Welcome to the continually updated live feed from the Athletic Trainers Society of New Jersey 2nd Annual Concussion Summit. I would like to thank the ATSNJ in particular; John Furtado, Eric Nussbaum, and Mary Jane Rogers for the help in getting things set up. We are at the Wyndham Princeton Forrestal Conference Center & Hotel in a stunning amphitheater, attendance is anticipated to be high. I anticipate updating this post as soon as possible after each speaker. Follow @concussionblog for updates.
6:25am CST: Crowd flowing in with provided breakfast in hand.
6:33am CST: Jason Mihalik, PhD “Biomechanics of Concussion”;
- Concussion is a FUNCTIONAL injury not structural injury
- Brian injury a major public health concern (showing a pyramid with the head injuries on the bottom, unseen or caring on their own)
- Things that feed into Traumatic Brain Injury:
- Cognition, Concussion History, Postural Stability, Mechanism of Injury, Physical Exam, Symptomatology, Knowledge/Attitude
- Injury Prevention (anticipation, infractions, play type, closing distance)
- Kinds of impacts that cause concussion; research obviously done primarily on animals beginning in the pre 40’s. The coup-contracoup model was found by using animal models
- Research moved from animal models to human analogs; wax skulls/gelatinous brains
- Ommaya & Gennarelli (1974) – Rotational acceleration
- NFL Concussion Committee; reconstructed videos of concussion injuries in laboratory.
- 80G collision = seat belted in dummy hitting a wall in a car going 35mph
- HITS System – fits helmet naturally, real time coding and collection of data
- Builds head impact profiles (still young in development), can identify poor tacking techniques
- Is leading with head still a problem in football? –> Yes, need coaches to help
- Athletes who sustained a 90G force without symptoms did not show any deficit; not all threshold breaking hits = concussion.
- What is the threshold? 70G, 80G, 90G, 100G? The impact severity does not equate in probability of concussion, yet…
- Special Teams in football = increased impacts and concussions
- Closing Distance (greater than 10 yards); 50% increase in long closing distance and 4.56x greater for severe impact.
- HITS system was adapted to the hockey helmet, but need to “manufacture” the helmet padding.
- Impacts same as college football, impacts not as frequent as college football (youth hockey)
- Injury prevention: Anticipation (showing video of NHL and youth hockey hits), responsibility of player to know surroundings
- anticipated hits resulted in less concussive episodes
- Injury prevention: Infractions
- enforcing the rules, they found that illegal hits had more concussions than legal hits
7:07am CST: Margot Putukian, MD “In Office and Sideline Evaluation” *She did an awesome job of battling through some AV issues!!
- Definition has change rapidly over recent years
- No biomarkers/genetic marker or neuroimaging
- Have a plan: removal and not RTP with concussion or suspected concussion
- baseline is of high priority
- know the limitations of this injury (delayed s/s)
- Team Physician Consensus Statement (2011) defined concussion definition
- Identified the symptoms (similar to CDC)
- Emergency Action Plan
- ID high risk sports, EDUCATION, baseline, ID modifiers, emergency protocols & procedures, know your facilities
- TPCC Modifiers (2011) – history, symptoms, signs, susceptibility, age, pre-existing conditions
- Sideline evaluation
- ABC’s/R/O spine/fx
- Symptoms, Cognitive Function and Balance
- People want a tool that will be quick and definitive
- When to refer to ER (Zurich) – Prolong disturbance, deterioration of condition, focal neurological deficit, drowsey/lethargic
- Sideline Symptoms; persistent symptoms = more vulnerable to another injury and prolonged recovery.
- Lovell (2006) = reliable with truthfulness and specific reporting from athletes
- Sideline Cognitive Testing; DO NOT REPLACE more sophisticated testing (SCAT & SCAT2 not validated as of yet)
- Sideline Balance; deficits return in 3-7 days; BESS (sensitive not as reliable, but specificity is very good)
- Reviewed NFL sideline test
- Severity; unknown for each individual
- Disposition; post injury care is important, see improvement, if any deterioration send to ER
- Discussed Zurich RTP Guidelines; individualized
- Concussions do not have a cook book to handle the injury
- NP Testing = CANNOT be used on their own
- As always more research is necessary
7:38am CST: Steve Broglio, PhD “Assessing Balance in Concussion”
- Using one area of concussion eval tool will produce a 60% effective rate, when using all the tools about 98% accuracy in prediction concussion
- Re-emphasized that there is not imaging (currently used) that will identify the concussion
- Showed Hovda data showing the neurometabolic cascade.
- Explains the re-routing of pathways like being in traffic, you will get there but it takes longer
- 1.6-3.8 sport related concussions annually (significant increase); volume of concussions are greater at younger age
- Explains that the increase in the concussion rate is most likely due to better evaluation by medical personnel
- Variable Injury Response; Female (more honest=longer recovery), History, Learning disabilities
- Concussion Assessment
- self report symptomology
- Balance = The ability to maintain their center of mass within their limits of stability (static and dynamic)
- Maintaining balance
- Somatosensory Input; body position in relation to joint position
- Visual Input; fixed point on the horizon, provides reference
- Vestibular Input; linear and angular accelerations of the head
- Measuring balance (SOT – gold standard of balance assessment)
- Six testing conditions – fixed floor: eyes open, eyes closed, wall moves/dynamic floor: eyes open, eyes closed, wall moves
- This test can farm out all three balance maintaining systems
- Measuring balance (BESS – very good cost effective)
- Can be very comparative to the SOT in sideline evaluations
- Baseline scores are in the 12 range worst score is 60
- Broglio believes that using all six conditions should be used not just the three on the ground
- Balance Changes after Concussion
- Decrease in composite, mainly in visual and vestibular, somatosensory system remains unchanged
- Return to normal 3-5 days in both SOT and BESS testing
- What is meaningful in poor balance
- BESS = 3 or more error increase
- Factors Affecting Acute Balance
- Exercise, Ankle Support (be mindful of the baseline), and Repeat Testing
- Persistent Effects after concussion (not clinically significant)
- Compensation for balance error differ with previously concussed
- Concussed spend more time on two feet as compared to unconcussed
Awesome conversation with Kurt Kaiser, ATC of Hackettstown High School (@01keeper), regarding all the topics in the concussion realm, a continuation from our 3 plus hours from last night… Dude knows his stuff…
Attendance from a rough count about 75-85 attendees, good turnout…
8:45am CST: Robert Cantu,MD “Chronic Effects of Concussive Injury”
- Reviewed concussions and how they begin to possibly lay down issues that will translate to lasting effects
- Relationship between concussion and CTE
- Concussion and PCS are temporary
- CTE is progressive neurodegeneration that is triggered to repetitive mTBI. Evolves slowly, and symptoms may be unapparent until years later
- Cantu is excited about Hockey Canada’s decision to remove head contact
- Used Eric Lindross, Rob Drummond, Max Taylor, Jeff Beukeboom as examples
- Short Term Risks of Mismanaginig a Concussion
- Repeat concussion with PCS and Second Impact Syndrome
- 38% of catastrophic injuries in football occurred when the patient was still symptomatic
- s/s lasting longer than 3 months = PCS, they eventually turn into emotional/psychological issues
- Dr. Cantu sees 1/2 patients with PCS
- PCS individuals have; multiple prior concussions, double hit situations, playing while symptomatic
- Reminds us that the is ALWAYS injured, below the neck it is an injured vs. hurt situation
- Brain injuries are not always cumulative or get more severe over time, they are all UNIQUE injuries
- Long Term Risks of Mismanaging a Concussion
- Prolonged PCS and CTE (not with certainty)
- Described first in 1928 – Punch Drunk Syndrome (Martland)
- chronic condition seen in professionals
- motor dysfunction, masked Parkinson’s
- Prevalence varies 0-55%
- Boxing and Medicine (Cantu)
- Used work from Martland, Critchley, Millspouch and Courville
- Corsellis (1973)
- Abnormalities of septum pellucidum
- Cerebral atrophy
- Degenearation of the substantia nigra
- CTE in Sports as reported in literature
- Boxing, Horse Racing, Rugby, Professional Soccer, Professional Wrestling, Parachuting
- Corsellis (1976)
- CTE in non sports issues as well; battered wives, autistic children with head banging
- Center for the Study of Chronic Traumatic Encephalopathy (Cantu, Ann McKee, Chris Nowinski, Robert Stern)
- Goals; longintudinally study of large diverse sample… Understand risk factors… Clarify clinical presentation and course
- Registry; need more athletes that have not had apparent head trauma issues (used Wayne Gretzky as example)
- Goal Long Term:
- Establish Brain Donation Registry
- Conduct Logitudinal Clinical Research
- Create a Brain Bank
- Showed slides and explained exactly what they are finding (Hyperphosphorylated tau protein)
- Extreme cases can be seen even before staining of the brain; hallmark is the medial temporal lobe atrophy
- All research is just “the tip of the iceberg”
- In 2009 there was literature showing 51 cases over all in 2011 there are 102
- Although CTE is most commonly found in athletes, many individuals are susceptible: epileptics, persons who suffer falls, accidental blows from moving objects, or motor vehicle accidents, and military veterans
- First symptoms of CTE are insidious;
- Changes in memory and personality
- 69% cognitive changes, 65% personality changes, 40% movement abnormalities
- Frontal Temporal Dementia, Alzheimer’s and CTE share similarities but can be differentiated
- In CTE its in the II and III layers of the cortex, Alzheimer’s is seen down to the V and VI layers, thus distinguishing the difference
- Alzheimer’s has a tau and beta-analoid deposits, CTE no beta-analoid
- Longer living individuals have greater deposition of tau
- Showed slide of an 18 y/o who had tau (using tau immunohistochemstry) in the brain, small lesions seen, there was no beta-analoid
- Seeing samples of brains that are under the age of 21 with signs of CTE progression
- Showed multiple case studies with histories in football
- 73% of FB players with CTE died violently/suddenly
- Of the four found in hockey players they were all enforcers/fighters
- Take home messages from Center about CTE
- Repetitive brain trauma with/without symptomatic concussion
- Responsible for neurodegenerative changes highlight by abnormal alteration and accumulations of two proteins in the brain, tau and TDP-43
- Over time CTE results in progressive decline of memory and cognition, depression, suicidal behavior, poor impulse control, aggressiveness, Parkinsonism, and eventually dementia
- In some individuals it leads to motor neuron issues, TDP-43 in cortex and spinal cord
- Used Kevin Turner as an example
- CTE may be widespread in former contact sports athletes
- CTE may be a public health issue
- 14 cases of CTE in military with blast injury
- Developed an animal blast injury model (showed a slide of set up)
- Not the blast wave itself, but the blast “winds” that reverberated off surrounding structures, multiple shaking
- Dave Duerson case study; Cantu believes there is a spiral downward starting with emotional issues
- Classic case
- Suicide and CTE
- They DO NOT need those that are troubled enough to do that, those with the thoughts need to seek help
- Used a graph to show the media attention is progressing must faster than actual science
- Questions going forward;
- What is prevalence and incidence?
- Why do some get CTE and others do not?
- What are risk factors?
- APOE and genetics
- severity and frequency, time interval between traumas, age?
- What is clinical presentation and course?
- How can CTE be detected and diagnosed during life? (biomarkers)
- How can we treat CTE?
- Public Health Impact
- Athletes of all ages and levels (youth sports)
- Combat military (TBI, blast injury, suicide)
- Hypothesized about CTE being responsible for suicides and troubling incidents (murders), it is COMPLETELY EARLY and unknown
Wow, his billing was correct, a very good talk and made it very understandable for all. I am very impressed with his information.
10:00am CST: Round Table Discussion, Emceed by Eric Nussbaum, and done very well, BTW
1. Is there an optimal age to begin contact?
- Cantu – opinion; there is no need for anyone younger than high school level to subject to head trauma, i.e. collision sports. There will be a modification to sports in future. Take checking out of hockey, flag football at younger ages. He realizes that it wont change today or be popular.
- Putukian – Younger ages have different mechanisms that are yet unstudied and agrees with Cantu.
- Mihalik – Proper techniques are not sufficient at younger ages, and that should be part of education.
- Moser – “Don’t need 5 year old’s heading a ball”.
2. What is Asymptomatic?
- Echemendia – Use of baseline will help identify the “normal”. Is it asymptomatic in what condition? It is a clinical judgement, very subjective.
- Putukian – We need to be careful with the normalized NP testing as a marker of asymptomatic condition. Education is necessary so we can get the most truthful answer from the concussed.
- Detwiler-Danspeckgruber – Imaging cannot tell this at this time, working to find something that can be more diagnostic.
- Cantu – We shouldn’t just think about asymptomatic but use the whole picture as a more clear picture. We need to be careful about what the products coming out are pushing, the wise thing to do when suspected concussive episode; sit them out and get to a trained professional.
- Moser – Fear of the apps coming out, self-diagnosis.
3. Is it appropriate to refer to concussions as “mild”?
- Cantu – Changing the world’s literature is difficult, but he does not use or should we use “mild”. It is a brain injury.
The above questions manifested into a diverse discussion about the who and whats with the terming and clearing of concussions, including legislation. Many examples from panel and attendees of issues surrounding the full understanding of concussions. Each panelist emphasized that you should not “box” the injury into terms. The general consensus was that education and communication is very important. Dr. Putukian made a GREAT point about being proactive rather than reactive.
4. Is there such a thing as “concussion rehab”?
- Mihalik – Yes, but there is not a set “protocol” as of yet. There is not only one way to rehab a concussion, each is individual is different. Dual-tasking may be a good way to help with rehab.
- Cantu – There needs to be more research for acute concussions that show improvement with significant numbers over standard rest or evolution of concussion.
- Broglio – Needs to be a time of rest first, if there is not a recovery in the accepted 7-10 day window then possibly getting the injured into rehab.
- Moser – Concussion rehab is vastly different than brain injury rehab as most know it. The hardest thing is to get parents and kids to buy in and do what is necessary.
- Putukian – Almost statistically impossible to find out if one thing is better than another with concussion rehab. Getting patients back to some level of activity is very important.
- Echemendia – Should include education about the injury.
Nussbaum – Asked panel about neck strengthening.
- Mihalik – Anticipation can decrease the acceleration in the head when hit, due to tightening of neck muscles. Majority of head injuries are due to hit to the head
- I dropped in the Woodpecker question to which Mihalik did a great job answering.
- A helmet question came from the attendees about helmets and weight of helmets
- Cantu – Helmets do not prevent concussions and are not the final answer but are needed in other positions/sports where they are not currently (girls lacrosse).
Nussbaum – What about the blood test?
- Cantu – It was not specific enough for anything other than severe traumatic brain injuries. He wondered out loud how it got as far as it did.
Audience – How many concussions are too many?
- Cantu – There is not a magic number, research is looking into it. Concussion are not created equal, some can have one concussion and be greatly effected while others can have multiple and be fine.
A very good panel discussion and was run very well and engaging.
Lunch was AWESOME… Man they do it right here in NJ…
12:00pm CST: Ruben Echemendia, PhD, PSY “The Role of Neurocognitive Testing”
- Slide on acute phathophysiology of a concussion, that was very good.
- Metabolic Cascade is dynamic
- Post Traumatic Blood Flow Issue creating and energy, this is the vulnerable time for the brain
- Review of signs and symptoms of the four categories, sleep disturbance is very underrated
- Must address the emotionality category early on
- Neuropsychology and NP Training
- Study of brain behavior relationships and the application of that knowledge to diagnose and treat brain related disorders
- Independent 7-9 years post bachelor degree
- Eary 1900’s
- Increase after WWII
- Early 1970’s applied to the assessment of mTBI
- Barth developed the modern day Neuropshych
- Neuropshychological Testing
- Learning, Memory, Information
- Help with making a RTP decision
- Neuropsych Eval (Typical Components)
- Vary in length and complexity
- Forensic (10-14 hours)
- Sports (20-30 minutes)
- Establish Premorbid Baseline
- Learning Disabilities, Head Injuries, Drug/Alcohol, Surgeries, Amount of Quality Education, Language Barriers, etc.
- Historical/Demographic Variable Approach
- Psychometric Approach
- Types of Tests “ImPACT does not equal neuropsychological testing”
- Paper and Pencil (showed examples of them)
- Advantages: direct observation and monitoring, superior assessment of memory, broad normative data
- Disadvantages: labor intensive, variability in standardized admin, self scored
- Computer: adapted paper and pencil, developed de novo for computers
- Recognition testing is easier than free memory test
- Adv: large groups, standardized admin, immediate scoring, multiple languages, finer assessment
- Disadv: less complete assessment of memory, loss of observational data, less control of effort, computer-specific measurement issues, data loss
- Hybrid Approach
- Combine both p&p and computerized tests
- Baseline for normative data
- Computer + P&P post injury
- Typical Neuropshych Testing Program (serial)
- Sub Acute
- Long Term Follow Up
- Sports Specific Issues
- Baseline Testing – is it necessary/helpful?
- Theoretically designed to minimize error due to intra-individual comparison (can it actually do that)
- Multiple post injury tests
- How often should it be repeated
- Age dependent
- Test-Retest Reliability (significant variability across studies)
- Practice Effects (content vs. procedural)
- Does NP Testing work in sports?
- Yes, but how well.
- Note on concussion symptoms: not specific to just a concussion, some standard symptoms occur naturally
- One test will not be sufficient to evaluate a brain injury
- Value Added of NP Testing
- 59% concurrence rate with testing
- 41% deviate from testing
- How does NP testing fit into RTP?
- Slide by Echemendia and Cantu that is very good, only had NP testing as one part of the puzzle.
- How do effort and motivation affect the NP test?
- Bailey & Echemendia, JINS, 2006
- How do cultural and lingustic factors affect NP testing?
- Significant variability in both P&P and ImPACT even though in native language
- Why combine the two types of tests?
- Is baseline testing necessary?
- New just submitted data
- 46% who sustained a concussion showed decline
- 32% scored 1 std dev below
- 80% of cases predicted without baseline with IJT
- 86% with other model
- Prelim data, you can capture relevant information even without baseline
- Are the other 14% dealing with other co-morbidities
- Dr. Ruben Echemendia believes that if resources are limited they should be put in post injury testing and only baseline those you feel are high risk.
- Interpretation of test data is complex and a Neuropsychologicalist should be used as a resource
1:00pm CST: Annegret Detwiler-Danspeckgruber, EdD; “Imaging Concussion: DTI and fMRI”
- Definition of concussions include “no abnormality on standard structural neuroimaging studies”
- Imaging modalities that have been demonstrated; PET scan, SWI, MRS, STI, and fMRI
- Positron Emission Tomography (PET)
- Demonstrates metabolic activity in the brain tissue
- Disadv: necessitates injection of radioactive tracer isotope, costly
- Susceptibility Weighted Imaging (SWI)
- BOLD venographic imaging, sensitive to venous blood
- Small focal hemorrhages are much more visible
- Adv: clinical package, MRI based and non-invasive, minimal post processing of images
- MR Spectroscopy
- Biomechanical information about brain tissue
- NAA, Cho, Cr, sugars are the metabolites studied
- Significant difference in NAA/Cr and NAA/Cho ratios at 3 and 15 days post concussion
- Combined fMRI and DTI Experimental Protocol
- 3 imaging sessions to assess learning (pre-train, post-train, retention)
- 3 training sessions to improve a specific measure
- Diffuse Tensor Imaging
- Comparison between white and grey matter of the brain
- FA Map (how the fibers are laying in the brain)
- Showed an AWESOME video of the DTI imaging, it is really a very impressive scan
- Data Processing
- FA and MD non-linearly transformed to MNI space
- Mean FA image of all concussion/control subjects created a thinned to construct a mean FA skelton
- Voxelwise between group stats on skeletonised FA MD data
- Found clusters and fiber tracks in concussed patients that was not present in control
Side note: there is A LOT of talk about the Corpus Callosum in many of the presentations… FWIW…
- Functional MRI (fMRI)
- Used mouse to assess accuracy, reaction time, total movement time and straightness index on a pattern while being MRI’ed (was a signigicant difference between groups)
- Behavioral Tasks did not show a difference between concussed vs. non-concussed
- Results are that concussed individuals activated more in the pre-frontal cortex, there seems to be different patterns in simple tasks, in complex tasks the concussed did not activate nearly as much as the non-concussed in pre-training
- Imaging is starting to show some relevance but has not been completely identified, more research is needed in this area. Her and their research was in individuals that had ongoing symptoms longer than one month.
- Combined DTI and fMRI studies may be the best avenue
- Not ready to be used clinically as of yet
1:52pm CST: Rosemarie Scolaro Moser, PhD, ABPP-RP, ABN “Adolescent Concussion and Cognitive Rest”
- General Prevalence: in a sample of 223 HS students 63% had or had history of concussion (Moser, Schatz & Jordan, 2005)
- General problem with reporting about concussions
- Underreporting (McCrea et al., 2004)
- Problems with identification/treatment (applying adult guidelines to youth)
- Baseline Test Invalidity in High School Students (Schatz, Moser, Solomon, Ott, and Karph, in press)
- Baseline Test Validity as a Function of Individual vs. Group Administration (Schatz, Moser, Nowinski and Ott, in press)
- Explained the variables that need to be considered with youth (color blindness, word comprehension, etc.)
- Implications for Baseline Testing
- Be vigilant looking for invalidity
- Youth recovery seem to take longer
- Note from Dr. Moser “we longer grade concussions”
- Second Impact Syndrome in adolescents
- Enduring Effects in Youth (Moser, Schatz & Jordan, 2005, Neurosurgery)
- Early Indicators of Enduring Symptoms in High School Athletes with Multiple Previous Concussions (Schatz, Moser, Covassian and Karpf, 2011, Neurosurgery)
- Importance of REST
- Have to allow the brain to recover, and any stimulus will impede on recovery
- Case Study: 14 y/o female, 4 previous concussions
- Dr. Moser went through the entire dossier of this patient, very little restrictions were given throughout the 4 previous concussions. Eventually it was termed a “psychiatric problem” by treating physician. There was no academic accommodations, nor was there correct education of the support group
- Dr. Moser finally saw case 13 months after initial injury and prescribed 2 weeks of REST
- After rest and some problems from parents, the patient subjectively recovered to 95%, continued rest and moderated cognitive exertion
- By week 8 she was cleared to return to gym class
- Showed serial ImPACT testing of this case, very intersting
- SCCNJ RTP Recommendations
- NP at baseline or stable
- Physical exertion test
- In youth 3 week post no symptoms urged
- SCCNJ Treatment
- School Interventions and Accommodations
- Athletic Training
- Exertional Testing
- Neurological Evaluation
- Biofeedback for Headache
- Gave an example of academic accommodations
- 504 Plan only needed for chronic issues, longer than 3 months, with no improvement
- It is unreasonable to expect a student who is recovering from a brain injury to not only keep up with the regular school load, but to also make up for all assignments missed
- Remember…the point of education is to educate our children and help them master skills, not to torture them with unreasonable expectations
- “Love Your Brain…Love Your Sport
2:25pm CST: Joseph Rempson, MD “Return to Play Considerations”
- Recent research suggests the “one month off” principle may be the way to go with especially youth, it is becoming a belief system
- Mechanism of Injury
- Sheering event is something to be remembered
- Acute vs. Subconcussive issues
- Threshold Issue
- How many are too many? It is different from one person to another
- Present approaches differ
- There is not an absolute day for return, there is a threshold, individual to each person
- Multiple factors in determining RTP
- Not a function of getting through the steps
- Predisposition and complicating pre-injury issues
- Risk benefit issue/analysis
- What about the scholarshiped athlete in one sport getting concussed in a different sport?
- A 10 y/o with multiple concussions
- Dr. Rempson did show us comparisons to stroke (not equal to concussion but neural tissue is neural tissue)
- Kids should not be retired from sports, there needs to be counseling done to find an area of safe participation
- Retiring athletes
- basic contact causes injury
- longer and longer recovery between episodes
- persistent symptoms
- “Risk-Benefit” is the biggest consideration with RTP for any concussed athlete
A very good interactive presentation, in light of being the last speaker of the day and being behind schedule.
I would like to first thank the ATSNJ for the event held today, the types of speakers and topics dynamic, but on the top of most peoples list of “must haves”. Eric Nussbaum and John Furtado did a good job of keeping the conference on task and provided any resource or speaker needed to not only me but the entire audience.
Events like this are wonderful for the state and region and granted they seem to be popping up all over the place, but we need to as athletic trainers take advantage of such opportunities. The access to some of the speakers and topics are difficult to procure, so if we as AT’s get the information we then in turn can take it to those that need it the most, the parents/coaches/kids/teachers.
I have now been to two top-notch “Summits” (Kentucky) in the past month, both of which provide a wealth of current and new information that all involved with concussions need to know. I would also like to thank those that helped with the resources to get me out east. If any other program would like me to blog about what you are doing feel free to send me an email.