New Paradigms in Sports Concussion: Introduction (01:51)
Carlin Senter introduces the discussion on innovations in the mechanism of injury, the physiology of recovery, and legal issues. Dr. Kevin Guskiewicz will speak on the mechanism of injury and head impact Telemetry.
Mechanism of Injury and Head Impact Telemetry (04:11)
Guskiewicz provides an overview of the mechanisms of concussive injury, limitations of protective equipment, emphasizes the importance of helmet certification, and illustrates the challenges and values of innovative technologies. He discusses the first study involving helmet sensors and concussions. Studies indicate that omega-3 fatty acids, hyperbaric oxygen treatment, and progesterone improve patient recovery.
Left Side of the Concussion Equation (04:07)
If scientists can inform helmet manufacturers on how to improve their product, and inform coaches how to teach their athletes to play, concussions could be prevented. Bill Meehan studied the mechanisms of concussion injury in 2010. Concussion-proof helmets do not yet exist.
Evaluating Helmets (02:57)
The star rating system evaluates helmets for concussion prevention. Stefan Duma and Steve Rowson use accelerometers to analyze impacts and collisions on the field. Guskiewicz discusses why fit is important, and recommends looking only at helmets rated between three and five. Mouth guards reduce the risk of concussions but are not foolproof.
After Market Helmet Inserts (02:13)
Manufacturers warn against using inserts with protective equipment. Head impact sensors and accelerometers help inform rule and equipment changes, and counsels athletes and coaches on behavioral modification; none of them measure angular acceleration effectively. Guskiewicz cautions against using this technology to diagnose concussions.
What Is the Threshold? (02:57)
Guskiewicz describes several study' findings on threshold and the likelihood of a concussion; the amount of g's is a poor predictor of a risk of injury. Less than 0.5% of impacts exceeding 80g cause a concussion.
Studies Affect the NFL (03:59)
A head impact telemetry system recorded that 40% of the impacts a high school student linebacker received were congratulatory slaps to the back of his head. The NFL changed the kickoff rule because Guskiewicz provided evidence of the increased risk of concussive injury with a ten yard running start.
Behavior Modification (02:53)
Scientists currently study using telemetry for behavior modification purposes in high school student athletes. Football players with two or more concussions demonstrate increased risk for further injury. Scientists need to continue to educate athletes, coaches, and parents about modifying behavior, identify pre-dispositions to concussions, and record chronic neurologic impairment.
Dr. Ann McKee (01:50)
McKee will discuss neurodegeneration associated with repetitive head injury. Harrison Martland first discovered punch-drunk in 1928 and described symptoms that occurred to boxers. MacDonald Critchley renamed it Chronic Traumatic Encephalopathy.
CTE Studies (04:17)
Studies published over the past 80 years include work by J.A. Corseillis who described the neuropathological findings in former boxers. McKee published criteria for a CTE diagnosis in "Brain." The National Institute of Neurological Disorders and Stroke (NINDS) funded a conference to try to validate pathological criteria for the disorder.
Future Directions (02:46)
Scientists do not understand the clinical correlates of concussions. CTE involves brain atrophy, deposition of TDP-43, significant axonal injury, and neuro-inflammation. Boston University and the Veteran's Administration began a brain bank to study tissues that were exposed to traumatic injury.
Selection Bias (02:40)
The brain bank is not an accurate representation of society. Of the 143 athletes diagnosed with CTE, most were former NFL players. Some tissues demonstrated co-morbidities such as Alzheimer's disease and motor neuron disease.
Tau Pathologies in CTE (04:07)
The four stages of CTE progress from individuals possessing only one or two of the pathogenic lesions to widespread involvement of the brain. Scientists discovered the length of exposure to football correlated to the individual's stage of CTE; McKee elaborates on specific cases.
Other Studies (04:15)
Bob Stern studies what clinical correlates can be implemented and observes how mood and behavior changes in individuals afflicted with CTE. Phil Montenegro's work involves symptoms associated with the disease. McKee recommends a large scale epidemiological study to determine frequency and addresses research gaps.
Cause Versus Effect in Degeneration and Chronic Traumatic Encephalopathy (05:43)
Senter introduces Dr. Rudy Castellani who is a professor of pathology. He discusses the difficulties of clinically correlating and diagnosing CTE.
Control Studies (03:13)
Dr. Castellani investigated tissues of patients with E2/E3 APOE genotype and wonders if these brains were healthy. Recent literature about CTE demonstrates that the relationship between concussion and tau proteins remains unclear.
Preeminent Tauopathy (02:40)
Because Auguste Deter demonstrated a progressive neurological decline coupled with a clinical pathology, scientists diagnosed her with Alzheimer's disease. Most CTE cases lack one of the components. Dr. Castellani explains why phosphorylated tau (P-tau) should be looked at as a response to another event.
Tau—Prion Disease (02:45)
Prion diseases include Creutzfeldt-Jakob disease, mad cow disease, cannibalism, and kuru. A journal published an article from a mobel laureate comparing CTE to prion diseases. Evidence suggests that P-tau in the locus ceruleus starts accumulating as early as childhood.
P-tau is Non-toxic (02:45)
Studies indicate that P-tau sequesters toxic-free radicals and metals in the brain. Scientists can only determine if a person diagnosed with Alzheimer's disease has neurodegeneration in end-stage pathologies. Dr. Castellani cites two studies that determined patients who had Alzheimers were cognitively proficient.
Suicide In Athletes (04:56)
Dr. Castellani advocates treating suicide as a psychiatric illness instead of looking for a neurodegenerative disorder. Studies indicate that p-tau in athletes exposed to head trauma distributes differently than healthy brains. Dr. Castellani discusses research gaps and problem areas.
Short and Long-term Outcomes from Sport Related Concussion (03:50)
Senter introduces Dr. Christopher Randolph who will discuss the risks of sports-related concussions. Credible scientific evidence supporting the idea that uncomplicated concussions produce long-term impairments is erroneous. Studies indicate that if bruising, bleeding, or swelling of the brain does not occur, the individual will recover.
Course of Recovery (02:55)
Most uncomplicated concussion sufferers will exhibit heightened symptoms initially and gradually return to baseline. Kevin Guskiewicz measured balance using the Balance Error Scoring System (BESS) and proved that patients who have had more than one concussion carry an increased risk for further injury. Multiple concussions do not appear to cause any measurable neurocognitive impairment.
Short-term Risks: Myth Two (02:46)
Post-concussive symptoms are not always the result of brain injury. Psychological factors play a major role in concussion symptomatology. Changes in cognitive status, balance, and suggestive non-specific symptoms occur, but recover quickly.
Management Strategies: Myth Three (03:23)
No scientific evidence supports a management strategy to treat sport-related concussions. Most of the guidelines stipulate that the affected patient needs to be symptom-free. Mike McCrea published a study demonstrating that 40% of patients returned to sports, while still exhibiting symptoms.
Long-term Risks: Myth Four (05:23)
Credible evidence that athletes who compete in contact sports carry an increased risk for some types of late life neurological disorder does not exist. Guskiewicz studied late life cognitive impairment in former football players. Randolph explains a study of death rates in NFL players and gaps in its findings.
Survey/ Clinical Data (03:41)
Guskiewicz and Randolph compared 41 former football players who they believed suffered from mild cognitive impairment, a group of patients believed to suffer from Alzheimer's disease, and a control group.
Additional NFL Clinical Studies (03:09)
Hart and Casson studied NFL players with cognitive complaints. Children who started playing football prior to 12 did worse overall on reading pronunciation testing. Randolph elaborates on the unreliability of the findings.
Research Gaps (03:31)
Randolph believes that random sampling of the population is required and needs to be compared to demographically random controls. Major depression can contribute to neurodegenerative function. He discusses research gaps and problem areas.
Head Injury, Return to Play, and the Legal Landscape (06:03)
Senter introduces Richard Adler, who spearheaded efforts to create legislation aimed at preventing youth brain injury. Zackery Lystedt returned to a football game after receiving a concussion and now suffers permanent impairments.
Lystedt's Story (02:53)
Rules dictated that Lystedt needed to be removed from the game for one play; he walked off the field on his own. Surgeons removed the left and right side of his skull to relieve pressure. The Centers for Disease Control believes there may be as many as 3.8 million sports-related concussions annually.
Educate vs. Legislate (03:39)
Brain Injury Alliance of Washington, the CDC, and the Seattle Seahawks joined the campaign to increase awareness of youth sports-related concussions. Educating the public alone would provide inconsistent results and take decades to change policy. The state legislation enacted the Zackery Lystedt Law in 2009.
Zackery Lystedt Law (03:55)
Core principles of the law include education, removal, and proper clearance in potential concussions. Children and parents need to sign a form outlining symptoms and risks. Washington Interscholastic Activities Association (WIAA) states that a physician, doctor of orthopedic medicine, physician assistant, nurse practitioner, or athletic trainer needs to observe the suspected individual and provide written documentation before he or she returns to play.
Lobbying with NFL (02:56)
A template of the Lystedt Law passed in all 50 states. States mandated competency testing and continuing education for players, coaches, and parents. Fifteen states adopted the Lystedt formula of suspicion of concussion.
Issues to Watch (02:18)
Adler discusses research gaps and problem areas. A doctor in south Seattle recently gave an athlete written clearance to return to play the same day he received a concussion.
Vulnerable Window in Concussion (02:48)
Senter introduces Dr. John DiFiori who will explain how science and clinical research can translate into patient care. Taking the time to perform a thorough assessment on the patient is critical to treatment. Studies indicate a period of increased cerebral vulnerability (ICV) following a concussion.
Returning to Play too Soon (02:20)
Patients might take longer to recover, run the risk of repeat concussions, and could potentially lead to long term consequences. DiFiori describes the pathophysiology post-concussion.
Diagnosis and Management of Concussions (02:07)
Remove the individual immediately from the contest or practice and perform a thorough assessment; monitor ongoing deterioration. DiFiori recommends the Standardized Concussion Assessment (SCAT 3). A study in the New York Times demonstrated that many students do not report symptoms because they do not want to be removed.
Return to Play (02:40)
Patients might suffer second impact syndrome, repeat concussions, chronic headaches, depression, cognitive deficits, and post-traumatic encephalopathy if they come back too early. A study in mice demonstrated that a repeat concussion occurring three to five days after the initial concussion yielded greater cognitive impairment and axonal injury.
Additional Studies on ICV (06:32)
MRIs displayed significantly larger lesions if another concussion occurred one day after injury; patients demonstrated cognitive impairments after one month. Another study showed increased glucose utilization and histopathological findings. Amyloid beta increases in rats that were injured every 24 hours.
Determining Play Eligibility (02:35)
DiFiori recommends using balance testing, exercise testing, and computerized nerve conduction tests to assess whether a patient is healthy. Drawbacks include patients gaming the system and poor signal detection. DiFiori reviews current methodology and reminds the audience that prolonged rest can be detrimental.
Promoting Recovery (04:58)
Supplements and delayed exercise can have positive effects. Scientists study advanced neuroimaging techniques, serum biomarkers, and prevention education to determine efficacy. DiFiori summarizes his talk.
Q/A: Classifying CTE with Age and Link to Depression (06:03)
Dr. McKee explains that the staging is an indication of the severity of the CTE; it can be present in younger athletes. Dr. Castellani describes how he found an association between depression and players who received four or more concussions; it exhibited most frequently during negative lifestyle changes.
Q/A: Visualizing the Concussion and Prolonged Rest (02:49)
Although metabolic changes are prolonged, physicians do not know how it correlates clinically. Studies need to be conducted to decide which imaging tool is effective.
Credits: New Paradigms in Sports Concussion (00:19)
Credits: New Paradigms in Sports Concussion
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