The Concussion Blog

Welcome to the intended live feed from the 2nd Annual Sports Concussion Summit here in Lexington, Kentucky.  We are at Cardinal Hill Rehabilitation Hospital, a beautiful facility.  Attendance looks to be very good, about “60 or so” according to Jonathan Lifshitz, host of the event.  I will be updating this post as we go along with a time, follow @concussionblog on Twitter for updates.

7:05am CST:  Jonathan Lifshitz, PhD opens up the conference, a big “walk-in” group, I still think I may be the only one not from KY here.

7:10am CST: Dr. Lifshitz had a great perspective on announcers and how the terminology of the game regarding head injuries has to slowly begun to change.

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7:50am CST: Dan Han, PsyD “Contemporary Perception on CHI: Multidisciplinary Initiatives”

• 1.7M documented TBI; 52,000 deaths per year, 275,000 Hospitalizations (CDC Numbers)
• 75% of TBI (1.3M) are concussions/mTBI/mDAI; 300,000 are DOCUMENTED sports concussions
• 0-4, 15-19 and 65+ y/o’s most likely to sustain a TBI
• Females have significantly higher odds of poor outcomes
• Documented TBI (see above) not the real issue; the undocumented TBI is the proverbial iceberg under the water
• Diffuse Brain Injury
• Secondary to stretching forces on the axons
• Moderate DAI = “Classic Concussion” (unconsciousness, possible basal skull fracture)
• Persistent confusion, retrograde & anterograde amnesia, mood/personality changes
• Severe DAI = Brainstem Injury (high mortality rate)
• And TCB Contributor Tracy Yatsko gets some run on a video!!!  Man girl you get around :)!
• Postconcussional Disorder
• LOC > 5 min or anterograde amnesia or new onset of seizures within 6 months after CHI
• Just learned a lot about seizures; many go unnoticed
• AND attention or memory deficit
• Plus 3 or more symptoms present for at least 3 months following CHI
• Significant impairment in social or occupational functioning
• Academic achievement decline
• HUGE Multidisciplinary Concussion Program at University of Kentucky, well on the way to being a leader in concussions

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8:50am CST: Greg Wheeler, MD “Treatment of Sports-related concussions and return-to-play clearance“

• Not only is Dr. Wheeler a Neurosurgeon but a high school football coach in his free time, UNIQUE perspective!
• Noticed that Dr. Wheeler’s son wears a Xenith helmet
• Dr. Wheeler notes rotational/torsional injury to brain may be more problematic than liner
• Discusses Hovda’s information regarding pathophysiology; also the vasospams in the brain
• “Brain is starving during a hypovolumous state”
• 8.9% of all highs school injuries are concussions
• Underreported by up to a factor of FIVE
• ONE player sustains a “mild” concussion in almost every football game (I think that is low)
• Girls soccer has double the rate of concussions as boys soccer (JAT 2008)
• girls better to self report
• neck musculature
• less pressure to keep quiet
• Younger brains and concussions
• 60x more sensitive to glutimate (NT)
• younger bodies not as muscular mature/big/fast
• kids have to go to school and learn
• kids have a tough time describing symptoms
• better potential for COMPLETE recovery
• Markers for Delayed Recovery
• Retrograde amnesia is 10x more likely to have prolonged symptoms
• Anterograde amnesia is 4.2x more likely
• Dizziness 6.4x
• Fogginess
• Recovery Time (this slide was fast may have missed exact numbers here)
• Rapid (< 7 days) – 32%
• Prolonged (7-14 days) – 39%
• Long-term (> 21 days) – 19%
• Post Injury Mangement
• Athletic Trainers have a grip on this
• Immediate removal – DO NOT RETURN
• Neurological testing within 72 hours
• Removal offending stimulation at home (texting, video games, TV, computers)
• Decrease academic load
• Return to activity using Zürich and UMPC models
• symptom free at rest, cognitive exertion and physical exertion
• Long-term Treatment
• Pharmaceutical (amantadine)
• Discussed Technology including; helmets, mouth guards and sensors

BREAK ———

10:00am CST: Tad Seifert, MD “Concussion and the Media’s Perspectives”

• Case Study (it looks an awful lot like Aaron Rodgers), good presentation
• And I was right, it was Aaron Rodgers
• “Helmets are designed to prevent concussions, I think” – A. Rodgers post Peppers hit (room full of laughter)
• Very good presentation taking on helmet makers and the Aaron Rodgers incident, a lot like what we did on the site.
• VT Study, FTC Update
• On to Hockey, first case is Horton injury
• Talked about possible penalty and penalties in the future
• Back on to football; James Harrison becomes the topic
• Dude has a heck of a wrap sheet!!!  Geesh…
• Fencing Response is the topic now (and Dr. Seifert explained it on a neuropathological level, and I was lost!!! haha)
• Concussions and Suicide; a very interesting topic;
• Depression in population 5%, it is 40% in people with previous head trauma
• Owen Thomas, Dave Duerson
• Not a suicide but Derek Boogaard was discussed
• Discussed the reports of the ties between ALS and repeated head trauma
• Touched on King-Devick Test
• Very good examination of the concussion in the media, really a lot of stuff we have covered here, but good to see the medical professionals getting to see it (if they would follow the blog it would be old information, haha).

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10:45am CST: Robert Hosey, MD “Game day: Concussion Evaluation and Management”

• Dr. Hosey talks about being prepared in general and for any incident
• EAP and Concussion Management Plan
• Pre-Testing (UK uses SCAT2 and ImPACT)
• Sideline Considerations
• LOUD environment
• Distractions
• Difficult Communication
• Determination of “concussion” difficult
• Must know the players
• Not the obvious ones we see on TV, but the symptomatic reporting
• Differing opinion
• MUST KNOW THE PLAYER
• Once concussion known, take helmet (better than they did with Jake Locker)
• Evaluation
• History, Informal Talk, Symptoms, Memory, Balance, OBSERVATION (5 min recheck interval)
• What about those that are not dx’ed concussion but have symptoms?
• Once concussed no return on same day, out until cleared by MD, PsyD
• Guidelines, a lot out there, are there problems?
• Not scientifically validated
• Cumulative changes
• Evidence suggest second concussion 4x greater if previously concussed
• Generally Accepted Guidelines
• No RTP until asymptomatic
• Case by case basis
• More research needed
• NO HOLY GRAIL
• Would love to see an athletic trainer everywhere there is contact sports

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LUNCH (JJ’s always good and fast, #9 no onion with peppers, thanks for Dr. Lifshitz for lunch)

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12:30pm CST: Heather Mattocks-Greene, ATC “Are We Educating Enough: An Athletic Trainer Perspective”

• Heather is bringing up the audience on what the AT’s Role is in Concussion Management
• AT’s = Communicators, Educators, Facilitators and Protectors (athletes themselves and parents)
• Who do AT’s educate; Public, Athlete, Medical Team, Coaches, Parents, Adminstrators/Teachers
• Medical Team: MD’s, Neurologists/Neurosurgeons, AT’s, Psychologist/Neuropsychologist, Therapists
• Athlete: work through stigma; “never quit”, disappointment, “lose my position”
• Very good example of a high school kid not being accepted by his teammates and coaches initially, not unlike John Gonoude
• Coaches: What is a concussion?  How does it affect the team?  Hitting Techniques, Are they Overeducated?
• Parents: How do we know the MD that will do eval knows about concussions?  S/S, Expectations, Academics
• Administrators/Teachers: What is a concussion? How does it affect academics? EAP’s and Academic Accommodations
• Public: What is a concussion? S/S and Preventative Measures

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1:10pm CST: Scott Livingston, PhD, PT, ATC, SCS “Pediatric Concussions: Are Children Different from Adults?”

• Dr. Livingston is battling through some issues with his voice, WAY TO GO, must be an AT!
• TBI (all causes) = 473,947 ED visits, 207,830 ED visits are sports related (males = 70+% of those), 10-14 and 15-19 y/o’s
• Bicycling, football, playground activities, basketball, ATV’s led (CDC numbers)
• What do we know about Youth Sports Concussions
• Age matters, brain development differs
• Functions differ (symptom recognition)
• Recovery length
• School and cognitive demands
• HS athletes demonstrate longer period of recovery (younger than HS should be more conservative)
• How does it affect school learning and performance
• New Learning/Acquiring Knowledge
• Practicing incompletely
• Mental Exertion is essential
• Guidelines (CDC); REST including cognitive, adequate sleep, no additional forces, NO OVER EXERTION including cognitively
• Again younger children will be more sensitive, use increased caution with children
• Developing brain 60x more sensitive to EAA (excitatory amino acids); 2-3x greater force need to produce s/s in children [Ommaya et al, 2002, McCorey et al, 2004]
• Validation of adult concussion assessment tools for children is questionable
• Symptom scales not adequately studied in grade-school athlete [Gioia et al., 2009]
• Very good topic and summation!!!!

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2:05pm CST: Julian Tackett – KHSAA “Current Rules and Regulations in High School Sports”

• National Chairman for NFHS Football Committee
• KHSAA makes safety a top priority
• Required Health/Safety courses (online) for all head and assistant coaches, includes concussion
• KHSAA Concussion Policy (Point of Emphasis)
• Preparation must include prevention where possible; varsity contests may have medical practitioner available but COACHES must have some knowledge.
• Coaches “MUST CHANGE” the warrior athlete mentality when it comes to concussions
• Evolution
• Local reviews ongoing, high-profile college and professional athlete used
• Dr. Dawn Comstock’s RIO data
• Created the educational aspect that NFHS uses (KY already uses an educational course, NFHS not used at this time)
• Implementation
• Uses definition; “a brain injury that results in a temporary disruption of normal brain function.” (THAT IS AWESOME!!!)
• RTP; athletes with con’t concussion symptoms are at significant risk for recurrent, cumulative and even catastrophic consequences. (In other words any s/s should not be allowed to play)
• Using NFHS rule
• Officials are part of the recognition process (sport specific rules DQ players for time)
• Once a possible head injury is there someone has to decide; MD, DO, APRN, ATC or PA in KY
• Once deemed concussion they are out and cannot return until MD/DO ONLY clears
• No official form for return to play, up to MD/DO
• In a multiple-day event there are specific rules keeping athlete out
• It is ALWAYS a role and responsibility of the coach to determine if a kid is safe to play, error on side of caution
• Mr. Tackett brings up a GREAT point on NFL and legislation (I want this guy to speak EVERYWHERE!!!)

Sidebar to the presentation, Mr. Tackett is one very persuasive individual, and he is an AWESOME presenter, he really is a great ally to athletic trainers and for concussion awareness!!!  I wonder how many people actually get him mad enough to get “slapped” around, I wouldn’t want to!!!

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2:45pm CST: Marty Moore – KY Pro Football Association “Changes in the Perceptions of Concussions from a  Player Standpoint”

• Former NFL Linebacker, 2001 Super Bowl, has the ring to prove it, IT’S HUGE!!!
• Is a friend with Ted Johnson (just noticed I don’t have a link for this)
• Began with some very illustrative hits, players who “launched” themselves
• The Last 50 years of football development
• Size of athlete, MUCH BIGGER
• Showed slides with average size of players by position each decade, it was VERY TELLING
• Conditioning, Weight Training, Diet, Agility, Speed has all increased (specialized)
• Conditioning; has trickled down to even high school level, March through December
• Wt Training/Agility/Speed; mandatory any more, speed of athletes is increasing over time
• AWESOME real life stories intermixed with the information from his UK and Pro days; talking about pressures on the athletes
• Diet; no longer is “fast food”/normal food acceptable at pro level, colleges have nutritionists, even HS have plans
• Helmet design, better technology (Marty likes Xenith as well), points to NFL and its contractual obligations
• Mouthpieces; really only talked about how they help with oral/dental injuries, but he did allude to mouthpieces help in concussion prevention (Going to have to disagree with him on this)
• Other protective equipment (collars/neck rolls), possibly preventing proper technique for tackling
• Tackling Form; head up, “see what you hit”, facemask should be “wrecked” (showed slides of good form tackles that were fined by the NFL “they were against quarterbacks”)
• Factors contributing to increased concussions
• Bigger, faster, stronger athletes
• Poor form tackling with greater forces (need better coaching to fix this)
• Media awareness
• Attenuating the issue will take;
• More and PROPER awareness
• Better coaching
• Not returning a player too soon
• Equipment will unlikely make a major change in concussion issue
• Reducing the “pressures” from coaches, parents, and in pro’s the organization
• The NFL is going to have to set an example for the youth
• Using Ted Johnson as an example, the long-term effects of a multitude of head injuries there are a lot of questions

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3:30pm CST: Michael Sowell, MD “Evaluation of Pediatric Concussion”

• University of Louisville Department of Pediatric Neurology; Director, U of L Comprehensive Headache Program
• Interesting seeing the ED TBI injury information, bicycling is a very dangerous activity, wear your helmets kids
• Department of Defense TBI definitions are new to me;
• Mild; 13-15 GCS
• Mod; 9-12
• Severe; 0-9
• Good to see a slide on the difference between collision and contact sports, we often forget, and some of the contact sports turn into collision sports
• mTBI, DAI, Concussion are “largely” interchangeable terms
• Not only should coaches/parents/medical professionals be aware of s/s, peers should be as well
• Dr. Sowell still subscribes to the AAN 1997 grading scale (to which we say any grading scale is outdated)
• Showed the updated AAN Position Statement
• Dr. Sowell has a distinction between return to play (actually in game/playing) and return to play (from MD/DO care)
• Biggest question; When can he/she go back into the game?
• Uses the Zurich Recommendations
• No official recommendations for the pediatric patients
• Post Concussion Syndrome (DSM – IV), most Rx is off label
• Validity of baseline concussion testing questioned
• Recognize limitations and sandbagging
• Post traumatic headache a.k.a. migraines
• Touched on CTE
• Case Study; 15 y/o female (very good look at what Dr. Sowell sees)

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Panel Discussion: Had a great answer from the entire panel regarding “migraines” and the excuses that some are using.

I would like to express my deepest thanks to Dr. Lifshitz for inviting me out for this event.  I have rarely been to an event that was over 8 hours that did not grind on my attention span, this one did not.  The Sports Concussion Summit was unbelievably well-organized and planned in a fashion that made time and information fly!!!  When they do this next year, I hope to be in attendance, and YOU SHOULD be to…  Perhaps Dr. Lifshitz can give us a “save the date” card early in the year.

Also for supplemental reading; Cantu and Gean: Journal of Neurotrauma 27:1557-1564 (September 2010).  Some serious case studies and tear jerking instances of concussions mismanaged.

To be honest I don’t know if I gathered more information from the presentations or from the one-on-one side meetings throughout the day.  One thing that is for sure is that everyone involved, including the attendees, are very interested and bordering on passionate about concussion and its care.  I think it is safe to say that everyone here understands that a concussion is just part of sports, and that is not the true issue.  Rather it is how we evaluate and manage the concussion after the injury.

Thanks for following today, let everyone know they can read about this as well…