Lee has nothing to disclose Dr Espana has nothing to discloseDr Prost has nothing to disclose Dr Nencka has nothing to disclose Dr Kochhas nothing to disclose Dr Meier has nothing to disclose

Neuroimaging of concussion patients in an outpatient clinicJennifer McVige MD Said Shukri Vincent Bargnes Michael Lillis

ObjectiveTo evaluate the use of neuroimaging safety diagnoses and potentialtreatment of patients with concussion

MethodsThis retrospective study took advantage of a concussion database to an-alyze neuroimaging in concussion patients of all ages Details of neuro-imaging orders were tracked and categorized as hospital emergencyrooms primary care physicians neurologists at DENT or by other spe-cialists Neuroimaging consisted of MRI andor CT scans which wereclassified as normal or abnormal Abnormal MRI scans consisted of whitematter changes brain hemorrhage chiari malformation cyst arachnoidhydrocephalus incidental unrelated finding or a developmental venousanomaly Abnormal was further defined as abnormal due to head injuryunrelated to the concussion but unlikely to prolong recovery time orunrelated to the concussion but may prolong recovery time

ResultsAmong the 835 diagnosed with concussion 715 (86) patients ages1ndash78 had neuroimaging completed (615 MRI and 422 CT) Amongthese patients 401 (95) had a CT order prior to coming to Dent 319(80) from emergency rooms 64 (16) from primary care physiciansand 18 (4) from other physician specialists The rate of ordering anMRI was 46 greater than the rate of ordering a CT scans while the rate

of discovering an abnormality withinMRI scans was 3 times greater thanCTs (243 vs 78)

ConclusionsThere exists a remarkable discrepancy between the rate of orderingneuroimaging in concussion patients (46 more MRI vs CT orders)and the rate at which neuroimaging in these patients discovered brainabnormalities (times211 more in MRI vs CT reads) We acknowledge thatimprovement is required in the length of time in the MRI scanner andcost of MRI technology However additional consideration is requiredin abnormality detection effectiveness cost efficiency and radiationsafety in balancing the use of MRI and CT technology

Disclosures Dr McVige has received personal compensation for consultingserving on a scientific advisory board speaking or other activities with AmgenAvinir Teva and Supernus Dr Shukri has nothing to disclose Dr Bargnes hasnothing to disclose Dr Lillis has nothing to disclose

Changes in functional connectivity are associated with oneseason of head-to-ball impact exposure in male collegiatesoccer athletesDerek C Monroe PhD David Keator Robert Blumenfeld James Hicks

Steven L Small MD PhD FAAN

ObjectivesReturn-to-play protocols could be improved by a better understandingof the physiologic effects of mild traumatic brain injury (mTBI)Autonomic dysregulation is thought to underlie many of the multi-dimensional symptoms following mTBI and may derive from alteredconnectivity in the brain central autonomic network (CAN)Understanding the relationship between injury and CAN connectivitycould lead to a useful biomarker for mTBI Toward this end the presentstudy aimed to establish a formal relationship between non-symptomatic head-to-ball impacts (ldquoheadersrdquo) and CAN connectivityin collegiate soccer athletes

MethodsEleven male NCAA Division I soccer players were monitored by athletictraining staff throughout 1 season for the number of headers Ten maleNCAADivision I athletes (3 cross-country and 7 golfers) served as controlsAll participants underwent resting-state fMRI pre- and post-season TwentyROIs were selected based on regions previously implicated in control andmodulation of autonomic function Graph theoretical analyses were used toprobe changes in network architecture and connectivity Specific contrastsfocused on pre- and post-season changes that were explained by individualdifferences in exposure to headers (p lt 005 uncorrected)

ResultsWithin the 20 node network increases in headers were associated withreduced degree centrality of the left and right insular cortex and rightputamen (plt 002) increased degree and betweenness centrality in the leftanterior and right posterior Para hippocampal gyri (plt 003) and increasedbetweenness centrality in the anterior cingulate cortex (p= 0006)Headerswere also associated with reduced functional connectivity within the sub-network including the anterior cingulate cortex (p = 00073) right hip-pocampus left putamen and left insular cortex (plt 004)

ConclusionHighly skilled soccer players who sustained the greatest number of headimpacts also experienced the greatest altered connectivity amongregions associated with autonomic function Future work to establishautonomic function as an injury biomarker should consider the im-portance of cumulative impact magnitudes

Disclosures Dr Monroe has nothing to disclose Dr Keator has nothing todisclose Dr Blumenfeld has nothing to disclose Dr Hicks has nothing to



disclose Dr Small has received personal compensation in an editorial capacity forBrain and Language as Editor in Chief

Association of acute depressive symptoms and functionalconnectivity in emotional processing regions following sport-related concussionLezlie Espana William McCuddy Lindsay Nelson Rasmus Birn Andrew

Mayer PhD Timothy Bradley Meier PhD

Few studies have examined the physiologic correlates of depressivesymptoms following sport-related concussion (SRC) despite theprevalence of these symptoms following brain injury We hypothe-sized that concussed athletes would have disrupted resting-statefunctional connectivity in emotional processing regions compared tocontrols and that this disruption would be associated with greaterpost-concussion symptoms of depression Forty-three concussedathletes at approximately 1 day (N = 34) 1 week (N = 34) and 1month (N = 30) post-concussion were evaluated along with 51healthy athletes assessed at a single visit Resting-state fMRI wascollected on a 3T GE scanner (TR = 2s) depressive symptoms wereassessed using the Hamilton Rating Scale for Depression (HAM-D)Emotional processing regions of interest (ROI) were defined using anautomated meta-analysis of brain regions associated with the termldquoemotionrdquo Fisher-Z transformed correlations were calculated be-tween each ROI A multivariate approach assessed connectivity byanalyzing ROI as simultaneous response variables Concussed ath-letes had significantly higher depressive symptoms relative to controlsat all time points but showed partial recovery by 1-month post-concussion relative to earlier visits (prsquoslt 005) Functional connec-tivity did not differ between controls and concussed athletes at 1 dayor one-week post-concussion However concussed athletes had sig-nificantly different connectivity in regions associated with emotionalprocessing at 1 month relative to 1 day post-concussion (p = 0002)and relative to controls (p = 0003) Follow-up analyses showed thatincreased connectivity between attention and default mode networksat 1-month post-concussion was common across both analyses Inaddition functional connectivity of emotional processing regions wassignificantly associated with depressive symptoms at 1 day (p = 0003)and one-week post-concussion (p = 7 times 10-8) with greater HAM-Dscores correlating with decreased connectivity between attention anddefault mode networks These results suggest that intrinsic connec-tivity between default mode and attention regions following SRCmaybe compensatory in nature

Disclosures Dr Espana has nothing to disclose Dr McCuddy has nothing todisclose Dr Nelson has nothing to disclose Dr Birn has nothing to disclose DrMayer has nothing to disclose Dr Meier has nothing to disclose

Advanced white matter mapping in the subconcussive brainBradley Caron Nicholas Port Franco Pestilli

The topic of behavioral and structural deficits caused by concussions isan increasingly important 1 in the related research fields With anincidence rate of 29 competition concussions per 1000 athleteexposures (NCAA 2013) in collegiate football the concussion risk toathletes is significant However even subconcussive blows or blowsthat do not lead to a concussion diagnosis appear to create health risksfor athletes These impacts appear to lead to significant neural changesthe severity of which may depend on the number of hits (McAllisteret al 2014) An anatomically informed personalized-medicine trac-tography approach was used to determine which major white mattertracts showed the greatest degree of difference in white matter tensormeasures between 17 Division I upperclassmen football players 15Division I upperclassman cross-country runners and 9socioeconomically-matched non-athlete controls We determined theunderlying microstructural white matter biomarkers using a classic

diffusion-tensor model (Pierpaoli and Basser 1999) as well as NeuriteOrientation Dispersion and Density Imaging (NODDI Zhang et al2012) that predict differences across different white matter tracts inthe groups of athletes Results show widespread differences in whitematter tissue properties in multiple tracts and among the 3 athletesgroups including decreased FA increased ICVF and OD in thefootball players vs the 2 control groups These differences occurredmore often in longer fiber tracts compared to shorter fiber tractssuggesting a differential effect of head impacts based on the geometricproperties of these tracts We developed a fully automated processingpipeline for this study available as open source code as well as openservice at brainlifeio These results support the hypothesis that mul-tiple subconcussive blows can result in white matter structuralchanges with differential effects based on the length of the fiber tractbeing investigated that are detectable with diffusion MRI andtractography

DisclosuresDr Caron has nothing to disclose Dr Port has nothing to discloseDr Pestilli has nothing to disclose

Use of supervised exercise during recovery following sports-related concussionMichael Popovich MD Andrea Almeida MD Jeremiah Freeman James T

Eckner MD Bara Alsalaheen Matthew T Lorincz MD PhD Andrew R Sas

MD PhD

ObjectiveTo assess the safety of supervised exercise (SE) in acute sport relatedconcussion (SRC) and explore its influence on recovery

BackgroundPrevious guidelines for the management of SRC have suggested com-plete physical and cognitive rest until asymptomatic while he 2017Berlin consensus statement now suggests return to light activity after24ndash48 hours The influence of early exercise on recovery following SRCremains unclear and there is little evidence regarding its safety orefficacy

DesignmethodsRetrospective chart review of 124 patients with SRC who presented toa university sports neurology clinic within 30 days of injury betweenSeptember 2016 and January 2017 Symptomatic patients who initiatedSE within 16 days of injury were compared to those who did not un-dergo SE or initiated SE later than post-injury day 16 using Cox re-gression The regression model controlled for multiple covariatesincluding age sex history of previous concussions injury severity rel-evant co-morbidities and other treatments received

ResultsNo serious adverse events were observed in the early SE groupFurthermore early SE was associated with earlier return to sport(hazard ratio = 235 p = 0030) and the early SE group had fewerdays from SRC until clearance for return to sport (mean 265 plusmn 112days vs 351 plusmn 265 days p = 0020) There also was a non-significanttrend toward fewer asymptomatic days in the early SE compared tonon-early SE groups (mean 167 plusmn 71 days vs 224 plusmn 225 days p =0054)

ConclusionEarly SE performed in the acute symptomatic stage of SRC was safe andwas associated with earlier return to sport

Disclosures Dr Popovich has nothing to disclose Dr Almeida has nothing todisclose Dr Freeman has nothing to disclose Dr Eckner has nothing to discloseDr Alsalaheen has nothing to disclose Dr Lorincz has nothing to disclose DrSas has nothing to disclose



Treating prolonged post-concussion symptoms in a pediatricpatient with the simultaneous application of cognitivebehavioral therapy and subthreshold exercise A case studySonal Singh Douglas R Polster PhD Meeryo Choe MD Christopher Giza

MD FAAN Talin Babikian

ObjectiveUse a novel simultaneously applied cognitive behavioral therapy (CBT)and subthreshold exercise treatment (STE) for a 14-year old patientwith persistent post-concussion symptoms (PPCS) to facilitate a returnto function in schoolsport

BackgroundPatient sustained a mild TBI while playing basketball on October 292016 Neurologic exam on July 7 2017 was negative but the patientreported PPCS with a graded symptom checklist (GSC) score of 26Primary symptoms were headache and anxiety in relation to cognitiveandor physical exertion The patient attributed anxiety to anticipatingthe onset of symptoms after exercise

DesignmethodsThe 6-week combined CBTSTE intervention included psycho-education cognitive restructuring and relaxation training combinedwith the STE protocol Supervised physical exertion exposure beganwith aerobic exercise on a stationary bike and progressed to sport-specific activity while the patient simultaneously engaged in CBT Pre-and post-intervention data included physiologic measures (heart rate[HR] and power output [PO] on exercise bike) a subjective measure ofexertion (Borgrsquos Rating of Perceived Exertion [RPE]) and psycholog-ical self-report questionnaires

ResultsAfter 6 sessions patient was able to engage in strenuous exercise withreduced symptom exacerbation as demonstrated by his ability toreach 175 bpm HR with 350 watts of PO with decreased reportedsymptoms a significant improvement from the first session Thepatient reported a decrease in anxiety and psychological distress aswell as an increase in emotional and school functioning Parent reportindicated an increase in the patientrsquos overall health social andemotional functioning

ConclusionsEngaging in a six-week combined CBTSTE protocol resulted inimprovements in ability to tolerate physical exertion decreases in psy-chological distress and a return to function This case study demon-strated the feasibility amp positive impact of simultaneous dual treatmentmodel for PPCS in adolescents It also highlighted the need to addressthe psychological distress that occurs in patients with PPCS

Disclosures Dr Singh has nothing to disclose Dr Polster has nothing to dis-close Dr Choe has received research support fromNeural Analytics Dr Giza hasreceived research support from NINDS Neural Analytics SBIR grant (NS0922092016ndash2018) Avanir (research grant 2017ndash2018) NCAA-US Dept of DefenseCARE [research grants 2014-present] Dr Babikian has nothing to disclose

Time-of-day influence on the stability Evaluation Test incollege-age womenBrandon Doan Jeff Pasley Tiffany Rodriguez Katherine Valencia Tim

Tolbert

Postural control is impaired following a concussion and is 1 diagnosticmethod used by medical professionals for return-to-play decisions inpotentially concussed athletes Circadian rhythm (time-of-day) affectshuman function including postural control This research investigatedtime-of-day influence on 1 postural control diagnostic protocol the Sta-bility Evaluation Test (SET) on a Neurocom Balance Master The

Georgia Gwinnett College Institutional Review Board approved this re-search protocol The research participants were 9 healthy women with anaverage age of 204 years height of 1658 cm and weight of 653 kg Theparticipants completed the SET in the morning (between 700 AM and 1000 AM) for 1 treatment and in the evening (between 300 PM and 700 PM)for the other treatment A SET familiarization session was completed andtreatment order was randomized and balanced to attempt to account fororder effects Average postural sway velocity for each of the 6 SET con-ditions were compared between times of day There was less postural swayduring the morning testing for all conditions reaching statistical signifi-cance (p lt 005) for 2 of the more challenging balance conditions (FoamDouble Leg and Foam Tandem) as well as for the overall SET compositescore While greater sample size age and gender range are needed theseresults may begin to inform practitioners as to the importance of con-trolling time-of-day between baseline and post-injury testing which mayenable more accurate and reliable return-to-play decisions

DisclosuresDr Doan has nothing to disclose Dr Pasley has nothing to discloseDr Rodriguez has nothing to disclose Dr Valencia has nothing to disclose DrTolbert has nothing to disclose

The effects of altitude on concussion incidence in the2013ndash2017 National Hockey League seasonsRyan Adams Halley Kaye-Kauderer Syed Haider Akbar Maniya Stanislaw

Sobotka Tanvir Choudhri

IntroductionAltitude cannot be adjusted yet can still impact quality of play andconcussion incidence The current body of published evidence evalu-ating environmental effects on concussion is divided We aim to sys-tematically compare the prevalence of concussions that occur utilizing1000 feet as a marker for high altitude Our research also takes a novelapproach utilizing average games missed as a proxy for concussionseverity

MethodsData on concussion incidence for the 2013ndash2017 National HockeyLeague seasons was collected utilizing FOX Sports Hockey Referenceand elevation map We adopted 1000 feet (3048 meters) as high-lowaltitude cutoff We also evaluated our data utilizing a previously pub-lished high-low altitude cutoff of 644 feet One caveat to our data col-lection was the striking lack of publicly available data pertaining to theconcussions sustained by each NHL team Data was analyzed utilizingSAS programing

ResultsWe documented 133 concussions through the 2013ndash2017 NHL seasonsWe noted an increase in concussion reporting during the most recent2016ndash2017 season compared to previous ones Effect of altitude varianceon concussion rate was evaluated utilizing 644 and 1000 ft as the altitudesplit This produced 4 distinct categories (1) low-low (2) low-high (3)high-low and (4) high-high We noted a significant difference in con-cussion rate when teams based at altitude above 1000 ft played at lowaltitude Average games missed demonstrated that teams above 1000 feetexperienced less games missed compared to low altitude teams

ConclusionsThough underreported in the total number of concussions our datasuggests that high altitude teams experience a reduction in mean con-cussion rate when playing at lower altitudes Our data also indicateda reduction in average games missed post-concussion for higher altitudeteams We hope our findings contribute to a larger discussion aboutconcussion incidence and can be applied to additional sports leagues

Disclosures Dr Adams has nothing to disclose Dr Kaye-Kauderer hasnothing to disclose Dr Haider has nothing to disclose Dr Maniya has nothing



to disclose Dr Sobotka has nothing to disclose Dr Choudhri has nothing todisclose

Relationship between fractional anisotropy andneuropsychological evaluation in sports-related concussionHaruo Nakayama Yu Hiramoto Yuriko Numata Satoshi Fujita Nozomi

Hirai Norihiko Saito Morito Hayahsi Kazuya Aoki Satoshi Iwabuchi

ObjectiveTo evaluate the relationship between functional anisotropy (FA) andneuropsychological evaluation in concussion

MethodsDiffusion tensor MRI included FA of the Brain and neuropsychologicalevaluation were conducted on 10 patients with concussion who werediagnosed from April 2017 to March 2018 FA was extracted from 2regions of interest in Corpus callosum (CC) and corticospinal tract(CT) Detailed neuropsychological testing with an emphasis onWorking memory (WM) and Processing speed (PS) was also con-ducted The FA value in that 2 regions were compared between the 2groups of 5 patients (group F) who failed either inWMor PS and 5 cases(group NF) who did not admit it

ResultsMean FA values in CC and CT in the Group F were 070 and 052 MeanFA values in CC and CT in the Group NF were 048 and 055

ConclusionsOur result suggests that the FA value of CC did not explain thesignificant fluctuation of the neuropsychological function HoweverFA value in CT were shown to explain the fluctuation of WM andPS

Disclosures Dr Nakayama has received personal compensation for activitieswith Nippon Professional Baseball Organization as medical committee supervi-sor Dr Hiramoto has nothing to disclose Dr Numata has nothing to discloseDr Fujita has nothing to disclose Dr Hirai has nothing to disclose Dr Saito hasnothing to disclose Dr Hayahsi has nothing to disclose Dr Aoki has nothing todisclose Dr Iwabuchi has nothing to disclose

Recovery time risk factors and volumetric analysis in acutemTBITeena Shetty MD Joseph Nguyen Taylor Cogsil Apostolos John Tsiouris

Sumit Niogi Aashka Dalal Kristin Halvorsen Tianhao Zhang Joseph C

Masdeu MD PhD FAAN Pratik Mukherjee Luca Marinelli

ObjectiveThis study investigated the influence of demographic factors the courseof recovery and the utility of investigational MR sequences (specificallyvolumetry) in mild traumatic brain injury (mTBI) patients

BackgroundMost literature suggests that the majority of mTBI patients achieverecovery within 1 month of injury or sooner This may be affected byyounger age female sex concussion history learning disability psy-chiatric history or migraines The role of volumetric analysis in mTBIrequires further investigation

MethodsOne hundred eleven patients (15ndash50 years old) enrolled in the studywithin 10 days of head injury Patients completed a maximum of 4encounters over 3 months undergoing volumetric structural imaging ateach visit Patients were contacted to determine recovery date

ResultsRecovery date was obtained in 73 patients at HSS The median daysto recovery was 44 days (IQR 23ndash88 days) 33 of this population

was recovered in 30 days 63 in 60 days and gt75 in 90 days Ofthe subjects who were not recovered by 90 days the right thalamusvolume trended towards a negative correlation with SSS at that timepoint Initial symptom severity score (SSS) was significantly corre-lated with increased days to recovery (p = 0382 p = 0001) Averagedays to recover was longer in patients with diagnosed depressionanxiety or other psychiatric disorder (121 vs 70 days p = 0037) Nosignificant differences in days to recovery were found between agegroups sex learning disorder previous concussions or history ofmigraines

ConclusionAverage time to recover from mTBI may be longer than previouslyreported Acute SSS may be a useful indicator in determining recoverytime Of previously reported risk factors personal psychiatric historymay have the greatest effect on recovery time Despite being interestingthe volumetric correlations did not survive multiple comparison cor-rections and may not be the most sensitive variable for mTBI imaging

Disclosures Dr Shetty has received personal compensation for activitieswith GE as a member of NFL Advisory Board Dr Shetty has received re-search support from GE NFL Medical Advisory Board GE NFL ResearchGrant Abbott Research Grant ChembioPerseus Grant ElMindA ResearchGrant Teva Pharmaceuticals Grant Dr Nguyen has nothing to disclose DrCogsil has nothing to disclose Dr Tsiouris has nothing to disclose Dr Niogihas nothing to disclose Dr Dalal has nothing to disclose Dr Halvorsen hasnothing to disclose Dr Zhang has received personal compensation forconsulting serving on a scientific advisory board speaking or other activitieswith General Electric Dr Masdeu has received personal compensation forconsulting serving on a scientific advisory board speaking or other activitieswith General Electric Health Eli Lilly Dr Masdeu has received researchsupport from GE Health Eli Lilly Biogen Avanir Abbvie Novartis DrMukherjee has received compensation from GE and the NFL for the HeadHealth Initiative Dr Marinelli has received personal compensation forconsulting serving on a scientific advisory board speaking or other activitieswith General Electric

Migraine phenotype prolongs recovery time in traumaticbrain injury (TBI)Cynthia Bennett-Brown Sarah Ostrowski-Delahanty Tracy Lynn Johnson

RN M Cristina Victorio Susan K Klein

We proposed that children and adolescents who had headache of mi-graine phenotype at initial neurologic assessment after mild TBI wouldtake longer to clear for return to play than those who did not have thoseheadache characteristics Additionally we predicted that those withmigraine phenotype would be more likely to have comorbid mood orcognitive symptoms which would also contribute to prolonged re-covery To test this we assessed all new patients for the presence orabsence of migraine phenotype with the Three-Item ID migrainescreener (Lipton et al 2003) at the first outpatient visit Over the 5months follow up interval (October 2017ndashFebruary 2018) office visitdata for 121 patients (ages 0ndash19 years) showed that 61 presentedinitially with a migraine phenotype In that interval 48 (N = 58)were cleared for return to play Those with migraine phenotype head-ache took longer to clear (99 vs 71 days respectively p = 0004) Neitherage nor gender made a significant impact on length of recovery whenonly the presence or absence of migraine phenotype alone was con-sidered If patients had a migraine (vs non-migraine) phenotype head-ache and comorbid cognitive or behavioral symptoms (38 in oursample) their time to recovery was prolonged (109 vs 74 days re-spectively F (1 56) = 7215 p = 0009) These data suggest that earlyidentification of migraine phenotype in assessment of post-traumaticheadache can lead to aggressive treatment of headache thus shorteningthe interval of disability after TBI Cognitive and behavioral symptomsseem to have additional impact on recovery and should be addressedand supported in rehabilitation



Disclosures Dr Bennett-Brown has nothing to disclose Dr Ostrowski-Delahanty has nothing to disclose Dr Johnson has nothing to disclose DrVictorio has received personal compensation for activities with Merck ManualPediatric Annals for preparing manuscripts Dr Klein has nothing to disclose

High sensitivity C-reactive protein Potential biomarker ofinflammation in acute mTBITeena Shetty MD Taylor Cogsil Aashka Dalal Kristin Halvorsen Kelianne

Cummings Joseph Nguyen

ObjectiveThis study investigated the utility of high-sensitivity C-Reactive Protein(hsCRP) as a blood biomarker for mild traumatic brain injury (mTBI)

BackgroundValidation of a blood biomarker panel will greatly improve mTBI di-agnosis and prognosis hsCRP has been validated as a sensitive bio-marker for inflammation Previous studies have established relationshipsbetween CRP levels and TBI but the utilization of hsCRP levels inassessing mTBI requires further exploration

MethodsRetrospective chart review collected hsCRP values in acute mTBIpatients seen within 30 days of injury Patients with any comorbiddiagnosis known to cause elevation of inflammatory proteins were ex-cluded Continuous hsCRP levels were transformed into quartileslt0200 mgL for Quartile 1 (Q1) 0200ndash0415 mgL for Quartile 2(Q2) 0415ndash1100 mgL for Quartile 3 (Q3) and ge1100 mgL forQuartile 4 (Q4) Multivariable binary logistic regression modelingidentified potential factors for elevated hsCRP at first visit Cox re-gression analysis identified potential factors for delayed time to recovery

ResultsThree hundred twelve injuries in 311 patients were reviewed (mean age21 plusmn 12 years 53 female) Mean hsCRP was elevated patients whopresented within 2 days of injury and was found to significantly decreasebetween first visit and 4 weeks post-injury (p = 0016) Initial hsCRPlevel was positively correlated with age (r = 0163 p = 0004) andnegatively associated with previous concussion history (p = 0031)When analyzed as quartiles patients in Q4 were more likely to haveendorsed headache (p = 0036) or fatigue (p = 0030) Age significantlyincreased between quartiles (p = 0013) Multivariable binary logisticregression showed that increased age (OR 348) and patients pre-senting with headache (OR 348) or fatigue (OR 216) were signifi-cantly associated with increased risk of having an hsCRP level in Q4Females (HR 032) and increased age (HR 095) were associateddelayed time to recovery

ConclusionshsCRP may be a viable addition to acute and longitudinal biomarkerpanels for diagnosis and prognosis of mTBI

Disclosures Dr Shetty has received personal compensation for activities withGE as a member of NFLAdvisory Board Dr Shetty has received research supportfrom GE NFL Medical Advisory Board GE NFL Research Grant Abbott Re-search Grant ChembioPerseus Grant ElMindA Research Grant Teva Phar-maceuticals Grant Dr Cogsil has nothing to disclose Dr Dalal has nothing todisclose Dr Halvorsen has nothing to disclose Dr Cumming has nothing todisclose Dr Nguyen has nothing to disclose

Case study An evidence based approach to the use of dryneedling for a concussion within the cervicogenic pathwayKristina Green Hollie Walusz Stephanie Naylor

Concussion management and treatment continues to be a popular topicof current literature As discussion of concussion pathways continues tobe highlighted specific intervention strategies are gaining popularity as

best treatment options For patients that fall into the cervicogenicpathway of concussion DN is an intervention modality that is becomingmore prevalent in its use This presentation will describe the commonpresentation of patients that fall within this concussion pathway andhighlight how DN reduces pain and disability within this subset ofpatients We will discuss the current evidence and efficacy of DN as anintervention tool in our clinical practice specifically for the cervicogenicpathway of concussion We will outline and demonstrate proper appli-cation procedures for DN within the cervical occipital and temporalregions with discussion of safety considerations We will then correlatethis intervention tool with the use of outcome measures within clinicalpractice and tie it back to patient reported concussive symptoms Finallywe will discuss the impact on time to resolution of symptoms DN canhave in our patients Learning Objectives (1) Discuss the theory ofConcussion Clinical Pathways (2) Understand a specific clinical pre-sentation of a patient within the Cervicogenic Pathway (3) Define DryNeedling (DN) (4) Understand the utilization and pathophysiologybehind DN in clinical practice (5) Understand the proper application ofDN in the cervical occipital and temporal regions (6) Recognize thebenefit DN has on this specific pathway (7) Recognize patients that canbenefit from this intervention through the use of a case presentation

Disclosures Dr Green has nothing to disclose Dr Walusz has nothing todisclose Dr Naylor has nothing to disclose

Cannabis concussion and chronic pain An ongoingretrospective analysis at Dent Neurologic Institute in BuffaloNYJenniferMcVigeMD Vincent Harry Bargnes III Said Shukri LaszloMechtler

MD FAAN FASN

ObjectiveTo examine medical cannabis (MC) as treatment for concussion-relatedchronic pain

DesignmethodsIndividuals with concussion often experience chronic discomfort fromheadaches MC treatment was approved for use in chronic pain by NewYork State in March 2017 DENT has treated 4123 patients with MCincluding 2792 for chronic pain and 142 with concussion symptoms Sixty-six charts were reviewed with a total of 100 expected by presentation

Preliminary results(1) The Patient Global Impression of Improvement (PGI-I) scalerevealed 80 of patients experienced significant improvement in activitylevel and symptoms (2) Five common concussion symptoms (head-ache mood sleep attention and dizziness) were evaluated via modified-Likert scale (0 rated as ldquoMuch Worserdquo and 10 as ldquoMuch Betterrdquo)Moderate improvement (MI) was defined as 7ndash8 and significant im-provement (SI) 9ndash10 Improvement was greatest in mood (63 MI20 SI) sleep (53 MI 23 SI) and headache (60 MI 14 SI) (3)Quality of Life after Brain Injury Score (QOLIBRI) scores wereobtained on patients who had started MC (46) and those who had notyet (19) Comparison of the groups showed a significant improvement(p = 00035) in quality of life in individuals on MC (4) The routes ofadministration that produced optimal benefit were 11 (THCCBD)oral tincture at an average dose of 15 mL TID for prophylaxis and 201vapor pen for acute pain Together these products cost an average of$242 per month (5) 15 of patients reported side effects all minimalwith 63 related to administration route (poor taste cough) Nopatients discontinued MC due to side effects

ConclusionsThese results support MC as an option for treatment of concussion-related chronic pain While prospective studies are required these



preliminary results lay the foundation for investigating MC as a validtreatment for concussion and chronic pain

Disclosures Dr McVige has received personal compensation for consultingserving on a scientific advisory board speaking or other activities with AmgenAvinir Teva and Supernus Dr Bargnes has nothing to disclose Dr Shukri hasnothing to disclose DrMechtler has received personal compensation for consultingserving on a scientific advisory board speaking or other activities with TevaPromius Allergan Avanir Amgen

A systematic review of the emotional responses of studentathletes post concussionGaurav Majmudar Jill Johnson Evan Anderson Sherry Morgan

BackgroundThe estimated incidence of sports related concussion has increased from300000 in 2007 to over 16 million in 2017 with a large percentageoccurring in youth athletes There are growing concerns about thecognitive and emotional wellbeing of young athletes during concussionrecovery

ObjectiveTo review research evaluating how concussion relates to changes inemotion and mood in high school and college athletes

DesignmethodsRelevant articles from 1997 to 2017 were searched on PubMed usingkeywords and official MeSH terms such as (1) concussion or braininjuries traumatic or TBI and (2) high school or college and (3)depression or affect or mood English language articles were includedfor analysis if they measured concussed high school or college athletesusing a validated instrument for assessing emotion and mood

ResultsTen published studies met the inclusion criteria Five studies measuredchanges in emotional response in athletes after concussion The otherstudies compared emotional response in athletes after concussion to theemotional response in athletes after non-concussive sports injury suchas musculoskeletal or orthopedic injury

ConclusionDespite heterogeneity in methods and limitations in the literature ourreview suggests growing consensus that concussions result in alteredemotions and mood However current research shows conflictingresults on whether alterations in emotional response are different post-concussion than post non-concussive sports injury

Disclosures Dr Majmudar has nothing to disclose Dr Johnson has nothing todisclose Dr Anderson has nothing to disclose Dr Morgan has nothing todisclose

A comprehensive ldquoConcussion Recovery Programrdquo withemphasis on brain coaching and EEG-based neurofeedbacktherapy A retrospective analysisMajid Fotuhi MD PhD

PurposeWe have developed and implemented a ldquoConcussion Recovery Pro-gramrdquo (CRP) which combines promising treatment strategies from themedical literature into a comprehensive multidisciplinary and person-alized program for patients with Post-Concussive Syndrome (PCS)The programrsquos goal is to treat all of a patientrsquos PCS-related symptomsunder the care of a single physician Patients receive brain coaching twiceweekly in order to address their anxiety insomnia attention headacheand fatigue issues We also use EEG-based neurofeedback twice weeklyto complement brain coaching sessions Patients median time spent in

the program was 16 weeks during which they received a median numberof 21 brain coaching sessions and 22 neurofeedback sessions

MethodsTo evaluate the effectiveness of CRP we performed a retrospectiveexploratory analysis using de-identified patient data from the Neuro-grow Brain Fitness Center (Virginia USA approved by the New Eng-land IRB) We used a computerized cognitive testing tool called CNSVital Signs to evaluate the cognitive performance of patients at thebeginning and end of the program

ResultsData from 46 patients reviewed showed significant improvements inseveral cognitive domains Primary outcome measures were the 3 CNSVital Signs domains known to be most sensitive to mild traumatic braininjury Complex Attention Cognitive Flexibility and Executive Func-tioning Paired t-tests were used to compare mean scores before andafter treatment For all 3 domains patients experienced significant im-provement after treatment (p lt 000001) with medium or large effectsizes For all 3 domains over half of patients experienced scoreimprovements greater than the Reliable Change Index

ConclusionsPatients with PCS who completed our CRP experienced significantimprovements in their symptoms These results are promising and nowa larger prospective study is warranted

Disclosures Dr Fotuhi has received personal compensation from NeurExpandBrain Center

Use of event related potential markers in patients withtraumatic brain injuryTad Dean Seifert MD Marco Cecchi

ObjectiveTo investigate whether event related potentials (ERP) could improvediagnosis and management of traumatic brain injury (TBI) patients inan outpatient setting

BackgroundThough important progress has been made in our understanding ofhow traumatic brain injury (TBI) affects the brain diagnosis remainssuboptimal especially in the mild stages of the disease A real timephysiologic measure of brain cortical synaptic function such as eventrelated potentials (ERP) can measure the sensory and cognitive def-icits that follow TBI even at the subclinical stages of the disease Eventhough the potential of ERP as a diagnostic tool for TBI has beenknown for several years the impracticality of running ERP tests inclinical environments on real patients has limited widespread clinicalapplication in the past Recently advances in electronics and analysisalgorithms have made it practical for ERP tests to be administered inoutpatient settings on real patients thus creating an opportunity toevaluate ERP as an index of functional pathophysiology for TBI inclinical environments

DesignmethodsThree patients with acute mild TBI were administered an auditoryoddball ERP paradigm in conjunction with standard clinical evaluation

ResultsERPs were an informative measure for understanding covert deficits incognition Several ERP components revealed selective dysfunction fol-lowing sport concussion ERP testing in this case series increased con-fidence in diagnosis and prognosis for this population of sport-relatedconcussion thus leading to better patient management Through thisdata we are now equipped with better insight on which TBI patients



would benefit most from the addition of ERP testing to the standardclinical workup

ConclusionsAnalysis of ERP data provides valuable information in patients withTBI especially in mild cases where neuroimaging studies are non-revealing

Disclosures Dr Seifert has received personal compensation for consultingserving on a scientific advisory board speaking or other activities with AmgenPharmaceuticals Ipsen Pharmaceuticals Cognision Inc Eli Lilly Pharmaceut-icals National Football League United States Department of Defense NationalHeadache Foundation and the Kentucky Boxing amp Wrestling CommissionDr Cecchi has nothing to disclose

The association of reported cognitive symptoms andobjective cognitive performance in patients with prolongedpost-concussion symptomsDouglas R Polster PhD Aliyah Snyder PhD Alma Martinez Collin Blout

Christopher Giza MD FAAN Talin Babikian

ObjectiveWithin a sample of patients with prolonged post-concussion symptomsthe current study evaluated the etiology of patients reported cognitivesymptoms

BackgroundApproximately 20 of individuals who sustain a concussion will go on tohave prolonged post-concussion symptoms There has been little re-search examining how patientsrsquo perceived symptoms relate to objectivemarkers especially in regard to perceived cognitive symptoms (egdifficulty concentrating) It is important to understand what contributesto patientsrsquo reported complaints in order inform prognosis as well asidentify areas for intervention We hypothesize that patients reportedcognitive complaints are better accounted for by other concussionsymptoms (eg somatic affective sleep) than by difficulties in theirunderlying cognitive abilities

MethodsThirty-seven patients between the ages of 12ndash23 were retrospec-tively included in the study based on the following reported post-concussion symptoms evaluated between 1 month and 1 yearpost-injury Hierarchical linear regression analysis was used to test ifobjective cognitive performance as measured by a verbal learningmemory task (RAVLT Total) and an attentionworking memorytask (WAIS-IV Digit Span Total) significantly predicted reportedcognitive symptoms above and beyond somatic sleep and affectivesymptoms

ResultsResults of the regression analyses indicated somatic sleep and affectivesymptoms significantly explained 503 of the variance in reportedcognitive symptoms Objective cognitive performance did not signifi-cantly predict reported cognitive symptoms above and beyond the 3other symptom factors (R2 Change = 004 F [231] = 145 p = 025)Additionally objective cognitive performance was not a significantpredictor of reported cognitive symptoms explaining only 24 of thevariance

ConclusionsResults suggest cognitive difficulties are unlikely related to un-derlying neurocognitive pathology but instead are related to func-tional challenges in the face of other symptoms (eg headache)Treatment of patients with cognitive complaints should focus ontheir entire symptom set likely leading to a reduction in cognitivecomplaints

Disclosures Dr Polster has nothing to disclose Dr Snyder has nothing todisclose Dr Martinez has nothing to disclose Dr Blout has nothing to discloseDr Giza has received research support fromNINDSNeural Analytics SBIR grant(NS092209 2016ndash2018) Avanir (research grant 2017ndash2018) NCAA-US Deptof Defense CARE [research grants 2014-present] Dr Babikian has nothing todisclose

Stable recovery during and after 6-week aerobic exercise withlimbs blood flow restriction and body cooling in post-concussion syndromeYi-Ning Wu Jessica Gravel Matthew White Josh Avery Terrie Enis Caroline

Stark Robert Cantu MD

Recent research has shown that exercise can improve post-concussionsymptoms It might be because exercise-induced human growth hor-mone enhances the brain function and recovery Exercise under bloodflow restriction (BFR) and cooling triggers physiologic responses ata relatively low intensity that might be beneficial to individuals with PCSand requires further investigation Therefore our ongoing study is toexamine the outcomes of aerobic exercise with (experimental) orwithout (control) BFR and cooling Twenty-three participants withPCS less than 1 year were randomly assigned to the control or theexperimental groups Both groups rode the recumbent bike (NuStep)for 30 minutes at 60 of the predicted heart rate while only the ex-perimental group exercised under BFR and cooling (Vasper system)twice a week for 6 weeks followed by 6 weeks of no intervention Inaddition to the aerobic exercise each participant received the stan-dardized physical therapy as part of the 6-week intervention A post-concussion SymptomsSigns checklist was filled daily by the participantfor 12 weeks To examine the symptoms fluctuations the variances ofchecklist scores for each participant during the intervention period andover the 6 weeks of no intervention were calculated Mann-Whitney Utest showed that variability of the overall symptom severity was signif-icantly less in the experimental group (p = 001) during the interventionperiod and the overall concussion load remained significantly stable inthe experimental group (p = 002) after the intervention ended Thesepreliminary results have demonstrated that aerobic exercise with BFRand cooling enhances the recovery of PCS Aerobic exercise alleviatedthe post-concussion symptoms of individuals with PCS less than 1 yearMore stable recovery was found in the individuals who exercised at 60of predicted maximum heart rate under BFR and body cooling ascompared to the individuals without body cooling and BFR

Disclosures Dr Wu has nothing to disclose Dr Gravel has nothing to discloseDr White has nothing to disclose Dr Avery has nothing to disclose Dr Enis hasnothing to disclose Dr Stark has nothing to disclose Dr Cantu has nothing todisclose

Heart rate variability as it pertains to sports relatedconcussion and post-concussion syndromeThomas Bottiglieri Randy Casals

ContextSports related concussions (SRC) occur frequently in contact andcollision sports and detection relies predominantly on subjective reportsby athletes themselves A non-invasive means of monitoring brainfunction and injury is desirable Existing literature has established au-tonomic nervous system (ANS) dysfunction in the setting of braininjury Heart rate variability (HRV) has been accepted as a means ofmeasuring ANS function and correlation of ANS dysregulation afterbrain injury through HRV measurement can aid in the detection ofconcussions monitoring of recovery and may offer a target forintervention

MethodsThe studies included were found on the Ovid MEDLINE PubMed andGoogle Scholar databases through searches of the following keywords



HRV heart rate variability and concussion post-concussion syndromeand HRV biofeedback We excluded studies that were not in English anddid not meet the inclusion criteria of pertaining to SRC sports per-formance or ANS function

DesignClinical review

ResultsCurrent literature supports the notion that SRC causes dysregulation ofthe ANS which can be detecting through changes in HRV MonitoringHR and analyzing HRV can be used as a tool to detect SRC monitorrecovery and set a target for treatment Biofeedback techniques tar-geting HRV have been used to improve HRV and expedite recoveryfrom SRC

ConclusionExisting literature has shown HRV is a tool for concussion detectionand HRV biofeedback can aid in recovery More rigorous study of thebest ways to measure HRV in athletes qualify and quantify changes inHRV specific to SRC timing of change timing of resolution of ANSdysfunction and clinical significance of persistent HRV change afterinjury were all identified as targets for future research Interventionalstudies evaluating the use of biofeedback as a means of improvingHRV and reducing concussion symptoms severity and duration arewarranted as well

Disclosures Dr Bottiglieri has received personal compensation for activitieswith Global Medical Imaging as an education video creator Dr Bottiglieri hasreceived personal compensation in an editorial capacity for Fidia Pharma DrCasals has nothing to disclose

fNCI-directed treatment of sports related post-concussionsyndrome ion syndromeChristiane Paney Marci Johnson Alina Fong Mark Allen

PurposeWe propose that our individualized Enhanced Performance in Cogni-tion (EPIC) Treatment can effectively address PCS in sports-relatedconcussions by employing functional NeuroCognitive imaging (fNCI)in conjunction with post-concussion symptom scale measurements toinform and direct treatment modalities fNCI is a specialized applicationof fMRI that utilizes a normative reference sample and biomarkers forconcussion to provide sensitive and specific predictive diagnostic valuesThe fNCI addresses neurovascular coupling (NVC) dysregulation thatcommonly arises in PCS These results inform individualized EPICTreatment to restore normal NVC function with a treatment protocolthat strategically integrates cardiovascular therapies with cognitivetraining

MethodsTwo hundred four sports concussion patients were assessed pre- andpost-treatment using both objective (fNCI) and subjective Post-Concussion Symptom Scale (PCSS) measures establishing pre-treatment benchmarks to measure therapeutic effectiveness Patientsunderwent EPIC Treatment which is a week-long multiple treatmentsper day period consisting of cognitive occupational and neuromusculartherapy informed by fNCI and standardized PCSS findings

ResultsfNCI Severity Index Score (SIS) reported an average 80 percent re-duction in objective measurements from the pre-treatment scan Sub-jective measurements from the Post-Concussion Symptoms Scale(PCSS) reveal 59 percent reduction of symptoms as described by pa-tient report The SIS measurements are stable in follow-up scans 1-yearpost-treatment

ConclusionWe provide evidence that fNCI can be used in assessment and treatmentof chronic PCS resulting from SRC Furthermore the results provideevidence that our fNCI-guided treatment has positive outcomes in bothobjective and subjective measurements This supports the hypothesisthat our treatment effectively addresses PCS symptoms resulting fromSRC Follow-up fNCI scans indicate that improvements are stable fol-lowing treatment

SignificanceSRC patients suffering from chronic PCS who were assessed by fNCIand underwent EPIC treatment report immediate sustainable andlongitudinal reduction in symptoms resulting in significant improve-ments to quality of life and functionality

Disclosures Dr Paney has received personal compensation for activities withCognitive FX as an employee Dr Johnson has received personal compensationfor activities with Cognitive FX as an employee Dr Fong has nothing to discloseDr Allen has nothing to disclose

Dual tasking to optimize performance for the tactical athleteSelena Bobula Jami Skarda-Craft Alicia Souvignier

This session with cover aspects of the DoDrsquos Intrepid Spirit (IS) modelfor caring for service members with symptoms of traumatic brain injury(TBI) and comorbidities and taking care further with interdisciplinarymanagement of the high-level functioning tactical athlete Traumaticbrain injury and concussion are common injuries among service mem-bers and athletes As more research is completed on concussion con-sequences of this injury have become better understood but much is stillleft unknown to include proper treatment for high performance tacticalathletes and service members This lecture will discuss interdisciplinarytreatment for high-level performance needs with emphasis on utilizationof dual tasking This session will describe the IS mission and programsavailable through the Warrior Recovery Center at Fort Carson thenfurther expand upon specialized co-treatments between Speech-Language Pathology (SLP) and Physical Therapy (PT) to push high-level patients to a higher standard These interventions includeaggressive dual-task demands with balance exertional and endurancetasks combined with challenges of working memory delayed recallvisual tracking language fluency visual reasoning and executive func-tions in English and the service memberrsquos secondary language A casereport will be provided to offer example interventions as well asimprovements throughout treatment for service members who partici-pated in this advanced intervention

DisclosuresDr Bobula has nothing to disclose Dr Skarda-Craft has nothing todisclose Dr Souvignier has nothing to disclose

Determining aerobic capacity at symptomatic threshold inindividuals with persistent concussion symptomsJacob James Michael Kay MS R Davis Moore

ContextResearch on exercise for concussion rehabilitation is gaining consider-able attention However unless adequately prescribed exercise caninduceexacerbate symptoms and impede neurologic recovery There-fore the primary purpose of this investigation was to determine themetabolic rate and aerobic capacity at symptomatic threshold in con-cussed individuals

MethodsThirty-seven concussed individuals (men = 14 women = 23 2297years plusmn513) completed a graded exercise test on a stationary bike usinga modified Balke protocol Symptoms (SCAT-4) and physical exertion(Borg Scale) were periodically monitored throughout testing which



ceased at the inductionexacerbation of symptoms Aerobic capacity wasassessed using an estimated VO2max calculation (ACSM 2015) De-scriptive and correlation statistics were computed with an apriori alphalevel of 005

ResultsWe observed that symptoms were inducedexacerbated at a meanpower output of 9524W (plusmn3430) which corresponded to a mean es-timated VO2max of 2129 (plusmn584) mLkgmin and a mean metabolicequivalent of 608 (plusmn167) METs No significant differences betweenmen and women were observed Interestingly neither total number ofsymptoms total symptom score (SCAT-4) nor self-report pre-testcardiorespiratory fitness level (Huet questionnaire) correlated withaerobic capacity at symptomatic threshold (p = 005)

ConclusionsOur results help to establish the symptomatic threshold in concussedindividuals during exercise Importantly we did not find a significantcorrelation between cardiorespiratory fitness and symptom thresholdsuggesting a fundamental change in underlying physiology induced byconcussion These findings can be used to design safer graded exerciseprotocols that aim to enhance rehabilitative efficacy Further METconversions may provide a useful tool in guiding rehabilitation of con-cussed individuals in every day activities Our data indicate that con-cussed individuals would benefit from initiating physical activity at anintensity level below the metabolic and aerobic capacity thresholdsdescribed herein

DisclosuresDr Kay has nothing to disclose Dr Moore has nothing to disclose

Why do pediatric athletes continue to play after concussionBert B Vargas MD FAAN Aaron Zynda Meagan Sabatino Jane Chung

Munro Cullum PhD Shane Miller

PurposeAs sport-related concussion incidence has increased in the pediatricpopulation the risks of continuing to play while injured have becomeapparent These risks include subsequent injury prolonged recoveryand Second Impact Syndrome The purpose of this study was todetermine why pediatric athletes continue to play followinga concussion

MethodsProspectively collected data of subjects enrolled in the North TexasConcussion Network Registry (ConTex) between December 2015 andApril 2018 was reviewed Subjects were included in this analysis if theywere diagnosed with a sport-related concussion less than 19 years old attime of injury reported they continued to play and provided a reasonfor continuing play

ResultsTwo hundred fifty-eight subjectsmet inclusion criteria Mean age was 139years (range 7ndash18 years) and 130 (504) subjects were female Onehundred forty-two (55) subjects reported they continued to play fol-lowing their concussion Of those subjects who continued to play 45(317) reported they ldquofelt okay at the timerdquo 41 (289) reported theywanted to ldquoplay through the injury or tough it outrdquo 36 (254) reportedthey ldquodid not realize it was a concussionrdquo 17 (119) reported they ldquofeltpressured to play from their coach or teammatesrdquo and 3 (21) reportedthey ldquowere allowed to continue to play by an athletic trainerrdquo No sig-nificant differences were noted in age gender or sport of the pediatricathletes amongst the reasons for continuing to play

ConclusionsMore than half of pediatric athletes continued to play following theirconcussion Pediatric athletes most frequently continued to play because

they were not experiencing symptoms at the time of the injury wantedto play through it and did not think their injury was a concussionFuture educational programs should take these reasons into consider-ation to prevent pediatric athletes from continuing to play followinga concussion

DisclosuresDr Vargas has received personal compensation from Amgen AlderAllergan Avanir Pernix Teva Lilly and Upsher-Smith for consulting serving ona scientific advisory board speaking or other activities Dr Zynda has nothing todisclose Dr Sabatino has nothing to disclose Dr Chung has nothing to discloseDr Cullum has nothing to disclose Dr Miller has nothing to disclose

Secular trends in emergency department encounters forconcussion at US childrenrsquos hospitals by age group(2008ndash2017)Amy Linabery Kara Seaton Alicia Zagel Alicen Spaulding Gretchen Cutler

Robb Doss Anupam Kharbanda

BackgroundIncreased concussion rates in US youth have been documented since2000 Concomitant rises in healthcare utilization for concussion arelikely attributable to public health media and legislative initiativesaimed at increasing public awareness of the importance of seekingmedical attention after injury Utilization trends in young children havenot been well-documented however

ObjectiveTo characterize recent secular trends in pediatric emergency de-partment (ED) encounters for concussion by 4-year age group

MethodsUsing Childrenrsquos Hospital Associationrsquos Pediatric Health InformationSystem data we examined a retrospective cohort of patients aged 2ndash17years with an ED encounter for concussion at 22 US pediatric hospitalswith continuous data between 2008 and 2017 Average annual change inrates of ED visits for concussion and sports-recreation-related con-cussion imaging and admissions were estimated via weighted least-squares regression

ResultsED encounters with a primary indication of concussion comprised 08(n = 86393) of all ED encounters in 2008ndash2017 Over time ED con-cussion visits in 6ndash17-year-olds increased by 05ndash11 per 1000 EDencounters per year (all Ptrendlt 00001) while rates among 2-5-year-oldsremained stable (Ptrend = 072) Rates for sports-recreation-related con-cussions increased significantly across all age groups (lt00001 le Ptrend le001) Absolute number undergoing any imaging increased in all agegroups however due to increased ED concussion encounters the rate ofimaging decreased overall (minus2971000 ED concussion encountersyearPtrend lt 00001) and across all age groups the imaging rate decreased lessfor 2-5-year-olds (minus1961000 encountersyear Ptrend lt 00001) Like-wise admission rates declined significantly over time overall (minus1011000encountersy Ptrend = 00006) and for all age groups

ConclusionsED concussion encounter rates in US youth aged 6ndash17 years continue toincrease at pediatric hospitals suggesting awareness efforts have beeneffective Conversely imaging and admission rates have decreased in-dicating efforts to curtail unnecessary irradiation and intervention havealso been successful Trends in 2-5-year-olds were somewhat differentfrom older youth and should be explored further

Disclosures Dr Linabery has nothing to disclose Dr Seaton has nothing todisclose Dr Zagel has nothing to disclose Dr Spaulding has nothing to discloseDr Cutler has nothing to disclose Dr Doss has nothing to disclose Dr Khar-banda has nothing to disclose



Gender differences in outcome following pediatricconcussionJacob James Michael Kay MS Chandler Melton Jeff Holloway Davis Moore

ContextConcussive injuries result in various somatic cognitive and mentalhealth alterations which can negatively influence academic and voca-tional performance Research demonstrates that gender may moderateconcussion recovery with females appearing to experience more severeand more protracted symptoms than males However we are just be-ginning to understand gender-based differences in concussion recoveryparticularly during development Accordingly the purpose of our in-vestigation was to advance the extant knowledge by examining the roleof gender in concussion recovery in a pediatric population

MethodsData were collected from a local pediatric sports medicine clinic Par-ticipants (8ndash18 years) who sustained concussions during the 2017ndash2018school years were examined Outcome measures of somatic (RivermeadPost-concussion Symptom Questionnaire) cognitive (CogState BrainInjury Battery) and mental health (Beck Depression Inventory-Youth)symptoms were analyzed Key demographic variables (eg age SESmedical history) and injury characteristics (eg time since injurynumber of prior concussion) were controlled for in the statisticalanalyses

ResultsPreliminary findings indicated a significant gender difference in self-reported somatic symptoms (p lt 005) with females (M= 53 SD = 38)reporting greater symptom scores on the Rivermead Post-concussionSymptomQuestionnaire than males (M = 28 SD = 25) In contrast nosignificant differences were observed for any metric of cognition ormental health (ps ge 015)

ConclusionsOur findings corroborate evidence that concussed females report greaterclinical symptoms than do concussed males Importantly no genderdifferences were observed in terms of cognition or mental health Thusdifferences in concussion symptom scales may not be useful proxies ofcognitive or mental health Future researchers and clinicians should gobeyond concussion symptom scales to gain a more accurate un-derstanding of gender differences if any following concussion

DisclosuresDr Kay has nothing to disclose Dr Melton has nothing to discloseDr Holloway has nothing to disclose Dr Moore has nothing to disclose

Executive functions in adolescent hockey players competingwith different rules for body checkingJean-Christophe Lortie Veronik Sicard Robert DavisMoore Dave Ellemberg

A history of multiple concussions may lead to later-life neuro-degeneration and persistent cognitive impairment Repeated sub-concussive impacts over a career could play a role in this processhowever evidence remains limited Although imaging studies revealcortical thinning and white matter changes no impairments are detectedin neuropsychological studies Thus we sought to explore the effect ofbody checking experience which can be considered as repeated sub-concussive impacts on executive functions in young hockey playersSixty-six young hockey players aged between 12 and 17 years wentthrough a preseason baseline cognitive testing In this age range playersare separated into 3 groups according to the body checking rule eachdivision is playing (ie full body checking progressive body checkingand no body checking) Executive functions were assessed using a task-switching paradigm Primary outcome measures were accuracy and re-action time An ANCOVA with age as covariate was conducted to

compare groups according to the body checking rule they have expe-rienced Analysis revealed no significant group difference in task per-formance (p = 091) suggesting that executive functions are notinfluenced by body checking experience Age strongly correlated withaccuracy (p = 001 r2 = 037) suggesting that younger athletes per-formed poorly on the task relative to their older teammates Thesepreliminary results support that body checking experience did not ap-pear to affect executive functions in adolescent hockey players How-ever age seemed to be a predictor of accuracy agreeing with literaturethat executive functions continue to develop during adolescence A post-season testing will be conducted to investigate the effect of bodychecking on executive functions over an entire season

Disclosures Dr Lortie has nothing to disclose Dr Sicard has nothing to dis-close Dr Moore has nothing to disclose Dr Ellemberg has nothing to disclose

Concussion in youth sports A survey study assessingknowledge attitude amp experienceKacie Kidd Trevor M Jones Pamela Murray Alex Ritter Andrew Cole Gurtis

PurposeResearch on concussive injuries among athletes has increased sub-stantially but is limited due to the lack of studies involving adolescentathletes who experience the majority of sports-related concussions anddifferences by sex and sport The purpose of this study is to betterunderstand how adolescents comprehend and experience concussions

MethodsA survey assessing knowledge attitude and experience regardingconcussion was administered to athletes ages 10ndash17 in the spring of2016 and 2017 Data collection occurred during an annual sportsphysical event and was administered on laptop computers Analysisincluded descriptive statistics as well as the χ2 testing of scoresreflecting knowledge and attitude among participants by age genderand sport

ResultsIn total 208 athletes (5096 male average age 136 years SD 184)completed the survey and (33 16) endorsed a history of concussionThey participated in 21 different sports and the majority (64) receivedformal concussion education While 98 understood that they were notallowed to return to play on the same day they were concussed 50indicated that they would continue to play with a headache sustainedfrom a sport injury When comparting the sports athletes played atti-tude score trends were more positive among low-impact sport athleteswhen compared to high-impact sport athletes (p = 00291)

ConclusionsWhile a high prevalence of concussions and unhealthy attitudes towardreporting are found at the highest levels of professional and collegiateathletics this study provides evidence that youth athletes are also vul-nerable This study and similar works on older populations suggest thata paradigm shift is likely necessary to change the culture of athleticsbeginning at the youngest levels with an emphasis on the responsibilityto protect onersquos brain over the need to get back in the game

Disclosures Dr Kidd has nothing to disclose Dr Jones has received personalcompensation from HealthWorks Rehab amp Fitness as an employee Dr Murrayhas nothing to disclose Dr Ritter has nothing to disclose Dr Gurtis has nothingto disclose

The gaps of concussion policy in soccer A visual reviewNikesh Bajaj DO

Concussion evaluation and treatment has been widely less widelypublicized in soccer vs American football However a recent assessmentfound that in the previous FIFAWorld Cup in 2014 63 of events when



players involved in head collisions were not assessed by sidelinehealthcare personnel within the 64 matches of the tournament Theupcoming 2018 FIFA World Cup should be approached with a morecritical eye in order to improve the rate of concussion assessment in headcollisions US Soccer National Teamrsquos Concussion policy ldquoplayers whoare suspected of having sustained a concussion shall be removed fromplay immediately and evaluated by team medical staffrdquo Not all headcollisions are required to be examined and a physician is not required toperform the sideline evaluation Since the start of the 2018 MajorLeague Soccer season at least 2 incidents of concussion diagnosis wereinstances which an initial evaluation allowed the player to return to playwhen a concussion diagnosis was made later A detailed examination ofprofessional soccer both on the American and World stage exposes gapsin concussion policy that must be addressed to improve the approach toathlete brain health

Disclosures Dr Bajaj has nothing to disclose

Streamlining clinical research The National Institute ofNeurological Disorders and Stroke (NINDS) NationalInstitutes of Health (NIH) and Department of Defense(DoD) sport-related concussion common data element(CDE) recommendationsKristen R Joseph MA Carolina Mendoza-Puccini Joy R Esterlitz Katelyn

Elizabeth Gay Muniza Sheikh Patrick Bellgowan

ObjectiveThe purpose of the NINDS CDE project is to educate new clinicalinvestigators increase efficiency and effectiveness of clinical researchstudies and treatment increase data quality facilitate data sharing sig-nificantly reduce study start-up time and more effectively aggregateinformation into significant metadata results In 2016 as part of theNINDS CDE project to develop data standards for all clinical neuro-science research NINDS NIH and the DoD initiated the developmentof Sport-Related Concussion (SRC) CDEs

BackgroundTBI CDE recommendations were published on the NINDS CDEwebsite in 2010 but lacked a thorough inclusion of SRC In August2016 a new SRC-specific working group (WG) began developing andidentifying CDEs template case report forms (CRFs) and guidelines toassist investigators conducting SRC-specific clinical research studies

DesignmethodsThe CDE WG which consisted of 34 worldwide SRC research expertsmet regularly via teleconference over several months The WG wasdivided into 3 subgroups to examine SRC during defined periods rela-tive to time of injury Acute (72 hours post-concussion) Sub-Acute (3days-3 months post-concussion) and PersistentChronic (3months andgreater post-concussion)

ResultsVersion 10 of the SRC CDEs were available on the NINDS CDEwebsite in June 2017 These include Core and Supplemental HighlyRecommended CDEs or instruments for cognitive measures andsymptom checklists as well as other outcomes and endpoints andsample CRFs for domains typically included in clinical research studies(eg vestibular oculomotor balance anxiety depression)

ConclusionThe NINDS CDEs are reviewed and updated regularly as researchadvancements or changes to specific recommendations are deemed ap-propriate Because the CDEs are an evolving resource continued feedbackis important for improved use and utility The use of SRC CDE

recommendations is highly encouraged for SRC related researchers as theyserve as a valuable starting point and facilitate streamlining and sharingdata

Disclosures Dr Joseph has nothing to disclose Dr Mendoza-Puccini hasnothing to disclose Dr Esterlitz has nothing to disclose Dr Gay has nothing todisclose Dr Sheikh has nothing to disclose Dr Bellgowan has nothing todisclose

Resting metabolic rate following sport concussion Apreliminary analysisSamuel R Walton MEd Candace Bernitt Brooke Daniell Steven Malin

Jacob Resch

ObjectiveAlterations in energy expenditure have been observed following mod-erate and severe traumatic brain injury (TBI) in animals and humansHowever few data exist characterizing how mild TBI specifically con-cussion affects whole-body energy expenditure The purpose of thisstudy was to examine resting metabolic rate (RMR) following sportconcussion in university and high school student-athletes

MethodsConcussed participants were recruited from a university and local highschools Concussion diagnosis was made by an athletic trainer or physi-cian Participants could have no other concurrent injury (eg fracture)RMR was determined by indirect calorimetry (VMax Metabolic Cart)with a ventilated hood lt 72 hours following a diagnosed concussion (T1)7 days after T1 (T2) and 7 days after T2 (T3) Predicted RMR (pRMR)was also calculated using 3 validated equations Harris-Benedict (HB)Mifflin-St Jeor (MSJ) and Schofield (SCH) These equations were usedto examine the magnitude of change in RMR following concussionMeasured and predicted values were compared at each time point usingpercentages ([RMRpRMR] times 100) Changes over time in measuredRMR were assessed using a repeated measures ANOVA

ResultsTwelve concussed participants (aged 177 + 215 years BMI 218 +294) completed T1 at 18 + 084 days post-injury There were 3 par-ticipants of each sex from each academic setting (university and highschool) Measured RMR percent of pRMRwas below 100 at each timepoint post-concussion (T1 HB = 53 + 76 MSJ = 55 + 86SCH = 53 + 91 T2 HB = 54 + 66 MSJ = 56 + 67 SCH =53 + 81 and T3 HB = 57 + 85 MSJ = 59 + 96 SCH = 57+ 90) Additionally measured RMR did not change over time (T1 =909 + 2260 kcal T2 = 905 + 1545 kcal T3 = 975 + 2667 kcal F2 =1348 p = 028)

ConclusionsConcussed student-athletes appear to have suppressed resting metab-olism of about 40 following injury when compared with validatedprediction equations Although future studies are needed to confirm ourfindings by comparing concussed participants to healthy-matchedcontrols these preliminary data suggest use of prediction equations toestimate concussed student-athletesrsquo dietary energy requirementsshould be used with caution

Disclosures Dr Walton has nothing to disclose Dr Bernitt has nothing todisclose Dr Daniell has nothing to disclose Dr Malin has nothing to discloseDr Resch has nothing to disclose

Catching the snitch or the consequences Profiling incidenceof concussions in Quidditch playersVi Tran Spencer Walser Jeff Wayland Adam Elwood Jose H Posas MD



BackgroundConcussions are caused by a blow to or a violent shaking of the head orbody With increasing popularity of novel sports such as Quidditchinspired by the Harry Potter series it is suspected that players arecommonly misdiagnosed or not seeking treatment after sufferinga concussion Here we look at the incidence of concussion in Quidditchplayers

MaterialsmethodsAfter obtaining IRB approval we conducted an anonymous cross-sectional survey amongst players in the Major League Quidditch for the2017 season The survey included questions corresponding to de-mographics previous medical history specific to concussions migrainesco-morbidities and suspected concussions whilst engaging inQuidditch

ResultsFour hundred sixty-four players were contacted via email with 34response rate Of 34 962 previously engaged in sports either highschool or collegiate level Twenty-six percent of males and 29 offemales reported having previously medically diagnosed concussionsoutside of Quidditch Fifteen percent reported never hitting their headduring a Quidditch match while 19 indicated more than 10 total headinjuries Twenty-five percent of players reported a medically confirmedconcussion during play with 20 indicating a suspected concussionwithout medical evaluation Thirty-four percent reported a history ofdepression or anxiety with 21 players reporting a history of migrainesThose with confirmed head injuries or suspected concussion 39 in-dicated that they sought medical treatment while 24 responded thatthey did not

ConclusionMajority of Quidditch players reported having suffered a concussionprior to playing while half reported suffering a confirmed or suspectedconcussion during a game Players were divided on seeking treatment Itis well documented that history of migraines or other comorbiditiescombined with multiple concussions leads to longer recovery times aswell as higher rates of post-concussive syndrome With the growing rateof traumatic brain injuries it is imperative that players are diagnosed andtreated to prevent future consequences

DisclosuresDr Tran has nothing to disclose Dr Walser has nothing to discloseDr Wayland has nothing to disclose Dr Elwood has nothing to disclose DrPosas has nothing to disclose

Neuro-visual miscalculations in acute mTBIAbby Wicks James A Black MD Matthew Donald Holtkamp MD

ObjectiveTo describe oculomotor abnormalities following acute mild traumaticbrain injury (mTBI) as a possible target for Rehabilitation

BackgroundMore than 361092 service members have sustained mTBI between 2000and 2016824 percent being mTBI The vast majority improve withina few weeks However small percentages continue to have symptoms ofChronic TBI including those with objective findings on oculomotorexam The neuropathology of these finding are well documented and arepossible targets of acute mTBI rehabilitation This case series explores thetypical finding of symptomatic patients after mTBI Neuro-optometry isa subspecialty which evaluates the visual system for dysfunction followingneurologic insult Binocular dysfunction is prevalent following mTBIRecent literature supports the hypothesis that the visual system can beutilized to evaluate the extent of brain injury The NSUCO oculomotortest allows for quantification of saccadic and pursuit inaccuracies

MethodsThe case series reported here from the Intrepid Spirit Center (ISC) FortHood focuses on the treatment of acute mTBI patients referred by primarycare providers or emergency departments Three military service memberswith acute mTBI underwent a complete neurologic examination witha neurologist including an oculomotor function assessment with a Neuro-optometrist utilizing the NSUCO oculomotor test (video attached)

ResultsWe have video documentation demonstrates typical oculomotor dys-function seen in acute mTBI patients including poor initiation of sac-cades inaccurate spatial planning and execution of saccades and fixationlosses on pursuits on binocular assessment

ConclusionOculomotor dysfunction is a verifiable reproducible documentation oforganic dysfunction in acute mTBI amenable to therapeutic approachesincluding neuro-optometric visual rehabilitation Neuro-optometric vi-sion rehab is a novel treatment modality for acute mTBI

DisclosuresDr Wicks has nothing to disclose Dr Black has nothing to discloseDr Holtkamp has nothing to disclose

Y-Balance test asymmetry is greater in collegiate athletes witha history of concussionMatthew Hoch Nicole Curry Emily Hartley-Gabriel Nicholas Heebner

Johanna Hoch

Athletes with a history of concussion (HC) are at an increased risk ofsustaining lower extremity injuries It is unclear if these individuals ex-hibit dynamic postural control deficits associated with lower extremityinjury risk The purpose of this study was to determine if collegiateathletes with a HC demonstrate differences in Y-Balance Test (YBT)performance compared to athletes with no history of concussion(NHC) A total of 116 varsity and club athletes from a Division-I uni-versity participated Forty participants reported a HC (femalemale319 age 200 plusmn 14 years height 1693 plusmn 131 cm mass 684 plusmn 140kg) while 76 reported NHC (femalemale 6016 age 200 plusmn 17 yearsheight 1685 plusmn 129 cm mass 687 plusmn 146 kg) Individuals with a currentconcussion or lower extremity injury or a history of lower extremitysurgery were excluded Participants completed the YBT anterior reachdirection barefoot on both limbs The YBT was completed by maximallyreaching anteriorly maintaining balance and returning to the startingposition without errors Participants completed 4 practice trials and 3test trials Reach distances were averaged and normalized to leg lengthBetween-limb asymmetry was calculated as the absolute difference be-tween the left and right limbs Separate independent t-tests examinedgroup differences in normalized reach distances and asymmetry Theproportion of participants in each group with gt4 cm of asymmetry wascompared using a χ2 test Alpha was set at 005 for all analyses No groupdifferences were identified in normalized reach distances for the left(HC 614 plusmn 92 NHC 608 plusmn 62 p = 088 ES = 008) or right(HC 614 plusmn 62 NHC 602 plusmn 68 p = 051 ES = 017) limbsHowever a greater proportion of HC participants demonstrated gt4 cmasymmetry (HC 400 NHC 197 p = 002) and these participantsexhibited greater asymmetry (HC 387 plusmn 369 cm NHC 240 plusmn 213cm p = 003 ES = 053) Athletes with a HC exhibited greater asym-metry compared to athletes with NHC Anterior reach asymmetries ofgt4 cm are associated with greater lower extremity injury risk The YBTmay provide a clinical technique to further explore the relationshipbetween concussion and lower extremity injury

DisclosuresDr Hoch has received personal compensation for editorial activitieswith the International Journal of Athletic Training and Therapy as AssociateEditor Dr Curry has nothing to disclose Dr Hartley-Grabriel has nothing todisclose Dr Heebner has nothing to disclose Dr Hoch has received personal



compensation for editorial activities with the International Journal of AthleticTraining and Therapy as Associate Editor

The effects of submaximal aerobic exercise on heart ratevariability in adolescent athletes with history of concussionBrett Steven Gunn Adam T Harrison R Davis Moore

The purpose of this study was to evaluate cardio-autonomic regulationin adolescent athletes with and without history of concussion at rest andfollowing moderate intensity aerobic exercise We hypothesized thatexercise would reveal covert impairments in cardio-autonomic functionfor athletes with a history of concussion following aerobic exercise Maleadolescent hockey players were recruited and divided into history ofdiagnosed concussion and matched controls without history of con-cussion Athletes in the concussion group were 3 + months from injuryasymptomatic and currently engaged in sport Cardio-autonomicfunction was measured for 5-minute at rest and for 10-minute followingcycle ergometery at 60ndash70 theoretical maximal heart rate Variableevaluated were mean normal-normal interval (mean NN) standarddeviation of NN intervals (NN) root mean square of successive dif-ferences (RMSSD) low frequency (LF) high frequency (HF) andapproximate entropy (ApEn) No differences were observed betweenthose with and without a history of concussion at rest However theconcussion group showed significant differences in mean RR intervaland approximate entropy following exercise relative to matched controls(p = 005) Moderate intensity exercise may induce cardio-autonomicdysfunction in adolescent athletes with a history of concussion evenafter they are asymptomatic and make a full return to play Thesefindings support prior reported findings that exercise can inducea decoupling between the autonomic and cardiovascular systems fol-lowing concussion

Disclosures Dr Gunn has nothing to disclose Dr Harrison has nothing todisclose Dr Moore has nothing to disclose

Propagating prion-like amyloid proteins invade target cellsthrough endocytic vesicle ruptureWilliam Patrick Flavin David Freeman Luc Bousset Zachary Green Yaping

Chu Jeffrey Kordower PhD Ronald Melki Edward Campbell

Numerous pathologic amyloid proteins spread from cell to cell duringneurodegenerative disease facilitating the propagation of cellular pa-thology and disease progression in a prion-like fashion Understandingthe mechanism by which amyloid assemblies enter target cells and in-duce dysfunction is therefore key to understanding the progressivenature of diseases like Alzheimerrsquos Parkinsonrsquos Huntingtonrsquos andchronic traumatic encephalopathy In this study we utilized an imaging-based assay to monitor the ability of amyloid assemblies to induce therupture of intracellular vesicles following endocytosis as well as toelucidate the cellular consequences of this damaging mechanism ofinvasion We observe that induction of vesicle rupture is a conservedability of fibrillar amyloid assemblies of alpha-synuclein tau andpolyglutamine-rich huntingtin Endocytic vesicle rupture potency isstrongly influenced by strain conformation and is increased by assemblyphosphorylation Vesicles ruptured by alpha-synuclein can accumulateand fuse into large intracellular structures resembling Lewy bodies invitro and the same markers of vesicle rupture surround Lewy bodies inbrain sections from Parkinsonrsquos patients Finally ruptured vesiclescontaining alpha-synuclein can be observed in the extracellular envi-ronment and can be seen trafficking from cell to cell These data un-derscore the importance of endocytic vesicle rupture as a conservedmechanism of cellular invasion by multiple disease-associated amyloidprotein assemblies implicate this process in the formation of pro-teinaceous inclusions such as Lewy bodies and suggest that this form ofcellular damage can serve as both a driving force and a vector for amyloidprotein release and subsequent transmission to neighboring cells

Disclosures Dr Flavin has nothing to disclose Dr Freeman has nothing todisclose Dr Bousset has nothing to disclose Dr Green has nothing to discloseDr Chu has nothing to disclose Dr Kordower has received personal compen-sation for activities with CDI NSGene Michael J Fox Foundation and nLifeTherapeutics as a consultant Dr Kordower has received personal compensationin an editorial capacity for Wiley Press as an Associate Editor Dr Kordower hasreceived research support fromMedos Inc and nLife Therapeutics Dr Melki hasnothing to disclose Dr Campbell has nothing to disclose

Mood alterations in concussed university athletes who madea complete return to playWilliam Sauve Robert Moore Dave Ellemberg

Affective disorders such as depression are now estimated by the WHOto be the greatest cause of disability worldwide (Mathers et al 2006)Brain research into affective dysregulation suggest that the prefrontalcortex plays a particular role in the regulation of affect (Johnstone ampWalter 2014) One common injury of the prefrontal cortex is con-cussion which accounts for 70ndash90 of all brain injuries(Cassidyet al 2004) Most of the literature related to the consequences ofconcussion is cross-sectional which mean that it is difficult to clearlyidentify a cause and effect relationship (Caruana et al 2015) Thepurpose of this study was to assess the mood states of universityathletes before a concussion and during the acute phase of the injuryAs such 15 collegiate athletes (age = 2087 plusmn 192) completed theBeckrsquos Depression Inventory-II (BDI-II) and the Profile of MoodStates (POMS) at baseline (7340 plusmn 3433 days prior to a concussion)and on average 6 days following a concussion after making a completereturn to play On the POMS subscales athletes reported lower vigor(p = 003) at day 6 (1247 plusmn 481) compared to their preinjury score(1460 plusmn 379) Athletes also reported greater intensity of depressivesymptoms on the total score of the BDI-II (p = 005) at day 6 (733 plusmn815) compared to their preinjury score (453 plusmn 429) A trend was alsoobserved (p = 008) on the somatic subscale of the BDI-II whereathletes reported greater somatic symptoms following a concussion(427 plusmn 397) compared to pre-concussion (287 plusmn 261) Although thecurrent results do not suggest concussions lead to clinically significantmood alterations they do support subtle mood alterations selective tovigor and depression

Disclosures Dr Sauve has nothing to disclose Dr Moore has nothing to dis-close Dr Ellemberg has nothing to disclose

History of undiagnosed concussion is associated withconcussion-like symptoms following subconcussive headimpactsJaclyn B Caccese PhD Fernando Vanderlinde SantosMariana Gongora Ian

Sotnek Elizabeth Kaye Felipe Yamaguchi John Jeka

ObjectiveImmediate removal from activity after sport-related concussion is as-sociated with less time missed from sport a shorter symptomatic periodand better outcomes on acute clinical measures than delayed removalfrom activity However the effects of undiagnosed concussion on clin-ical outcomes have not been studied In the case of an undiagnosedconcussion when the athlete is not removed from play heshe mayundergo subsequent repetitive head impacts Subsequent head impactsmay prevent complete recovery and make the athlete more sensitive toeven mild mechanical head impact The purpose of this study was todetermine if soccer players with a history of undiagnosed concussion aremore likely to report concussion-like symptoms following typical soccerheading than those without a history of undiagnosed concussion

MethodsThirty-one adult amateur soccer players (17 males and 14 females223 plusmn 45 years 1710 plusmn 92 cm 719 plusmn 114 kg) completed a self-reported concussionsport history questionnaire as part of a larger study



aimed to identify behavioral and biomarkers of subconcussion Partic-ipants were asked to report diagnosed and undiagnosed concussionsUndiagnosed concussions consisted of unreported and unrecognizedconcussions Participants also indicated concussion-like symptomstypically experienced after soccer heading A χ2 analysis was used todetermine if a history of undiagnosed concussion was associated withprolonged concussion-like symptoms following subconcussive headimpacts

ResultsIndividuals with a history of undiagnosed concussion weremore likely toreport concussion-like symptoms following soccer heading (χ2 = 5114p = 0024 Likelihood Ratio = 4693 p = 0030)

ConclusionsThe results of this study suggest that individuals who experience un-reported or unrecognized concussions may be more likely to experienceconcussion-like symptoms following repetitive subconcussive headimpacts and highlight the importance for athletes in immediatelyreporting concussion signs and symptoms We speculate that theseindividuals may not fully recover and may remain sensitive to mildmechanical head impact even years following their concussion

Disclosures Dr Caccese has nothing to disclose Dr Santos has nothing todisclose Dr Gongora has nothing to disclose Dr Sotnek has nothing to discloseDr Kaye has nothing to disclose Dr Yamaguchi has nothing to disclose Dr Jekahas nothing to disclose

Head impact burden and change in neurocognitive functionover 2 seasons of youth football participationSean C Rose MD Keith Yeates Matthew T McCarthy MD Darren R Fuerst

Patrick Ercole Joseph Nguyen Natalie Pizzimenti

ObjectiveTo determine the association of repetitive sub-concussive head impactswith neurocognitive outcomes in primary school and high school tacklefootball players

MethodsWe conducted a prospective cohort study of 35 primary school players age9ndash12 and 20 high school players age 15ndash18 who each participated in 2consecutive seasons of tackle football from 2016 to 2017 Helmet-basedsensors were used to record head impacts during contact practices andgames which were summed as a cumulative impact for the 2 footballseasons Players were also divided into high intensity and low intensitygroups based on whether they sustained high g-force impacts in bothseasons Players completed assessments on a variety of outcomes beforethe 2016 season and after the 2017 season neuropsychological test per-formance symptom ratings vestibular-ocular function balance parent-completed ADHD symptoms and self-reported behavioral adjustment

ResultsAverage cumulative impact was 6920 (SD 4553) g-forces combined forthe 2 seasons and did not differ between age groups (p = 066) Twenty-one players (38) were classified as high intensity based on individualimpacts After correcting for multiple comparisons neither cumulativeimpact nor impact intensity predicted change scores from pre-2016season to post-2017 season on any outcome measures Instead youngerage group and history of ADHD predicted worse change scores onseveral cognitive measures and ADHD symptom reporting

ConclusionsOver 2 consecutive seasons of primary and high school tackle footballparticipation cumulative head impact burden and intensity of impactswere not found to be associated with changes in cognition balancevestibular-ocular function or behavioral adjustment

Disclosures Dr Rose has received research support from Riddell and ElmindaDr Yeates has nothing to disclose Dr McCarthey has received research supportfrom Riddell and Elminda Dr Fuerst has nothing to disclose Dr Ercole hasnothing to disclose Dr Nguyen has nothing to disclose Dr Pizzimenti hasreceived compensation from a grant funded by Riddell and Elminda for part ofsalary

Greater exposure to repetitive subconcussive head impacts isassociated with vestibular dysfunction and balanceimpairments during walkingFernando Santos Jaclyn B Caccese PhD Mariana Gongora Ian Sotnek

Elizabeth Kaye Felipe Yamaguchi John Jeka

Exposure to repetitive subconcussive head impacts (RSHI) specificallysoccer heading is associated with white matter microstructural changesand cognitive performance impairments However the effect of soccerheading exposure on vestibular processing and balance control duringwalking has not been studied Galvanic vestibular stimulation (GVS) isa tool that can be used to probe the vestibular system during standingand walking The purpose of this study was to investigate the associationof soccer heading with subclinical balance deficits during walkingTwenty adult amateur soccer players (10 males and 10 females 223 plusmn45 years 1705 plusmn 98 cm 700 plusmn 105 kg) walked along a foam walkwaywith the eyes closed under 2 conditions with GVS (40 trials) andwithout GVS (40 trials) Outcome measures included mediolateralcenter-of-mass (COM) center-of-pressure (COP) separation footplacement mediolateral ankle modulation hip adduction and anklepush off For each balance mechanism a GVS response was calculated(GVS mean [without GVS]) In addition participants completeda questionnaire reporting soccer heading exposure over the past year Alinear regression model was used to determine if vestibular processingand balance during walking were related to RSHI exposure Both footplacement (R2 = 0324 p = 0009) and hip adduction (R2 = 0183 p =050) were predicted by RSHI whereby greater exposure to RSHI wasassociated with greater foot placement and hip adduction responsesHowever COM-COP separation (R2 lt 0001 p = 0927) ankle mod-ulation (R2 = 0037 p = 0417) and push off (R2 lt 0001 p = 0968)were not related to RSHI exposure Individuals who were exposed togreater RSHI were more perturbed by vestibular stimulation duringwalking suggesting that there may be vestibular dysfunction and balanceimpairments with frequent heading specifically individuals with greaterexposure to RSHI responded with larger foot placement and hip ad-duction responses to GVS

Disclosures Dr Santos has nothing to disclose Dr Caccese has nothing todisclose Dr Gongora has nothing to disclose Dr Sotnek has nothing to discloseDr Kaye has nothing to disclose Dr Yamaguchi has nothing to disclose Dr Jekahas nothing to disclose

Attention deficit hyperactivity disorder increases anxiety anddepression in concussed college athletesBrett Steven Gunn Jacob James Michael Kay MS Toni Torres-McGehee

Davis Moore

The purpose of this study was to compare symptom profiles of anxietyand depression in athletes with ADHD a history of concussion a historyof concussion and ADHD and controls We hypothesized collegiateathletes with ADHDwho experienced a concussion would report higherlevels of anxiety and depression than other athletes Nine hundred se-venty nine NCAA Division-I college athletes at the University of SouthCarolina (USC) were surveyed as part of a larger performance healthand wellness management program at USC We acquired ADHD di-agnoses history of concussion physician diagnosed concussions State-Trait Anxiety Inventory (STA-I) and Center of Epidemiologic StudiesDepression Scale (CES-D) Athletes were divided into 4 groups (1)ADHD with Concussion (2) ADHD no concussion (3) ADHD no



concussion and (4) No ADHD no concussion for comparison StateAnxiety scores were significantly higher in the ADHD with concussiongroup (421 plusmn 142) compared to all other groups (334 plusmn 89) De-pression scores were also significantly higher for ADHD with concus-sion group (255 plusmn 102) than all other groups (163 plusmn 57) Tukey posthoc revealed both the anxiety mean difference of 84 (95 CI[068ndash62]) and depression mean difference of 97 (95 CI [42ndash151])were statistically significant (p lt 005) These findings suggest ADHDmay have a cumulative effect on state anxiety and depression beyondthat of either ADHD or concussion alone Therefore athletes withADHD should receive extra care and management as they will likelyexperience more severe symptoms following injury

Disclosures Dr Gunn has nothing to disclose Dr Kay has nothing to discloseDr Torres-McGehee has nothing to disclose Dr Moore has nothing to disclose

Abnormal respiratory patterns in a series of post-concussivepatientsKarissa Arca MD Brent P Goodman MD Amaal J Starling MD

BackgroundAutonomic nervous system dysfunction has been identified in patientsfollowing traumatic brain injury (TBI) including concussion Abnormalpostural heart rate and blood pressure instability have been identified inpost-concussive patients Recently we have identified abnormal re-spiratory patterns during autonomic testing for post-concussive symp-toms Tachypnea is a clinical feature of autonomic instability inparoxysmal sympathetic hyperactivity following severe TBI and thepurpose of this study is to identify abnormal respiratory patterns inpatients with autonomic nervous system impairment following mildTBI

MethodsA retrospective review of patients in the Mayo Clinic Arizona Con-cussion Program from October 2017 to March of 2018 was performedClinical features and autonomic testing were reviewed Autonomictesting included blood pressure and heart rate responses to Valsalvaheart rate variability during deep breathing blood pressure and heartrate responses to head-up tilt sudomotor testing and respiratoryresponses using respiratory inductive plethysmography Patients withco-morbidities or medications with potential to influence autonomictesting were excluded

ResultsFifteen patients with a history of concussion were studied Nine of 15patients had abnormal cardiovascular responses on autonomic testingtypically excessive postural tachycardia with head-up tilt Abnormal re-spiratory patterns were identified in 8 of 9 patients with abnormal au-tonomic testing and in 3 of 6 patients without other abnormalities onautonomic testing A number of different respiratory patterns wereidentified including tachypnea prolonged apneic episodes Cheyne-Stokes and other unusual respiratory patterns

ConclusionWe have identified abnormal respiratory patterns in a series of con-cussion patients with or without other signs of dysautonomiaTachypnea has been previously reported as a clinical feature of parox-ysmal sympathetic hyperactivity following severe TBI and was present insome patients in this series The clinical significance and mechanismsinvolved in the generation of respiratory dysrhythmia require furtherstudy but may be another manifestation of post-concussivedysautonomia

Disclosures Dr Arca has nothing to disclose Dr Goodman has nothing todisclose Dr Starling has received personal compensation for consulting serving

on a scientific advisory board speaking or other activities with Eli Lilly ampCompany eNeura Alder and Amgen

Symptom-based clinical profiles in the classification of post-traumatic headacheAndrew H Ahn MD PhD Sylvia M Lucas MD PhD

There are currently no established therapies for post-traumaticheadache (PTH) One key obstacle standing in the way of meetingthis unmet need is the fundamental gap in our understanding of theclinical course and functional impact of PTH In this presentation weexamine the existing schema used to characterize the clinical charac-teristics of PTH including the International Classification of Head-ache Disorders (ICHD) and find that they leave major unresolvedquestions about the diagnosis classification and measurement of theclinical impact of PTH Specifically current data suggest that theICHD classification which is based on the extent of brain injury andthe duration of condition have limited prognostic and treatmentimplications There are several challenges to the classification of PTHas the clinical manifestations of PTH do not map well to the primaryheadache disorders and the definition of the continuous and chronicdaily headache require further study Importantly the existing classi-fication do not provide or imply specific outcome measures for PTHagain a fundamental roadblock to testing therapeutic hypotheses forPTHWe hypothesize that a symptom-based classification is needed tobegin an examination of these unresolved questions and to establishclinically relevant endpoints for research and clinical trials for effectivetherapies

Disclosures Dr Ahn has received personal compensation for activities with EliLilly amp Co as an employee Dr Lucas has received personal compensation foractivities with Allergan Zogenix Allozyne Kineta Wadsworth FoundationBiogen and Genzyme as a speaker andor an advisor

Migraine with aura is the predominant phenotype amongacute post-traumatic headache in sportsTad Seifert MD

IntroductionHeadache is the most common symptom after traumatic brain injury(TBI) a global health concern with an estimated 25 million people inthe United States reporting TBI in a single year Regrettably there islittle evidence on the medical management of post-traumatic headache(PTH) Generally treatment is approached as the primary headachedisorder it most closely resembles in phenotype In the lay public themajority of PTHs exhibit migraine or probable migraine characteristicshowever PTH phenotypes within a sporting context have not beenreported

MethodsThis cross-sectional survey evaluated the characteristics of headache in102 student-athletes ages 13ndash23 who had sustained sport-related con-cussion Acute post-traumatic headache and sport-related concussionwere defined by the International Classification of Headache Disordersand the Concussion in Sport Group definitions respectively Thesample included male and female athletes from a variety of sports withdiffering degrees of contact exposure The survey collected data onpersonal and family history of headache as well as specific headachecharacteristics

ResultsThe study included 54 males and 48 females Migraine with aura (454)was the predominant phenotype is this cross sectional cohort of sport-related acute post-traumatic headache This was followed by migrainewithout aura (227) tension-type headache (218) and other (101)



ConclusionsMigraine with aura is a common phenotype among sport-related acutePTH Further studies should evaluate for potential differences in re-covery trajectories when compared to other headache phenotypes

Disclosures Dr Seifert has received personal compensation for consultingserving on a scientific advisory board speaking or other activities with AmgenPharmaceuticals Ipsen Pharmaceuticals Cognision Inc Eli Lilly Pharmaceut-icals National Football League United States Department of Defense NationalHeadache Foundation and the Kentucky Boxing amp Wrestling Commission

Feasibility of smartphone-delivered progressive musclerelaxation (PMR) therapy in post traumatic headache (PTH)managementSaima Usmani Sandra India Aldana Mia T Minen MD Emma Ortega

BackgroundProgressive muscle relaxation (PMR) has level A evidence in preventingmigraine and tension-type headaches However there is limited researchon behavioral therapy for post-traumatic headache (PTH) let alonedelivered via a smartphone application

AimsobjectiveTo gain preliminary evidence as to whether smartphone based PMR isfeasible for subjects with PTH

Method(s)We performed a single-arm study of prospective patients calling our Con-cussion Center between June 2017 and May 2018 Subjects met ICHD-3criteria for persistent headache secondary to mTBI were age 18ndash85 and3ndash12 months post injury with no prior behavioral treatments for headachein the past year We assessed prior and current headache and neuro-psychologic histories Using the RELAXaHEAD smartphone applicationsubjects were instructed to record headache symptoms daily and practice 20minutes of PMR daily There was a 1-month follow-up assessment

ResultsIn our ongoing study 21 subjects are currently enrolled 13 female(62) with mean age 414 (SD 131 range 20ndash65) Nine (43) subjectshad pre-existing headaches Subjectsrsquo injuries were on average 6 monthsprior to enrollment (SD 26 range 4ndash12) Three (14) were sports-related In the month prior to enrollment subjects reported 193headache days (SD 876 median 20 range 5ndash30) 17 (81) subjectsreported memory problems and 18 (86) reported impaired concen-tration Of 17 subjects enrolled for at least 1 month 9 (53) imputeddata for 20 or more days within the first month (mean 17 days SD 122median 20 range 0ndash31) 4 (24) practiced PMR 2 + timeswk (mean84 days SD 86 median 6 range 0ndash31)

ConclusionPTH subjectsrsquo obstacles regarding adherence to mHealth technologyshould be further assessed before PMR efficacy can be assessed Notablymany subjects concurrently reported difficulties with memory andconcentration which may be contributing to poor adherence Futurework will attempt to assess for differences among users vs non-users

Disclosures Dr Usmani has nothing to disclose Dr Aldana has nothing todisclose Dr Minen has nothing to disclose Dr Ortega has nothing to disclose

Early prophylactic treatment reduces development of chronicpost traumatic headache after concussionIan Crain MD Justin Hoskin MD Yazan Al-Hasan MD Glynnis Zieman MD

Javier Cardenas MD

BackgroundHeadaches after concussion are common potentially debilitating andlong lasting There are currently no guidelines on the treatment of post

traumatic headaches (PTH) The aim of this study is to investigate theeffects of early prophylactic pharmacologic treatment on the de-velopment of chronic post traumatic headaches (cPTH) in adolescentand adult concussion patients

MethodsPatients were retrospectively enrolled from the patient population at theBarrow Concussion and Brain Injury Center (Phoenix AZ) from theprevious 5 years Males and females ages 13 and older with a diagnosis ofPTH attributed to mild head injury based on ICHD2 criteria who wereoffered a headache prophylactic medication were included Patients weredivided into 3 groups those who did not take treatment (Untreated) thosewho took nortriptyline (Nor) and those who took topiramate (Top)Groups were subdivided into those that developed cPTH and those whodid not (ncPTH) The average time from injury to start of treatment (SoT)in days were analyzed using t-tests within and between groups

ResultsOne hundred twenty patients met inclusion criteria for the study(Untreated = 36 Top = 46 Nor = 38) Overall 64 of 120 patients metcriteria for cPTH (53) SoT and development of cPTH is significantoverall (35 vs 23 pamplt 0001) SoT is significant for Untreated (NcPTH144 vs cPTH 356 p = 0001) and Top (NcPTH 239 vs cPTH 355 p =0002) but not for Nor (NcPTH 319 vs cPTH 340 p = 0372) ForNcPTH there is a significant difference between SoT for Untreated andTop (144 vs 239 p = 004) and Untreated vs Nor (144 vs 319 p =0002) but not Top and Nor (239 vs 319 p = 009) For cPTH there isno difference for SoT between groups

ConclusionEarly intervention with nonpharmacologic treatments and topiramate isassociated with reduced development of cPTH

Disclosures Dr Crain has nothing to disclose Dr Hoskin has nothing to dis-close Dr Al-Hasan has nothing to disclose Dr Zieman has nothing to discloseDr Cardenas has nothing to disclose

Child Neurology Society survey of practitioners onmanagement of pediatric post-traumatic headacheDesiree Levyim MD Rachel Pearson MD Raquel Leanne Langdon MD

Sharief Taraman MD Meeryo Choe MD

BackgroundTraumatic brain injury (TBI) is a significant cause of morbidity in thepediatric population with headache being the most common post-concussive symptom There are no established guidelines for themanagement of pediatric post-traumatic headache (PTH) This studyaimed to better characterize common clinical practices of child neu-rologists in order to guide additional research in this area

MethodsMembers of the Child Neurology Society were surveyed

ResultsNinety five practitioners responded to the survey Respondents wereheterogeneous in their experience and practice setting 337 ofrespondents evaluated less than 25 pediatric concussion patients peryear 400 evaluated 25ndash50 and 263 saw gt50 per year The majoritysaw patients with subacute to persistent mild TBI 389 of practi-tioners reported that they consistently use the International Classifica-tion of Headache Disorders (ICHD) criteria to diagnose pediatric PTHhowever only 189 correctly defined PTH as persistent at 12 weeks asper ICHD classification A majority of respondents recommendedNSAIDs as abortive therapy after PTH but instructions regardingtiming after injury and frequency of use varied The time-after-injurywhen prophylactic headache medication was recommended also varied



one-third considered prophylaxis within 1 month and one-third be-tween 1 and 2 months The medications most commonly used forprophylaxis were amitriptyline (937) topiramate (716) andvitaminssupplements (589) Injection-based therapies were used by380 937 recommended non-medical treatments and 380 rec-ommended injection-based therapies Prescriptions for cognitive andphysical rest and return to play were also variable one-third ofrespondents recommended cognitive and physical rest for 1ndash3 daysfollowed by progressive return to cognitive and physical activities whichis consistent with current guidelines

ConclusionsAs there are no established guidelines on management of PTH it is notsurprising that diagnosis and management varies considerably Furtherstudies are needed to define the best evidence-based practices for pe-diatric PTH

Disclosures Dr Levyim has nothing to disclose Dr Pearson has nothing todisclose Dr Langdon has nothing to disclose Dr Taraman received personalcompensation for activities with Cognoa Inc as Vice President of Medical DrTaraman holds stock options from Cognoa Inc Dr Choe received researchsupport from Neural Analytics



DOI 10121201wnl000055067032232b5201891S12 Neurology

Sandro James Corti Nicole Pizzimenti Matthew T McCarthy et al populations

Comparing the acute presentation of sport-related concussion in the adult and pediatric

This information is current as of December 5 2018

ServicesUpdated Information amp

httpnneurologyorgcontent9123_Supplement_1S121fullincluding high resolution figures can be found at

Citations

rticleshttpnneurologyorgcontent9123_Supplement_1S121fullotheraThis article has been cited by 1 HighWire-hosted articles

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content93104654fullpdf or page

nextAn erratum has been published regarding this article Please see

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httpwwwneurologyorgaboutabout_the_journalpermissionsits entirety can be found online atInformation about reproducing this article in parts (figurestables) or in

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httpnneurologyorgsubscribersadvertiseInformation about ordering reprints can be found online

rights reserved Print ISSN 0028-3878 Online ISSN 1526-632X1951 it is now a weekly with 48 issues per year Copyright copy 2018 American Academy of Neurology All

reg is the official journal of the American Academy of Neurology Published continuously sinceNeurology

CORRECTIONS

Clinical Reasoning A 58-year-old man with distal hand weaknessNeurologyreg 201993465 doi101212WNL0000000000008184

In the article ldquoClinical Reasoning A 58-year-old man with distal hand weakness by Vacchianoet al1 the affiliation for Prof Rocco Liguori should have read ldquoDepartment of Biomedical andNeuromotor Sciences University of Bologna Italy IRCCS Istituto delle Scienze Neurologichedi Bologna Italyrdquo The authors regret the error

Reference1 Vacchiano V Di Stasi V Donadio V Sturiale C Liguori R Clinical Reasoning A 58-year-old man with distal hand weakness Neurology

201992e1395ndashe1400

MRI predicts intracranial hemorrhage in patients who receive long-term oral anticoagulationNeurologyreg 201993465 doi101212WNL0000000000007920

In the article ldquoMRI predicts intracranial hemorrhage in patients who receive long-term oralanticoagulation by Martı-Fabregas et al1 first published online April 19 2019 Dr Medrano-Martorellrsquos affiliation should read Hospital del Mar-Universitat Autonoma Barcelona (UAB)Barcelona Spain The authors regret the error

Reference1 Martı-Fabregas J Medrano-Martorell S Merino E et al MRI predicts intracranial hemorrhage in patients who receive long-term oral

anticoagulation Neurology 201992e2432ndashe2443

Midlife adiposity predicts cognitive decline in the prospectiveMulticenter AIDS Cohort StudyNeurologyreg 201993465 doi101212WNL0000000000008187

In the article ldquoMidlife adiposity predicts cognitive decline in the prospective Multicenter AIDSCohort Study by Rubin et al1 first published online June 14 2019 in figure 3 label A shouldread ldquoHIV-rdquo The label appears correctly in the final print version of this article published onJuly 16 2019 The publisher regrets the error

Reference1 Rubin LH Gustafson D Hawkins KL et al Midlife adiposity predicts cognitive decline in the prospective Multicenter AIDS Cohort

Study Neurology 201993e261ndashe271

Comparing the acute presentation of sport-related concussion in theadult and pediatric populationsNeurologyreg 201993465 doi101212WNL0000000000007917

In the abstract ldquoComparing the acute presentation of sport-related concussion in the adult andpediatric populationsrdquo by Corti et al1 first published online December 5 2018 and in the 2018Sports Concussion Conference Abstracts Supplement Dr Pizzimentirsquos first name should beNatalie The authors regret the error

Reference1 Corti SJ Pizzimenti N McCarthy MT et al Comparing the acute presentation of sport-related concussion in the adult and pediatric

populations Neurology 201891(suppl 1)S12

Copyright copy 2019 American Academy of Neurology 465

Copyright copy 2019 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Disclosures Dr Urban has nothing to disclose Dr Kelley has nothing to dis-close Dr Espeland has received personal compensation from Schering-PloughBTG INO Therapeutics and Digestive Care Inc as a data safety monitoringboard member for several industry-sponsored trials Dr Davenport has nothingto disclose Dr Whitlow has nothing to disclose Dr Powers has nothing todisclose Dr Maldjian has nothing to disclose Dr Sitizel has nothing to disclose

Head impact analysis in elite football (soccer)Bianca Brigitte Rock Thomas Blaine Hoshizaki MD

IntroductionTrauma related neuropathologies including recent reports involvingchronic traumatic encephalopathy (CTE) in 8 soccer players have beenconcerning Purposeful sub-concussive head impacts known as headersare an integral part of the game The purpose of this study was todescribe dynamic head response and brain tissue strains for front ball-to-head impacts in elite soccer

MethodsVideo analysis thirteen (13) Championrsquos League soccer footage wascompleted to establish reconstruction parameters of head impact eventsAnalysis of 5 (5) front ball-to-head events were reconstructed usinga Hybrid III 50th percentile headform and a pneumatic linear impactorThe University College Dublin Brain Trauma Model was used to cal-culate maximum principal strain (MPS)

Results and discussionRecorded head impact velocities during elite soccer game play were35ndash230 ms Most purposeful head-to-ball impacts occurred on thefront-temporal region of the head (664) at 0ndash15 degrees of cervicalflexion There was an average of 15 unintentional head impacts and 622headers per game 496 of headers occurred at an inbound velocitybelow 10 ms The lowest velocity reconstructed was 47 ms yielding128 g and 604 rads2 for peak resultant linear and rotational accel-erations respectively the MPS for this impact was 009 Neurophysi-ologic changes and functional impairment have been reported in pastresearch on sub-concussive impacts with 5ndash15 strain The mean 011MPS yielded in this study reflects a potential for these changes in elitesoccer athletes

ConclusionThe main objective of this analysis was to identify impact characteristicsand quantify dynamic cerebral response and brain tissue deformation inelite soccer game play Further research must include cervical muscleactivation the level of play and player position inbound ball-to-headvelocities during different game play events and appropriate impactcharacteristics to appropriately characterize risk of injury in the attemptsof mitigating risk of head injury during soccer game play

DisclosuresDr Rock has nothing to disclose Dr Hoshizaki holds stock andorstock options in Oblique Technologies Dr Hoshizaki has received researchsupport from CCM Hockey Company

Football concussion case series using biomechanical andvideo analysisMirellie Kelley Jillian Urban Derek Jones Alexander Powers Christopher T

Whitlow Joseph Maldjian Joel Stitzel

Approximately 11ndash19 million sport-related concussions among ath-letes le18 years of age occur annually in the United States but there islimited understanding of the biomechanics and injury mechanisms as-sociated with concussions among lower level football athletes There-fore the objective of this study was to combine biomechanical headimpact data with video analysis to characterize youth and HS footballconcussion injury mechanisms Head impact data were collected fromathletes participating on 22 youth and 6 HS football teams between2012 and 2017 Video was recorded and head impact data were

collected during all practices and games by instrumenting players withthe Head Impact Telemetry (HIT) System For each clinically di-agnosed concussion a video abstraction form was completed whichincluded questions concerning the context in which the injury occurredLinear acceleration rotational acceleration and impact location wereused to characterize the concussive event and each injured athletersquos headimpact exposure on the day of the concussion A total of 9 (5 HS and 4youth) concussions with biomechanics and video of the event wereincluded in this study The mean [range] linear and rotational accelera-tion of the concussive impacts were 629 [293ndash1184] g and 30567[10468ndash69546] rads2 respectively Concussive impacts were thehighest magnitude impacts for 6 players and in the top quartile of impactsfor 3 players on the day of injury Concussions occurred in both practices(N= 4) and games (N= 5) Themost common injury contact surface washelmet-to-helmet (N = 5) followed by helmet-to-ground (N = 3) andhelmet-to-body (N = 1) All injuries occurred during player-to-playercontact scenarios including tackling (N = 4) blocking (N = 4) andcollision with other players (N = 1) The biomechanics and injurymechanisms of concussions varied among athletes in our studyhowever concussive impacts were among the highest severity foreach player and all concussions occurred as a result of player-to-playercontact

Disclosures Dr Kelley has nothing to disclose Dr Urban has nothingto disclose Dr Jones has nothing to disclose Dr Flood has nothing to discloseDr Powers has nothing to disclose Dr Whitlow has nothing to disclose DrMaldjian has nothing to disclose Dr Stitzel has nothing to disclose

Comparing head impact kinematics simultaneously measuredusing 6 different sensors in a human cadaver modelJames T Eckner MD R Scott Conley Hugh JL Garton Nikki Weiss Lauro

Ojeda Amanda O Esquivel Ryan Kassel Grant Kulik Patrick J Ransford

Steven Broglio PhD James A Ashton-Miller

ObjectiveTo compare head kinematics measurements obtained from 6 differenthead impact sensors utilizing different methods of sensor-to-headfixation

DesignFree-drop impacts (total n = 54) were performed at 35 and 55 msonto to the front back side and top of 2 elderly human cadaverichead-neck specimens a helmeted (Riddell Revolution Speed) malespecimen was dropped onto a NOCSAE testing pad an un-helmetedfemale specimen was dropped onto a framed sample of field turf Thespecimens were instrumented with an intracranial reference sensorsurgically mounted at the approximate head center-of-mass bya rigidly-fixed custom standoff pad an intra-oral test sensor rigidlyfixed to the upper teethhard palate by a custom orthodontic ap-pliance and 4 commercially available head impact sensing systemsX-Patch Vector mouth guard HITS (helmeted condition only) andG-Force Tracker (affixed to helmet interior or head band dependingon helmet status) Peak linear and rotational head accelerations(PLA and PRA) were compared between each sensor and the in-tracranial reference sensor using intraclass correlation coefficients(ICC [2 1])

ResultsAgreement with reference PLA and PRA values differed betweensensors with the greatest agreement observed for the rigidly affixedintraoral sensor (ICC = 0921 PLA ICC = 0810 PRA) Agreementfor PLA and PRA respectively was for X-Patch ICC = 0638 ICC =0155 for Vector mouth guard ICC = 0775 ICC = 0480 for HITSICC = 0662 (PLA only) for G-Force Tracker ICC = 0364 (PLAonly)


























Ellemberg






















Michael Hoffer


































































Hamilton PhD



























Davis Moore









R Sas MD PhD



























Munro Cullum PhD


























Shalini Narayana










Yarrow












































MD PhD


















Tolbert


















































MD FAAN FASN




























































































































Jacob Resch






















Johanna Hoch






































Davis Moore
































Javier Cardenas MD

























Citations


Errata





Reprints




CORRECTIONS




201992e1395ndashe1400






































Ellemberg






















Michael Hoffer


































































Hamilton PhD



























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R Sas MD PhD



























Munro Cullum PhD


























Shalini Narayana










Yarrow












































MD PhD


















Tolbert


















































MD FAAN FASN




























































































































Jacob Resch






















Johanna Hoch






































Davis Moore
































Javier Cardenas MD

























Citations


Errata





Reprints




CORRECTIONS




201992e1395ndashe1400


















Michael Hoffer


































































Hamilton PhD



























Davis Moore









R Sas MD PhD



























Munro Cullum PhD


























Shalini Narayana










Yarrow












































MD PhD


















Tolbert


















































MD FAAN FASN




























































































































Jacob Resch






















Johanna Hoch






































Davis Moore
































Javier Cardenas MD

























Citations


Errata





Reprints




CORRECTIONS




201992e1395ndashe1400





























































Hamilton PhD



























Davis Moore









R Sas MD PhD



























Munro Cullum PhD


























Shalini Narayana










Yarrow












































MD PhD


















Tolbert


















































MD FAAN FASN




























































































































Jacob Resch






















Johanna Hoch






































Davis Moore
































Javier Cardenas MD

























Citations


Errata





Reprints




CORRECTIONS




201992e1395ndashe1400




























Davis Moore









R Sas MD PhD



























Munro Cullum PhD


























Shalini Narayana










Yarrow












































MD PhD


















Tolbert


















































MD FAAN FASN




























































































































Jacob Resch






















Johanna Hoch






































Davis Moore
































Javier Cardenas MD

























Citations


Errata





Reprints




CORRECTIONS




201992e1395ndashe1400



















R Sas MD PhD



























Munro Cullum PhD


























Shalini Narayana










Yarrow












































MD PhD


















Tolbert


















































MD FAAN FASN




























































































































Jacob Resch






















Johanna Hoch






































Davis Moore
































Javier Cardenas MD

























Citations


Errata





Reprints




CORRECTIONS




201992e1395ndashe1400


























Munro Cullum PhD


























Shalini Narayana










Yarrow












































MD PhD


















Tolbert


















































MD FAAN FASN




























































































































Jacob Resch






















Johanna Hoch






































Davis Moore
































Javier Cardenas MD

























Citations


Errata





Reprints




CORRECTIONS




201992e1395ndashe1400


































Shalini Narayana










Yarrow












































MD PhD


















Tolbert


















































MD FAAN FASN




























































































































Jacob Resch






















Johanna Hoch






































Davis Moore
































Javier Cardenas MD

























Citations


Errata





Reprints




CORRECTIONS




201992e1395ndashe1400




















Yarrow












































MD PhD


















Tolbert


















































MD FAAN FASN




























































































































Jacob Resch






















Johanna Hoch






































Davis Moore
































Javier Cardenas MD

























Citations


Errata





Reprints




CORRECTIONS




201992e1395ndashe1400












































MD PhD


















Tolbert


















































MD FAAN FASN




























































































































Jacob Resch






















Johanna Hoch






































Davis Moore
































Javier Cardenas MD

























Citations


Errata





Reprints




CORRECTIONS




201992e1395ndashe1400
























Tolbert


















































MD FAAN FASN




























































































































Jacob Resch






















Johanna Hoch






































Davis Moore
































Javier Cardenas MD

























Citations


Errata





Reprints




CORRECTIONS




201992e1395ndashe1400




















































MD FAAN FASN




























































































































Jacob Resch






















Johanna Hoch






































Davis Moore
































Javier Cardenas MD

























Citations


Errata





Reprints




CORRECTIONS




201992e1395ndashe1400




































































































































Jacob Resch






















Johanna Hoch






































Davis Moore
































Javier Cardenas MD

























Citations


Errata





Reprints




CORRECTIONS




201992e1395ndashe1400




























Johanna Hoch






































Davis Moore
































Javier Cardenas MD

























Citations


Errata





Reprints




CORRECTIONS




201992e1395ndashe1400
















































Davis Moore
































Javier Cardenas MD

























Citations


Errata





Reprints




CORRECTIONS




201992e1395ndashe1400











































Javier Cardenas MD

























Citations


Errata





Reprints




CORRECTIONS




201992e1395ndashe1400


























Citations


Errata





Reprints




CORRECTIONS




201992e1395ndashe1400















CORRECTIONS




201992e1395ndashe1400















2018 Sports Concussion Conference Abstracts Supplementsociated with concussions among lower level...

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