Iowa Concussion Law 3. a. A student who has been removed from participation shall not recommence such participation until the student has been evaluated by a licensed health care provider trained in the evaluation and management of concussions and other brain injuries and the student has received written clearance to return to participation from the health care provider. b. For the purposes of this section, a “ licensed health care provider ” means a physician, physician assistant, chiropractor, advanced registered nurse practitioner, nurse, physical therapist, or athletic trainer licensed by a board designated under section 147.13. c. For the purposes of this section, an “ extracurricular interscholastic activity ” means any extracurricular interscholastic activity, contest, or practice, including sports, dance, or cheerleading.
Unintended Consequences?? (so far there is no evidence on either side) • Incentive to under-report • False sense of security – Untrained coaches/officials – Uncertainty about who can clear • Bypass ATC? • Transfer of liability • Cost • Second guessing officials
Covered Today • Definitions • Basic Pathophysiology (and CTE) • Basic Epidemiology • Iowa Concussion Law • Common Misconceptions • Review of Recent Concussion Guidelines • Concussion Clinic Protocol and Evidence Base • Recognition / Evaluation / Return to Play
Johnny doesn ’ t have a concussion. He didn ’ t get knocked out and had a normal CT scan
Berrington et al. Projected Cancer Risk from Computed Tomographic Scans Performed in the United States in 2007. Arch Intern Med. 2009;169(22).
OK, when should I image? • In the hours after an injury if: – Worsening symptoms – Declining level of consciousness – Worsening amnesia – Progressive balance disturbance – Focal neurologic deficits • Later if: – Seizures – Declining mental status
What ’ s coming • PET • SPECT • (fMRI) • DTI with Tractography
Fractional Anisotropy Free diffusion Diffusion in one direction Wilde EA et al. Neurology. 2008 Mar
Singh Met al. Magn Reson Imaging. 2010 Jan
Qualities for an ideal biomarker? 1. Sample source (CSF, serum, saliva, urine) 2. Sensitivity and specificity 3. Signal vs background
Biomarkers of Brain Injury Biochemical Physiologic Role Location Comment Marker Neuron Specific Involved in Cytoplasm of Detectable within 6 Enolase increasing neuronal neurons, platelets, hours, serum half RBC ’ s (NSE) chloride levels life of 24 hours S100B Calcium binding Astroglia, bone Detectable almost protein, may inhibit marrow, fat, skeletal immediately after synaptic plasticity muscle injury, ½ life 60 min Myelin Basic Protein Abundant protein in Myelin Increased only after (MBP) myelin severe TBI, peaks 48-72 hours Cleaved Tau Microtubule Axons in the CNS Poor marker in (c-tau) associated protein in pediatric population axons Glial Fibrillary Acidic Intermediate protein Astroglial skeleton Peaks in 24-48 Protein of astroglial skeleton hours found only in (GFAP) CNS
The more I rest now, the quicker I will recover.
49 high school and college athletes. Rest for 1 or 2 weeks when concussed. Measured ImPACT. Moser, Glatts and Schatz. Jpeds. 2012.
Moser, Glatts and Schatz. Jpeds. 2012.
Thomas, et al. Pediatrics. 2015.
Thomas, et al. Pediatrics. 2015.
Thomas, et al. Pediatrics. 2015.
Thomas, et al. Pediatrics. 2015.
Silverberg, et al. JAMA Pediatrics. 2016.
Silverberg, et al. JAMA Pediatrics. 2016.
Silverberg, et al. JAMA Pediatrics. 2016.
I just got Johnny this sweet mouthguard. It will protect him from concussions.
John Stenger DDS Notre Dame dentist 1964 5 case reports of players who were concussion prone before mouthguard but not after
Wisniewski DDS Guskiewicz PhD 2004 large NCAA dataset 506,297 exposures 369 concussions
McGuine PhD Brooks MD 2014 large high school dataset 2287 players 134,437 exposures 211 concussions
“ Unfortunately, no helmet can prevent a concussion ”
“ Unfortunately, no helmet can prevent acconcussion ”
What does work? • Limit hitting • Limit hitting • Limit hitting • Limit hitting • Maybe changing the way people hit
Pellman et al. Neurosurgery. 2004
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