Demystifying Difficult Brain and Spine: Introduction (01:58)
Dr. Marci Goolsby introduces panelists Dr. Ross Zafonte, Dr. Robert Cantu, and Dr. John Leddy at The American Medical Society for Sports Medicine.
Breaking Backbones: Diagnosis and Management of Spinal Fractures in Athletes: Introduction (02:14)
Dr. Cantu plans on discussing relative and absolute contraindications for return. Document any information. Different sports create varying mechanisms for injury; if an individual feels symptoms, they cannot play.
Types of Athletic Cervical Spine Injuries (02:54)
Injuries include nerve root, cervical sprain, transient quad, vertebral disk lesions, and fractures and dislocations. Nerve roots and brachial plexus neuropraxia are commonly referred to as "burners" or "stingers."
Cervical Sprain/ Ligamentous Injury (02:42)
Dr. Cantu advocates getting traditional radiographic studies as well as flexion and extension views. Individuals are allowed to return to play when symptoms abate and there is no evidence of instability and patients exhibit full range of motion. Fracture-dislocation is the most common cause of sports-related catastrophic injury.
Proposed Pinser Mechanism of Transient Neuropraxia (05:03)
Transient quadriplegia is diagnosed when the anatomical studies appear normal. After static x-rays, attain flexion and extension radiographic images. Dr. Cantu reviews different mechanisms behind cervical spine fractures.
Head Down Contact and Spearing (03:05)
Improved facemask and helmet technology allows athletes to use their head to make contact. Dr. Cantu explains how axial loading causes burst fractures.
Football Related Injuries (06:12)
The National Center for Catastrophic Sports Injury provides evidence that helmets and facemasks reduce the risk of catastrophic injury in football players. Most fractures occur on defense during a tackle. The National Athletic Trainers Association discovered that referees were not calling the spearing rule, because they could not prove the intent of the player.
Return to Play (02:20)
Dr. Cantu details the three classifications of Return to Play. Physicians use neurological studies, radiographic studies, test range of motion, and a head compression test to determine health of the patient.
No Contraindication to Return to Play (03:43)
Athletes can return to sports if a physician finds they have a healed C1 or C2, subaxial, or C7 spinous process fracture. Congenital issues like single level Klippel-Feil, spina bifida occulta, or Torg ration possesses no contraindications. Dr. Cantu discusses other degenerative or postsurgical issues.
Relative Contraindications to Return to Play (05:15)
Patients should obtain an MRI if they suffer from a prolonged burner. Dr. Cantu describes complicated cases where a physician may or may not allow an athlete to return to a contact collision sport. Patients who exhibit multiple episodes of transient quadriplegia, cervical myelopathy, fusion at c12, cervical laminectomy, and three or more spinal fusions are absolute contraindications.
In Conclusion (01:36)
Return to play after spine injury must be patient specific and doctors often disagree. Dr. Cantu advocates that it must be individualized based upon mechanism of injury, anatomical site, imaging results, and the athletes recovery response.
Q/A: Recent Studies About Helmets (01:31)
Dr. Albright conducted the study cited in 1976. Dr. Cantu advocates repeating the study and including a cervical MRI.
Q/A: Straightening of the Cervical Spine (01:29)
Scientists theorize it is cervical spasming. Dr. Cantu explains people diagnosed with Spear Tackler's Spine also exhibit degenerative processes such as space narrowing and osteophyte formation.
Q/A: Collaborations with Other Leagues (01:22)
Dr. Cantu describes recent advances made by the National Hockey League to prevent head trauma and advocates replacing officials who do not call the spearing rule.
When the Brain Bleeds: Introduction (02:02)
Dr. Zafonte explains how there is little level one evidence in head trauma. His talk will cover the background and physiology of brain injury, discuss available data, review controversial information, and theorize on future research. Most brain injury fatalities are related to hematomas.
Physiology of Brain Injuries (03:11)
Zafonte reviews subdural and epidural hematomas. The Monro-Kellie Doctrine theorizes that the volume of blood can only be raised a certain amount. Other changes that occur after a brain bleed include changes in the cellular wall, changes in mitochondria, ion flux, gene expression, and lipid peroxidation.
Axonal Injury (03:14)
Traditionally scientists believed axonal injury occurred in the corpus callosum and the rostral brainstem, but it is actually far more diffuse. Matt Hemphill theorizes that integrins may help produce subconcussive blows. Altered dopamine levels in the frontal cortex exist in animals with traumatic brain injury.
Different Surveys (04:07)
Dr. Zafonte discusses a recent survey from 2012 where half made an incomplete neurological recovery. Subdural hematomas with brain edema are more vulnerable in a younger population because they possess an altered reactivity through cerebral vascular challenges. The doctor describes a case study of repeat concussive events.
Return to Play Parameters (01:35)
Physicians should consider prior concussions, subconcussive impacts, sport, and style of play. Patients with subdural hematomas may need a longer recovery time. Dr. Zafonte discourages athletes return to a collision sport if they had an intracranial hemorrhage.
Return to Play: Controversies (03:21)
Dr. Zafonte describes how there is no level one evidence about returning to play after a linear subdural hematoma or craniotomy. Experts argue over whether it should be allowed, but most concede they would consider allowing an athlete to return if only a burr hole was done.
Dr. Grant Iverson examined patients on the British Columbia Post-Concussion Symptom Inventory and discovered most complained of dizziness. Patients suffering from Attention Deficit Hyperactivity Disorder (ADHD) are more vulnerable to concussion symptoms. Little evidence exists about the relationship of traumatic brain injury and Cavium Septum Pellucidum and ventriculoperitoneal (VP) shunts.
The Future (04:35)
Dr. Zafonte raises questions about finding old injuries, risk, gliosis, finding old contusions, and imaging markers. Susceptibility weighted imaging (SWI) can take a closer look at micro-hemorrhages. Dr. Zafonte discovered grey matter findings were different in patients with severe sport and military concussions.
Magnetic Resonance Spectroscopy (02:58)
N-acetylaspartate (NAA) is a marker of neuronal health and function. Dr. Zafonte reviews several recent studies on creatinine levels, abnormal activation, dysdiadochokinesia, cortical silent period, on patients diagnosed with traumatic brain injury.
Brain Physiology (02:28)
Dr. Zafonte theorizes improvements in imaging, genetics, neurological exams and bloodwork may help diagnose and treat patients with traumatic brain injury. The doctor cautions against returning patients with intrparenchylmal hemorrhages to collision sports.
Q/A: Diffusion Tensor Imaging Changing Physical Protocol (02:00)
Dr. Zafonte explains that scientists do not know how physicians will incorporate modern imaging modalities into a physical for sports. Iverson concluded that the white matter abnormalities in DTI may not have a physiological construct.
Q/A: Intracranial Bleed Risks (00:60)
Patients diagnosed with a former concussion carries increased risks of another brain injury, but no level one data exists to support the theory.
Q/A: Linking Nano Protein Particles to Imaging Abnormalities (01:24)
The McGovern Center at MIT is performing research on nano protein particles and imaging. Dr. Zafonte's group has begun to look at free water subtraction.
Diagnostic and Management Challenges When Concussion Becomes Post-Concussion Syndrome: Introduction (02:43)
Dr. Leddy wants to present an evidence-based approach to Post-Concussion Syndrome (PCS) and to provide effective treatments for Post-Concussion Disorders (PCDs) during his talk. Most high school children get better within three to four weeks. The DSM IV and World Health Organization (WHO) give different explanations for when concussions become PCS.
Diagnosing Concussions and PCS (02:08)
Prognostic factors include headaches, amnesia, memory, processing speed, history of concussions, age and gender. Because physicians do not agree what constitutes PCS, it is difficult to understand who is at risk. Dr. Leddy hopes to clarify that PCS is actually a series of disorders and not a single syndrome.
Establishing Recovery (03:32)
Dr. Leddy reviews the Zurich return to play graded protocol and explains how he uses a modified Balke treadmill test to determine concussion recovery. Dr. Darling concluded a computerized neuropsych test could not predict if an adolescent could return to their sport.
PCS: To Diagnose, Best to Have a Test (03:24)
Dr. Leddy cautions against using symptoms and describes a recent study he performed. Neuropsychological, fMRI, and DTI testing proves inconclusive in diagnosing PCS. Frequently patients exhibit orthostatic intolerances and physical examinations can help determine abnormalities.
Physiologic Dysfunction in PCS (02:53)
Patients who exhibit symptoms have lower heart rates than those who resolved their concussions, but perceive the exercise as more difficult. Current treatments include radical rest, counseling, anti-depressants, and compensatory strategies.
How Do We Treat Physiologic Post-Concussion Disorder (02:16)
Dr. Leddy outlines his strategy for treating PCD: diagnose using exercise intolerance, prescribe a sub-threshold exercise, and gradually increase the heart rate. Once the athlete can exercise at 85% the clinic diagnoses them as recovered and discusses RTP.
How Do We Diagnose Cervicogenic/Vestibular/ Ocular PCD? (06:08)
Patients will exhibit a normal exercise threshold and the physician will be able to detect abnormalities during the physical examination. Dr. Leddy reviews the tests he will give a patient during a physical examination.
Treating Cervicogenic/Vestibular/ Ocular PCD? (02:06)
Treatments include massage, flexor muscle stabilization, vision therapy, vestibular therapy, aerobic exercise. 64% of the individuals treated for PCD returned to full function. Katheryn Schneider found a combination of vestibular PT and orthopedic care optimal.
Affective PCD (02:34)
Dr. Leddy found only five percent of his patients had an underlying mood disorder causing their PCD. Medications include nSAIDs, anticonvulsants, and Amantadine. Dr. Iverson concluded that adults should only rest for three days if they suffer a concussion.
Sleep Disturbance in PCS (02:25)
Dr. Leddy discovered his PCS patients exhibited twice as many sleep disorders as the general populations. Consider a sleep study if Trazodone, melatonin, sleep hygiene or Amitriptyline does not alleviate symptoms.
Dr. Leddy advocates more randomized clinical trials to study PCS. Focus on a physical examination to determine underlying disorders.
Q/A: Posterior Tachycardic Syndrome in Children (01:20)
Dr. Leddy has seen POTS in older adolescents and obtains a supine and standing blood pressure and pulse in every examination.
Q/A: Doing Things Earlier? (01:56)
An audience member asks if Dr. Leddy's study might be too conservative and if he should progress patients earlier. Dr. Leddy advocates skipping the first two stages of the Zurich RTP protocol if the patient passes the treadmill test.
Q/A: Sleep Hygiene Protocol (00:51)
Dr. Leddy's handout includes establishing a regular bedtime and do not read or look at a computer in bed.
Q/A: Exercise Tolerance Test and Physiology (01:38)
Dr. Leddy is beginning to have patients wear a Transcranial Doppler to discover their cerebral blood flow. The physician hypothesizes that when blood flow increases, symptoms occur.
Q/A: Baseline incidence of Abnormalities (01:11)
Dr. Leddy focuses on whether visual tracking abnormalities give patient's symptoms.
Q/A: Faking the Treadmill Test (02:21)
One audience members use vestibular-ocular testing to determine if a patient is suffering from a prolonged concussion. Athletes will reach a point where they cannot continue exercising if they are suffering from symptoms.
Credits: Demystifying Difficult Brain and Spine (00:26)
Credits: Demystifying Difficult Brain and Spine
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