Zurich Day 2… And We Are Live

2 Nov

I have figured out the power situation so I will be trying to update the blog ASAP after each session…  For the time being make sure to follow on Twitter…

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1030 CST: Session 7, final session: The Sharp End

First debate between Dr. Cantu (yes) and Dr. Herring (no): is no RTP same day the best management paradigm?  Is keeping a player out one week long enough and is the graduated RTP protocol sufficient…

THERE WILL BE NO RTP on same day in the new statement!!!

Change of direction on Session 7, questions with panel answers, pro-con (if available)

Do 3 concussions end your career?

  • its comedy hour
  • Aubrey – treat each athlete individually
  • Dvorak – it has to be based on timing and complexity of each recovery – case-by-case basis
  • Putukian – if we can’t agree on dx how can we agree on a number
  • Overall theme is it is individualized, not all concussions are the same (Cantu)

Who is best qualified to make the sideline decision?

  • Cantu – multiple members working under a physician can make the call
  • Herring – concerning to him that some information is intrinsic to doctors so need to be careful
  • better question is who best qualified – person with most experience
  • Dvorak – looking at spectrum of games played, doctors are best qualified in most instances, but are they there in all matches?  We should aim all this to the “grass roots” as the professional level there is more than adequate coverage.
    • comedy about football versus american football
  • Ellenbogen – those that know the athletes should be making the decision, maybe a parent in youth sports, or athletic trainers, understanding the patients baseline is important
  • Putukian – balancing act, in a perfect world its a team approach (Athletic Trainer mention), and she says in the US the athletic trainer should be making the decisions on the sidelines…
  • Aubrey – Hockey Canada has a safety person (volunteer) in lieu of an athletic trainer
  • Cantu – brings up possibly training school teachers in concussion
  • Herring – if you are team physician do you need someone else to make the decision if you are on the sideline?  Panel – no

Is there a role for grading concussions?

  • Cantu – not perfect, but informing patient is important about severity and duration of recovery, after the fact
  • McCrory – we have moved from grading, look at the recovery – perhaps look at the SCAT/serial testing
  • Putukian – looking at history is more important than arbitrary “grade”
  • Herring – may help with continual care from one place to another, but again important to understand history

Should we be returning on the same day of concussion?

  • Aubrey – what about the NHL player in the playoffs (rhetorical question)
  • Cantu – no once recognized
  • McCrory – what about the players that clear the SCAT, so no concussion, but you know something is amiss?
  • Putukian – example of hockey player with delayed symptoms
  • McCrory – concussion is often an evolving injury
  • Ellenbogen – it is a traumatic brain injury, is the game worth it?  No.
  • Panel – consensus is NO RTP same day
  • McCrory to Aubrey about playoff example – what about a regular season, and Aubrey is being very honest, and he feels the player push back is greater
  • Ken Dryden from the audience – why are we treating professional athletes different from the youth or non-elite athlete
    • We are starting to move away from that, all athletes should be treated the same

Should there be helmets in woman’s lacrosse and field hockey?

  • Cantu – yes, because of stick and ball causation of concussion
  • Putukian – no, change nature of the game, no reports of intercranial bleeds in women’s lacrosse, weary of unintended consequences (BTW, probably has the most experience with this)
  • Cantu and Putukian discussing this topic
  • Change gears – what about football?
    • Dvorak not in FIFA’s plans to recommend, many reasons including the false security of wearing head gear
  • Audience Q: should we discourage the use of the head bands/head gear
    • Dvorak – your own prerogative but data does not support the use of them as recommendation (Czech goalie wears one)
    • McIntosh – Rules are more important at this time

Should there be age restriction on tackling in American football, heading in soccer and checking in ice hockey?

  • Cantu – his words speak for themselves, youth sports needs to look at how the game is played because of the differences between older
  • McCrory – in Australia you cannot get to the gladiatorial aspect of Aussie Rules until they are “of age” (13 if I heard correctly)
  • Ellenbogen – risk of activity, most concussions via CDC information is from wheeled sports and recreation, does not make sense at this time to him, advise accordingly
  • Cantu – youth sports don’t have the good data, personally he does not believe learning a sport at age 5 will make you elite, it is a genetic disposition in his opinion
  • Putukian – it makes sense to decrease exposure, US Lacrosse has put age 13 on checking, her take on soccer is that there is no data to support this when using proper sized ball and equipment
  • Dvorak – young soccer players learn sport first, and fundamentals of “football” its not “headball”, studies done on heading ball and with study there was no increase in biomarkers they were looking at it.  They don’t force kids to head ball until skills are sufficient.
  • Herring – false warranty?  Arbitrary age is concerning, take head out of the game rather then taking the game away from youth athletes.  The limit to exposure is accurate, but complete removal of the sport may not be necessary.
  • Cantu – sport needs to be safer for younger athletes
  • Aubrey – ice hockey has set limits on age for body checking, research is very important, it will help make decisions

—–

Dr. Jamie Kissick speaking on “From Consensus to Action”

  • Knowledge is power
  • “There is an app for that”
  • Knowledge Translation (KT) Concepts
    • When – NOW
    • Knowledge to action
    • Official definition
    • Who – public, media, physicians, etc. “All men by nature desire knowledge” – Aerostotle
      • Media – influential on athlete/coaches and parents
      • Coaches – influential on athlete
    • Lost in Translation
      • Ahmed OH, et al (2011) Br J Sports Med
    • How do we deliver it?
      • Conferences/Road Shows
        • Bagley, AF et al (2012) Clin J Sport Med
      • Online courses
      • Websites
        • CDC, Headway, etc.
        • Consistency is key
    • Coaches specifically
      • CDC – Covassin, T et al (2012) J School Health
      • Bok Smart
      • Coach.ca – RRR (recognition, response, return to play)
    • Teachers education
      • REAP guidelines (Rocky Mountain Hospital)
    • Innovation needs to be part of this
      • Dr. Mike Evans on YouTube
    • Experience is also very good in education “if its not personal it does not work”
      • Stopconcussions.com gets a shout out!
    • Social Media
      • Accuracy may be issue, but its a start – Sullivan et al (2011) Br J Sports Med
    • Apps
      • recognition apps are spreading and serve a purpose for education
      • Hockey Canada has an app that is even tailored to kids
    • Press
      • current easily accessed and available expert resources and opinion
      • We must respond to a teachable moment – Sidney Crosby example
  • Education may be an uphill battle
    • get the information to the consumer; credible, tailored, current, innovative, evaluated

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Dr. Charles Tator on influencing government, organizations and administrators

  • Making Progress
  • We should continue to use the term “concussion” rather than mTBI for consistency
  • Concussion are a public health concern – must frame that is not just limited to sports
  • Understanding where concussion fit in the overall spectrum of brain injury
  • Concussions can have an enormous economic burden
  • Need to influence: Governments, Sports Organizations at all levels, Non-Sports Organizations, The Public
  • We need to tell our audiences that good management of concussion is a TEAM SPORT and NOT CHEAP
    • Governments
      • Legislation for education and management
      • Funding is an issue; studies and management
    • Organizations
      • Sports and Non-Sports (equipment, health care professionals, ThinkFirst)
        • Approach each subset differently (amateurs, professionals, international)
        • Zero tolerance for concussion, improved rules, enforcement of rules already on books
          • Pros: they are mainly on “our” side it does trickle down
          • Non-sports: medical schools, nursing schools, greater emphasis on athletic trainers
    • Media
      • work with the proper people in the media
  • Greater funding for concussion research
  • Greater prevention efforts
  • Consistent messages

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Had lunch with some people: Dr. Ann McKee, Dr. Bob Cantu and Chris Nowinski, good peeps…

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0733CST: Session 6 – Long Term Problems and Difficult Cases

Presenters: Paul McCrory (spectrum of clinical presentation), Ann McKee (pathological evidence), Bob Cantu (CTE clinical evidence), David Maddocks (medico-legal concerns)

The NFL representation is taking notes, for those wondering…

McCrory -

  • Spectrum of clinical presentations for retired athletes
  • US Data: 1.6-3.8M concussions annually, estimated 6-10 x higher
  • Australia: horse racing leads the way in concussions “out paces the sissy sports” – will see long term issues
  • CQ5 – tool for assessing retired athletes
  • Started with retired boxers – Roberts (1969), Corsellis (1973)
    • ETOH sensitivity, emotional liability
  • 5-10% of people have impairment that last longer than 7 days
  • Some studies have shown depression in retired athletes that correlate with increased concussion exposure
    • Backmand et al 2003, Schwenck et al 2007, Miller et al 2002
  • fMRI studies
    • Chen et al (2007), Chen et al (2008)
  • Dementia is prevalent across the general population, especially older
  • Depression is common in general population
  • Chronic Problems
    • Persistent PCS (DSM4 > 3 months) – do get better with time in most cases in his opinion
    • Permanent PCS – mixed bag of structural, single severe injury, repeated injury
    • Illustrated the comorbidities associated with such chronic issues, like ETOH abuse, drugs, psych issues
  • Recommendations: think of the common stuff not the “canaries”

McKee

  • Pathological evidence of concussions in retired athletes
  • Neuropathology – Clincopathological Case Series
  • Definition of CTE/Dementia Pugilistica
  • tau protein can be found in the normal aged, but it is distinct and differs from what is found pathologically now with CTE
  • 1st instance of CTE was with an Alzheimer patient – professional boxer – latent period of almost 20 years before symptoms/issues arose
    • no beta amiloid in brain, an a lot of pTau
    • perivascular, which is distinct with CTE
  • Tom McHale and John Grimsley case studies presented
    • no beta amyloid, Hyperphosphorylated Tau Immunohistochemstry

Side Note: Dr. McKee is VERY PASSIONATE about this…

  • 48 cases in world lit of CTE in 2009, in 2012 68 cases at BU CSTE
    • high involvement in football players (boxing, military vets, hockey, wrestling, etc.)
  • Unique to CTE
    • pTau and TDP-43
    • axonal injury and loss
    • neuroinflamation
    • septal abnormalities (caveum something)
    • atrophy
    • slide on pTau staining – thalamus and even brain stem in severe cases (locus coeruleus)
  • Progressive disorder
  • Slide on difference between CTE and Alzheimer’s (note beta amyloid presence in AD)

Editorial: her slides and notes really make me question why people are questioning her work in this area, it seems about as clear as it can be, there is NO OTHER explanation in lit historically or now…

  • There are stages to CTE, I-IV, and some have comorbidities pathologically speaking
  • Case study of 18 y/o high school rugby player
    • pTau found – IN AN 18 YEAR OLD
  • Case study of 28 y/o US Marine Vet
  • Owen Thomas case study (college football player)
    • noting the perivascular prominence of pTau
  • Derek Boogaard case study
    • concedes that he had ETOH and drug usage issues
    • still showed evidence of CTE
  • Dave Duerson case study
    • Stage III CTE
    • axonal disease in his case, TDP-43 deposition
  • Former CFL player case study
  • CTE+motor neuron disease (MND) or ALS
    • 8 total cases
    • Lehman et al 2012, Neurology
    • Case study of 42 y/o former college football player
      • dx with ALS at 38
      • death at 42
      • CTE-MND
    • Talking about possible living example, Kevin Turner
  • Recommendations: need more research/funding, find a way to dx during life, find genetic risk factors, discover treatments, preventative education and better management.

WOW!

Cantu

  • Clinical evidence of CTE
  • History of CTE in literature
    • Clovis Vincent homage – Critchley in 1949 not 1957 Critchley paper
  • Discussed papers from Omalu and early discovery in Webster, Long and Waters
  • Incidence of CTE and CTE-MND is 4x higher in former professional football players – in a study done by death certificate research only.  This research/paper only stands out to begin a frame of reference.  It has a very small sample size to make assumptions. (sorry I don’t have the publication or author, I missed it)
  • CTE is progressive; believed to be caused by concussive and sub-concussive blows/unrecognized concussions, not prolonged PCS, not just a cumulative effect of concussions, symptoms begin years or decades after the brain trauma and usually worsens.
  • Determining Risk Factors
  • Prevention of Suicide
  • Credit to Robert A. Stern, PhD – does the interviews on the brain studies
    • Trying to get a prospective study done as opposed to retrospective
  • Discussed how AD dx. started and has become dx. in vivo, what they want to do with CTE
  • Primary Clinical symptoms reported in 40 CTE cases;
    • cognitive impaiment
    • mood disturbance (suicide)
    • motor disturbance
  • Potential biomarkers for CTE
    • CSF: pTau & normal beta amiloid
    • MRI: MTL/FL
    • MRS
    • PET tracers: FDG, amyloid
    • Future PET: Tau, microglial activation
  • Dementia issues have been common among CTE cases
  • Slide of stages of CTE show an age breakdown

Maddocks

  • Medico-legal concerns
  • “Liability is the big stick to change”
  • Overview: Litigation (paging Paul Anderson), Concepts in Concussion Litigation, Risk Management issues
  • Litigation in N. America Football
    • former players alleging long-term medical problems
    • he won’t comment on merits
    • he will comment on items in public record, including the official complaint
      • Dr. Maddocks is reading the highlights from the complaint, and the serious allegations, will need to watch this case world wide
  • Concussion Litigation (plaintiff = player, defense = doctor)
    • Causation (sued): standard of proof (law vs. medicine) and implications
      • plaintiff/defendant experts needed
      • premorbid issuse
      • strategic issues based upon location (jury versus judge)
      • state of knowledge (when and what was known); doctor can only be judged on what was known at the time
      • cross-examination: definitional issues, medical evidence, expertise/affiliations, retrospective analysis, other evidentiary factors
      • doctors evidence (recall vs. records)
      • players evidence (history, concealing symptoms)
      • legal prejudice
      • voluntary assumption of risk
  • Additional Risk to a Doctor
    • balanced assessment in terms of diagnosis, advice and management
    • issues: juniors/amateurs vs. professionals
    • examples: radiological and wrong dx.
    • hypothetical
      • pro player ruled out due to concussion missed a few weeks
      • reports depression and demonstrates erratic behavior
      • doctor advises of possible CTE
      • if player didn’t have CTE or organic cause that could be treated a doctor could be sued in that situation
  • Risk Management
    • Rule changes, education, further research, adopting all reasonable medical management practices
    • Better care for the player … decreased risk of litigation

Q/A and Panel Discussion will be on Twitter…

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Got to talk to Dr. Ellenbogen of the NFL, great guy and I truly believe in what he and the others are doing for the league.

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0425 CST: Session 5: Revisiting Management

Presenters: Dr. Michael Makdissi (the difficult concussion patient > 10 days), Dr. Stan Herring (is neck responsible for some symptoms), Dr. Kathryn Schneider (new rehab approaches), Dr. Simon Kemp (best practice recommendations for community w/o doctor), Dr. Karen Johnston (what should be included in concussion program), Dr. Gran Iverson (“rest the brain”)

Question to panel: Is it time to change the way we manage acute concussion?

Makdissi -

  • persistent symptoms greater than 10 days
  • represent 10-15% in american/australian football, 30% ice hockey, 50% in high school athlete
  • recommended that NP testing for these patients – opinion
  • neuroimaging vital for structural issues, fMRI and other imaging may track changes
  • no evidence that prolonged rest is beneficial, it is in acute settings
  • graded rehab has shown improvement in persistent symptoms (Leddy et al found resolution over time with this)
  • pharmacological treatment – mostly reviewed material (sleep disturbance) and small studies
  • Summary/Recommendations:
    • basic symptom check list on SCAT insufficient for prolonged patients
    • maybe need a difficult concussion tool for prolonged patients
    • prelim results are interesting, need to know pathophyisology
    • RTP protocols should not be applied to difficult cases, more specificity needed

Herring -

  • neck co-mobidity issues
  • headache is common at time of injury for concussion, 20-35% have neck pain as well
  • most post traumatic HA resolve in 7 days 83%
  • are HA driven by neck issues?
    • trigeminal nerve has pathway to head region (Trigeminocervical Nucleus)
    • pathway works both ways (head pain can create neck pain) – related
    • post traumatic HA is consistent with migraine or tension
    • less than 20% are cervicogenic
      • better assessment
    • 30% of Iraq veterans have persistent HA
    • difficult to define cervicogenic HA (international HA definitions murky)
    • baseline test needs to address neck pain, reexamine neck as recovering
    • cervical HA should be coming from C1-C3
    • Evaluation
      • manual dx, but not validated
      • flexion-rotation test
    • treatment
      • medications
        • no FDA drugs, options are antidepressants, antiepileptics, analgesics
      • exercise
        • strengthening, postural correction, some evidence shows improvment in HA
      • mobilization
        • manual therapy better then control at 12 wk. follow up
      • manipulation
        • some evidence for cervicogenic HA, risks abound, careful there are no guidelines no evidence of long term benefits
      • trigger point injections
        • unsure, maybe upper c-spine, no proof
      • occipital nerve blocks
        • chronic entrapment by scalp and neck muscles, maybe outdated
      • cervical facet injections
        • some value, not used in active athletes as much
      • radiofrequency ablation
        • caution, not recommened
    • Closing; most are migraine and tension, treat the HA not the neck >80% of cases
  • If HA after injury during follow up then eval and treat based upon dysfunction
  • Cervicogenic Vertigo – uncommon in athletes, true vertigo needs to be assessed

Schneider -

  • New treatments for SRC (sports related concussions)
  • Review of lit;
    • exercise: moderate exercise group showed best improvement
    • HBO2: shows improvement
    • sparse evidence in literature on new ideas, some evidence on pharm therapy
  • Calgary research (Dr. Schneider’s)
    • at baseline: 8% dizziness, 20% HA, 16% neck pain
    • HA, NP and DIZ intrinsic risk factors
    • 18.17 concussions/100 players
    • evaluation of: walk-talk test, cervical flexor endurance, computerized dynamic visual acuity
      • w-t test showed difference with females with concussion history
    • HA 70% reported symptom after SRC
    • PT protocol research group (blind draw)
      • tx group got vestibular and orthopedic work in addition to what control group
        • 11/15 in tx group were cleared while 1/15 in control group was cleared in time specified
      • 1st study of its kind
  • Multi-modal treatments are indicated for recovery

Kemp -

  • Improving the care pathway for community
    • enable more consistent contact
    • balance theoretical models with best practice
  • How do we deliver this to the community setting (BTW he understood my question yesterday)
  • Overview of removal of player and what medical clearance is
    • need improvement from medical personnel
  • Rugby Union schematic (you can search for this on the blog)
  • All athletes should be managed with same RTP protocol
  • Challenges to treatment/assessment in rural and developing countries
  • Better engagement with emergency med – Patricious Br J Sp Med 2012
  • Med Practitioner in RTP
    • important for everyone, not everyone has access to “knowledgeable” parties
    • if no access then 14 day stand-down for RTP, more conservative
    • still need medical clearance before RTP
  • Samoa example of not enough doctors is stunning
  • Broaden pool of access points (US Lystedt Laws)
  • Deficits in awareness of guidelines on concussion assessment and RTP world wide
  • Summary
    • successful models in the community are limited
    • successful implementation will require large and well trained workforce
    • global engagement in variable
  • Recommendations
    • design and influence implementation
    • guidance where and when to access
    • more comprehensive tools needed for all practitioners
    • consideration minimum periods of rest if you cannot get access

Johnston -

  • Comprehensive Concussion Program: what should be included?
  • Epictetus quote, 2nd Century
  • Idea: inclusive all athletes and those around them, collaborative, pro vs. community/recreational, multifaceted
  • Program
    • clinical, investigations, access to specialties, rehab, education, academic, medico-legal, administration
      • MD/DO – concussion expertise, or experience
      • History – detailed (video, etc)
      • Multifaceted – s/s, physical, cognitive testing and combination of these tests
      • Clinically – quiet and benign setting with privacy (touched on the emotional aspect of the patient – first mention)
      • Investigations – MRI, DTI, fMRI, electrical, vestibular, neck
      • Access to Others – long list of subspecialties (Psychiatry is KEY, not one Psych in the audience), Physiatry is also included on the list
        • Dr. Johnston feels strongly about the introduction of psychiatry (Dr. Brady will like)
      • Rehabilitation – PT or ATC needed to supervise RTP, community resources include yoga or swimming
      • Cognitive Rehab – return to school or work relations, OT’s
      • Education – Road Shows, redistribution of content like Zurich, social media, time, terminology
      • Academic/Research – studies or getting subjects into studies, advocacy, constant updates for caregivers, independence from organized sports, summits
      • Medico-legal – guidance, case issues, confidentiality
      • Administration – sport venue, needs a home maybe a clinic, timely appointments and reception is needed, funding, grants/donations

SIDE NOTE: If anyone is looking for someone to create and run such a program I am your guy…

Dr. Grant Iverson

  • Encourages psychiatry to get involved with SRC – calling Dr. Brady!!!!
  • Rationale for rest: neurometabolic crisis with energy crisis
  • Exercise is good for injured RODENT brain in research: there is a “temporal window”
  • How do we define rest, How long should an athlete rest, How do we define gradual resumption, How much rest is too much, When should we begin active rehab?
    • Idea rest until asymptomatic – difficult with younger kids
    • Evidence of rest in clinical trials/studies = ZERO
  • Bed Rest?
    • bed rest is bad in lit review for overall health; after 3-6 days of bed rest HA, reslessness etc is reported
    • bed rest on MTBI (de Kruijk et al. 2002): results at 2 wks show no improvement at 3 and 6 mo. follow up
  • Rest is OK, but not too long
  • Moser & Schatz, 2012 – Prescribed rest study – improved cognition and improved symptoms – more study needed
  • Symptom Free Waiting Period (SFWP) McCrea et al. (2009) – no differences in clinical outcomes of those that did the SFWP and those that did not
  • Rest is relatively unknown in regards to specifics, need to find answers to fundamental questions and gain evidence.
  • Active rehab is good, but when?

Q&A is on Twitter…

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Session 4: New Strategies

Presenters: Dr. Jeff Kutcher (new tools), Dr. Brian Benson (protective equipment), Dr. Andrew McIntosh (biomechanical studies), Dr. Barry Jordan (genes and biomarkers), Dr. Michael Turner (equestrian and combat sports)

Kutcher -

  • Gaps in dx: lack of diagnositc test, caregiver shortage,
  • Looking at new: qEEG, functional imaging, impact sensors, telemedicine, mobile devices
    • qEEG – shows enough to warrant more study specific to sports concussions
    • fImaging – show difference between concussed vs. non concussed fMRI most ready to be worked on – other fImaging: magnetoencephalography, near infrared spectroscopy, PET, single photon emission computed tomography
    • Impact sensors – not about biomechanics, more for clinical tools (possible uses)
      • Injury screening tool (threshold)
      • Impact dose monitoring
    • Remote medicine (telemedicine) – concerns/possible uses
      • Usability
    • Mobile devices (picture)
      • Education
      • Information utility
      • Diagnosis/management – who is using them, validation?
  • Summary: qEEG, fMRI show promise more coming on line, buckle up as more will be entering market

Benson -

  • Equipment is difficult to study (moving target) to many variables (Meeuwisse et al)
  • Measure of effect for equipment ranges from harm to no change to benefit all scientifically
  • Review was 2008 to 2012 – found only 3 studies (36 before date range)
  • Helemts/Head Gear
    • CYCLERS, RODEO, SKIERS, SNOWBOARDERS – yes
    • 6 rugby studies
    • 2 very old football studies
    • 1 hockey study (1970)
    • 1 soccer (2008), Delaney et al.
    • 3 snow studies
    • 1 rodeo
    • 6 cycling
  • Mouthguards
    • NO DIFFERENCE SHOWN
    • Singh et al – football – several biases
    • Benson et al – hockey – no difference in concussion or time loss
    • Mihalik et al (2007)
    • Wisniewski et al (2004)
    • Barbic et al (2005)
    • Marshall et al
    • Finch et al (2005)
    • Labella et al (2002)
  • Facial protection (ice hockey)
    • NO EVIDENCE SHOWN
  • There is not clear evidence currently and the research needs many aspects to make sure it is validated and meets all criteria

McIntosh -

  • Impact dose meter or injury prevention options
  • Studies have been changing to in vivo because of technology (linear and angular impact with duration)
  • Impact and head telemetry must address all angles of attack
    • having helmets that reduce G’s to 150-200 in the case of most bike helmets for linear acceleration does little for concussion
    • angular studies are rarely addressed by current helmet systems
    • McIntosh feels that there is a threshold based on linear and angular acceleration for concussion
  • Impact testing (mainly linear)
    • MIPS
    • There is an angular drop test
  • Boxing headgaurd
    • not impact tested/performance standards
    • boxing punch = 3-4000N, pro boxers have higher force (yet not headgear at professional level)
    • reduces impact/linear acceleration but does not decrease concussion risk
  • HITs
    • very successful research tool but very expensive and proprietary to Riddell helmets
    • has good predictive measures
    • good at linear impacts, average with angular acceleration
  • Instrumented Mouthguards (X2)
    • minimal research at this time
    • closer to center of mass of head, alternative to HITs
  • Technology needs to be low cost for most effective use by masses, higher cost technology should be helpful with management and trigger assessments, as well as monitoring cumulative hits

Jordan -

  • Biomarkers – serum, CSF, genetic and neuroimaging
  • May be able to use information from Alzheimer’s markers for chronic issues
  • Currently no biomarker sensitive enough to detect acute concussion
  • S100beta – most studied biomarker – not good for sports concussion
  • CK-BB – Boxing study shows increase in CK-BB after fight compared to cyclists
  • NSE shown in some studies on boxers
  • Zetterberg et al (2006) study very extensive for CSF biomarkers
  • Neselius et al (2012) CSF study (NFL increase) – degeneration
  • Zetterberg et al (2007) soccer study with heading – no changes noted
  • Genes that may influence
    • APOE, DOMT, DRD2, ACE, CACNA1A, p53, ANNK1
    • APOE4: most studied gene – unfavorable outcomes
      • e4 was not associated with initial severity but was associated with poor outcomes
      • Terrell et al (2012) – APOE e4, promoter and tau
      • Kutner et al (2000) – study on NY Giants
      • Omalu et al (2011) – 29% e4 allele

Side note on Dr. Jordan, this guy makes understanding the biomarkers and genes very easy, his review of studies was excellent and very relevant for the audience…

Turner -

Dr. Turner is a freaking comedian!!!  This dude is cracking me up…

  • Sissy sports = catching VD from lavatory seat…
  • Intervention in “grown up sports” includes rule changes, equestrian air vests
    • Taekwondo changes
      • 2009 increased points for blow to head
      • 2010 again increased points for blow to head
        • changes had increased overall blows to the head, possibly increased concussions
      • helmet being used may not meet standards
    • Equestrian
      • European helmet standards must be met which can be an issue across the continent

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Session 5: Revisiting Management

Presenters: Dr. Michael Makdissi (the difficult concussion patient > 10 days), Dr. Stan Herring (is neck responsible for some symptoms), Dr. Kathryn Schneider (new rehab approaches), Dr. Simon Kemp (best practice recommendations for community w/o doctor), Dr. Karen Johnston (what should be included in concussion program), Dr. Gran Iverson (“rest the brain”)

Question to panel: Is it time to change the way we manage acute concussion?

Makdissi -

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16 Responses to “Zurich Day 2… And We Are Live”

  1. barry125 November 2, 2012 at 03:02 #

    What did Brian Benson report about updated research and publication since Zurich report from 2008 on the efficacy and injury rate reduction and concussion reduction issues with respect to helmuts and mouthguards.

  2. barry125 November 2, 2012 at 03:33 #

    Did Brian Benson reference any studies specifically on mouthguards since 2008 that were published in regards to mouthguards and concussion prevention for us to read about?

    Does he think that any old school mouthguards such as what most high school kids wear (those ones that are always falling out their mouths types) or those newer pressure laminated mouthguards such as what NBA, NFL and top College teams are wearing (where they look like they just stay in place better) may be able to play a role in concussion prevention and further studies should be done?

    OR FINALLY

    Is it just not necessary to further evaluate different types of mouthguards as it has been finally concluded and validated in the updated reaseach papers since 2008 on mouthguards that it is impossible for mouthguards to actual play any role in concussion prevention?

    OR IF NOT
    Did he recommend how reseachers would go about the criteria needed researching the different types of mouthguards in regards to concussion evaluation to be able to come to a validated conclussion about mouthguards as a prevention piece of protective equipment beyond its primary purpose to protect teeth?

    • Dustin Fink November 2, 2012 at 07:50 #

      There are none, look at the notes Mark…

  3. brokenbrilliant November 2, 2012 at 06:39 #

    Thanks for the info – this is great stuff! Good notes for following trails of information, and thanks for the details on who’s speaking, too.

  4. Jon November 2, 2012 at 20:54 #

    This is quality info Dustin… appreciate your efforts

  5. Mark Picot November 3, 2012 at 04:25 #

    What knee jerk, you must be tired from your flight. Actually since you have this audience of experts. Can you ask them, “what is temporal mandibular joint dysfunction and what specific role does it play in symptom related issues? Follow up would be, have you had any training in Temporal Mandibular Joint Dysfunction and what can be done to help protect against the “glass Jaw” effect.

    Abstract;

    Traumatic brain injury (TBI), often caused by shock waves from blasts, has been called the “signature wound” of the wars in Iraq and Afghanistan. Commonly, the deleterious effects on the blast are compounded by the extra forces transmitted to the skull from the jaw through the temporomandibular joint (TMJ). In contact sports, it has been shown that mouth guards can be effective in reducing concussions and mild TBI. This proposal describes how a Massachusetts company., in collaboration with Dr. Robert Cantu of Boston University Medical Center and Emerson Hospital, a world-renowned authority on neurology and sports medicine, will develop an appliance to mitigate concussive forces associated with high-energy blasts. In Phase I, potential materials and relevant existing devices, particularly athletic mouth guards, will be researched for their application to a product that could be used by the military. Initial design concepts will be worked out based on this research. In the Phase I Option, more concrete models will be made as a precursor to an in-depth commercialization plan to be addressed in Phase II.

  6. Mark Picot November 3, 2012 at 04:39 #

    Why is CTE found primarily in the Medial Temporal Lobe, just millimeters from the TMJ. Why is there not more research, like the ARMY’s, focused on this region/mechanism? Nothing about orthodontic mouth guards or selling. Just the facts. Aside from Dr. Benson, there is probably not one TMD expert in Zurich, find a qualified one and I will pay for your flight next year.

    • joe bloggs November 3, 2012 at 07:36 #

      Mark,

      The evidence in Military subjects, blast injury, shows not only is frontal lobe affected but also the white matter damage that is not experienced in civilian injuries. UCL confirmed this in a well designed study presented recently in New Orleans.

      Mouth guards will do very little if anything in people exposed to blast.

      Once again, you are reaching.

  7. BryanATC November 3, 2012 at 11:14 #

    Temporomandibular Joint Dysfunction is just that. In no way does TMJ=Concussion or Concussion=TMJ. TMJ elicits similar symptoms to concussion due to forces exerted on cranial nerves, muscles and structures, but TMJ does not affect the brain. Concussion does as it is a “Traumatic Brain Injury”.

    As Dustin has said TIME AND TIME again is that mouth guards have been greatly proven to protect against mouth and TMJ injuries. What they have not been proven to do is prevent concussions. Thus making your statement “In contact sports, it has been shown that mouth guards can be effective in reducing concussions and mild TBI.” scientifically false at this point. Did you not hear about a certain mouthguard company being fined for trying to say that their product did just that?

    Yes athletes should wear mouthguards and probably soldiers should have something similar, but that and “protecting against concussions” are two totally different realities.

  8. Mark Picot November 3, 2012 at 12:48 #

    Brian, exactly

    “TMJ elicits similar symptoms to concussion due to forces exerted on cranial nerves, muscles and structures”

    TMD is a completely different set of circumstance related to the lower brain stem/cervical spine, that needs its own focus of research and classification of injury. No protocol is in place to measure the degree of manipulation or positioning needed to the cervical spine or jaw in those with TMD. BRain pad mouth guards do nothing but arbitrarily position the jaw with no science, dental training or protocol, hell you fit them over your kitchen sink. Orthodontic and neuromuscular appliances are made to strict dental/medical standards. This is just an advancement of technology in oral appliances for those with orthotic needs, just like orthotic ski boots for those with foot issues. Just as you have seen in the helmet industry, these advancements are documented and recognized by U.S. Army research, the ADA, and the CDC, yet no mention of any extended research by any large institution or governing body, only the Army in collaboration with Dr. Cantu. Concussion symptoms from a cerebral event are a completely different set of circumstances and not related to TMD in athletes. Blows to the jaw and whiplash, needs more focus in relation to this theory put forth to the military by Dr. Jeffery Shaefer a Harvard MGH expert.
    The question remains, is the micro trauma experienced, such as dings, dizziness, the sensation of seeing stars and nausea, which is often shaken of and ignored. Is this what is causing CTE and not the major concussive blow to the top of the head. Here’s the smoking gun, CTE is found exactly millimeters from where this jawbone trauma occurs, not the top of the head. Boxers dementia, the boxers glass jaw, what role does this play in the development of CTE. More focus, that is what we are advocating for, yet none, at FIFA.

    • Dustin Fink November 3, 2012 at 16:07 #

      TMJD is not Concussion… Migraine is not concussion… Tension headaches are not concussions… Dehydration is not concussion… Hypoglycemia is not concussion…

      Guess what they all have similar or overlapping symptoms… There is no way in heck that mouthguards can protect against concussions, period… Not only is it impossible due to Physics it is also scientifically PROVEN that they do not, PERIOD…

      You keep asking me to prove a negative… How about this you prove to me and the audience how and why your product, made by Maher Co. (putting this in here so when the FTC looks, and they do), will protect against concussions…

      In fact I will gladly post and forward your information and claims to Washington DC so it gets to the right people…

      Just like FIFA stated yesterday in regards to head “bands/gear” for soccer, there is no data to suggest they help in any fashion, therefore FIFA does not recommend or suggest their usage…

  9. Mark Picot November 4, 2012 at 08:11 #

    TMJD is not Concussion… Migraine is not concussion… Tension headaches are not concussions

    We are not claiming concussion prevention, what the Army is investigating is, what role does TMD have in micro trauma, not concussion. Does micro trauma, dings, nausea, headache, dizziness, have a role in the development of CTE, not concussion. We know subjects with TMD report a much higer rate of these microtrauma symptoms.

    One case, the U Penn player that was diagnosed with CTE, yet never reported one concussion. Did the micro trauma cause his CTE. Was it the small “events” accumulating time and time again. How prevalent are these symptoms in every player in every sport. Why does it only occur in some athletes and how can we better prepare athletes from this. These are questions that need to be answered.

    Not even helmets can be promoted as preventing concussion. Yet they have been investigated by researchers to the end. Cantu has stated, you can’t improve them much more than they already are with out making them oversized and they are only designed to prevent skull fracture. This TMD, temporal bone, brain stem region the Army has funded research of, needs more outside attention, because it is exactly where CTE originates. The jaw, TMJ area is part of the head last time I checked, Yet, there is probably no discussion of this in Zurich and I would be shocked if you could find one expert there that would be qualified to dispute Dr. Jeffery Shaefers findings.

    • Dustin Fink November 5, 2012 at 10:36 #

      TMD a role in micro-trauma? Is that what you’re getting at? OMG…

      The hypothesis is that yes it was a cumulative effect in Owen Thomas’s case, however CTE was not the reason he took his life… Microtrauma symptoms are completely unknown from a scientific perspective, Cantu spoke on them… Again TMD and concussion or any brain issue will and does have overlapping symptoms

      No helmets prevent concussions, none say they do…

      I want this clear for all to read… You, Mark Picot of Maher Lab Co., is hypothesizing that the mandible crashing (if it actually does) into the base of the temporal portion of the skull (again not sure if it does with enough force to translate to the brain sitting beyond the bone and CSF) causes CTE?

      • Mark Picot November 5, 2012 at 13:19 #

        You, Mark Picot of Maher Lab Co., is hypothesizing that the mandible crashing (if it actually does) into the base of the temporal portion of the skull

        I can’t take credit for what a Harvard expert and the U.S. Military have undertaken.

        To explain in more detail, the paper-thin bone separating the end of the jawbone and the brain or medial temporal lobe, is paper thin. TMD occurs when the dime sized cartilage disk, which sits in that pocket of paper-thin bone, slips out of place. This slipped meniscus leaves that area vulnerable to receive direct forces to the medial temporal lobe. This condition is diagnosable and has a certain set of symptoms recognized by the ADA and CDC. It is a completely different injury and mechanism of head injury compared to Cou contra Cou. The link below shows the disk on blue when it is in its natural protective position. Protecting the skull base, nerves, brain stem and paper thin bone. Many candidates with this condition are post orthodontic or have had some type or jaw injury, hence the boxer’s glass jaw. Why do only some of these athletes become prone to the symptoms of dings, dizziness, nausea, inner ear issues, micro trauma not concussion.

        Force received on the chin, chin strap, radiates to the temporal bone, traumatizing the TMJ and surrounding area. When out of alignment, damaging the meniscus disc, more severe symptoms and ongoing issues have been found in many NFL, NHL and NBA player. Not to mention scores of high school, college and U.S. Army soldiers.
        This theory, backed by Dr. Shaefer, Army doctors is the basis of the Army grant
        More focus is needed, is this to much to ask?

        The last time we went over this, you were ok with the Tmd/orthodontic approach. What has changed.

  10. Renee Roberts November 25, 2012 at 08:51 #

    Is there anyone on here that can help me find a support group for what our doctor is calling
    POST CONCUSSION SYNDROME /CTE. My husband suffers from bouts of anger, agression, confusion, and depression. This is the short list, learning how to prevent in great, but what about the people who are trying to survive with Doctors who don’t have a clue how to help those of us who are trying to manage day to day life with someone that suffers from this condition. He played high school and college football and a severe concussion from a fall from an 18ft ladder on to a concrete floor.
    Any HELP or ADVISE would be helpful!

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