charles tator april 23, 2015 niagara falls what is new in concussion? summit 2015 niagara parachute...

Charles TatorApril 23, 2015Niagara Falls

WHAT IS NEW IN CONCUSSION?

SUMMIT 2015NIAGARA

PARACHUTE CANADA

OBJECTIVES

INTRODUCTION/BRAIN INJURIES

CONCUSSION

WWW.PARACHUTECANADA.ORG

OBJECTIVES


CONCUSSION

Professor of Neurosurgery, University of Toronto

Project Leader, Canadian Sports Concussion Project, Krembil Neuroscience Centre, Toronto Western Hospital

Founder, ThinkFirst CanadaBoard Member, Parachute Canada

MY AFFILIATIONS

THE CONCUSSION SPECTRUM OF DISORDERS-FROM ACUTE

CONCUSSION TO CTE

Charles Tator

Canadian Sports

Concussion Project

Toronto Western

Hospital and University of

Toronto

OBJECTIVES


CONCUSSION

CONCUSSION TOPICS FOR TODAY

1. Definition of Concussion and the Concussion Spectrum of Disorders

2. Mechanisms of Concussion3. The Problems of Recognition and Diagnosis

of Concussions 4. Return to Play, Work or School Guidelines5. The Major Consequences of Concussion such

as Second Impact Syndrome, Post Concussion Syndrome and Brain Degeneration

6. Prevention of Concussions

OBJECTIVES


CONCUSSION

These are Epidemics!!!

HOW BAD IS THE TRAUMA PROBLEM IN GENERAL?

Trauma

Brain Injuries

Concussions

WE SHOULD BE DOING SOMETHING ABOUT IT

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OBJECTIVES


CONCUSSION

Concussion is the most frequent brain injury. In North America, there are HUNDREDS OF THOUSANDS per year.

25% of players on a Junior B hockey team, average age 18, are concussed each season Echlin et al 2010 Neurosurgery Focus

In football, probably 50% of players each season

WHERE DOES CONCUSSION FIT IN THE OVERALL PICTURE OF BRAIN INJURIES?

OBJECTIVES


CONCUSSION

Concussion or mild traumatic brain injury (mTBI) (THE MOST COMMON)

Bruising or ContusionTearing or LacerationBleeding and Blood Clots

(Intracerebral, subdural and extradural)

TYPES OF BRAIN INJURIES

OBJECTIVES


CONCUSSION

THE IMPORTANCE OF BRAIN INJURIES

Half of trauma deaths are due to brain injuries

Brain injuries account for most cases of permanent disability after trauma

Kraus JF Epidemiology of Head Injury.

In Head Injuries. 3rd Ed. Cooper, P.R. (Ed), 1993

FOCUSING ON

CONCUSSION

OBJECTIVES


CONCUSSION

CONCUSSION - FOR MORE INFORMATION

OUR Website parachutecanada.org

Also Good: CDC Website cdc.gov

CLINICAL

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CONCUSSION

THE CONCUSSION SPECTRUM OF

DISORDERS Acute Concussion Second Impact Syndrome Post Concussion Syndrome Psychological Consequences -Depression/Anxiety

Brain Degeneration - Chronic Traumatic Encephalopathy (CTE), Movement Disorders, Etc.

PREVENTION

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OBJECTIVES


CONCUSSION

Immediate and temporary alteration of mental functioning due to trauma

The trauma does not have to be directly to the head, and can be due to a whiplash effect on the brain from a blow elsewhere on the body

DEFINITION OF CONCUSSION

CLINICAL

PREVENTION

MANAGEMENT

COMPLICATIONS

(OLD Terms: “Bell Ringer”,

“Ding”, “Seeing

stars” were allconcussions)

OBJECTIVES


CONCUSSION

CONCUSSION IS THE MOST COMMON TYPE OF MILD TRAUMATIC BRAIN INJURY (MTBI)

Concussion is a better term

1.Concussion is now widely recognized by the public 2.The consequences of concussions are often not mild3.More Homogeneous-no admixture of clots and bruises

in mTBI, GCS=13-15

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OBJECTIVES


CONCUSSION

WHAT IS THE MECHANISM OF CONCUSSION?

Exact mechanism unknownRotational acceleration more important

than linear acceleration–the “jiggle” of the brain within the skull causes concussion

Axonal injury may occurProbably, the first concussion is a

biochemical injuryNOT DUE TO BleedingNOT DUE TO Tearing or Bruising of the brain

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CONCUSSION

BRAIN MOVES WITHIN SKULL

CLINICAL

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OBJECTIVES


CONCUSSION

Concussion may be a biochemical injury. Mouse cursor on centre of diagram to start movie.CLINICA

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CONCUSSION

SCIENTIFIC EXPLANATION OF CONCUSSION

A genetic predisposition has been suspected, but is unproven. If there is a genetic predisposition, then screening might be feasible and would be desirable

UNKNOWN

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OBJECTIVES


CONCUSSION

CAUSES OF CONCUSSION

Motor vehicle crashesFalls at homeWork related injuriesSports and recreation – e.g. football, hockey, rugby, soccer, lacrosse, etc.Military actionSpousal abuse

CLINICAL

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OBJECTIVES


CONCUSSION

CONCUSSION IN SPORTS ARE IMPORTANT

Concussions in sports are especially common in collision sports such as hockey and football

Players often have repetitive concussions

Repetitive concussions can have major consequences – brain degeneration

CLINICAL

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CONCUSSION

FEATURES OF CONCUSSIONS

1. Mild injury - usually, especially the first concussion, usually with complete recovery

2. Diffuse injury without focal neurological deficits in cranial nerves, movement or sensation

3. Causes subtle deficits- eg dizziness, nausea4. Major cumulative effects from repetitive

injury

CLINICAL

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MANAGEMENT

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OBJECTIVES


CONCUSSION

Activity- Hockey Football

Age-especially adolescents

Gender-women

Number of Previous Concussions

Genetic Effects- runs in some families

Effects of Pre-Existing Conditions: migraine, ADD, ADHD, Depression

FACTORS AFFECTING THE INCIDENCE OF CONCUSSION

OBJECTIVES


CONCUSSION

Initial SymptomsAmnesia Loss of Consciousness*Headaches Nausea/VomitingDizziness Loss of VisionPoor Concentration Etc.

SYMPTOMS AFTER SYMPTOMS AFTER CONCUSSIONCONCUSSION

*NOTE – SYMPTOMS VARY AMONG PATIENTS**NOTE – SYMPTOMS VARY AMONG PATIENTS*

CLINICAL

PREVENTION

MANAGEMENT

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HOURS-DAYS

1 2

Later symptomsMemory Loss Fatigue InsomniaBlurred Vision VertigoPersonality ChangeDouble Vision Seizures Sensitivity to Light Ringing in Ears Sleepiness Irritability

Etc.

Late symptomsDementiaDepression/AnxietySuicide Homicide Etc.

3

YEARS

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Can You Diagnose a

Concussion on a CT Scan or

MRI?NO!

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OBJECTIVES


CONCUSSION

Routine CT and MRI are always

normal after concussion

CLINICAL

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If there is a lesion

identified, it is more than a concussion

OBJECTIVES


CONCUSSION

Clinical Exam (SCAT3) YES

Routine CT and MRI- NO!!!!!

Functional MRI ??DTI MRI ??BOLD MRI ??MRS ??Mini-Neuropsych Tests NO!!Maxi-Neuropsych Tests USEFUL

PET ??Event Related

Potentials (ERP) ??Electrical Connectivity

??MEG ??Blood Biomarkers NOCSF Biomarkers NOMechanical Tests NO

POTENTIAL BIOMARKERS OF ACUTE CONCUSSION, POST-CONCUSSION

SYNDROME,SECOND IMPACT SYNDROME

CLINICAL

PREVENTION

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OBJECTIVES


CONCUSSION

CLINICAL

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CONCUSSION DIAGNOSIS

The diagnosis of concussion is made CLINICALLY

The diagnosis depends on a knowledgeable doctor and a compliant patient

Therefore, BIG PROBLEMS!!!! because of uninformed docs and non-compliant patients

OBJECTIVES


CONCUSSION

INTERNATIONAL CONSENSUS STATEMENTS ON CONCUSSION IN

SPORT

Consensus Statements based on International Sport Concussion Conferences among Leading

Concussion Experts.Last conference in Zurich in 2012 and

statement was published in 2013

CLINICAL

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OBJECTIVES


CONCUSSION

CONSENSUS STATEMENTS - MANAGEMENT

A. First StepsIf there is loss of consciousness – Initiate Emergency Action Plan. Call 911 to get an ambulance. Assume possible neck injury.Assess ABCs: Airway, Breathing and CirculationImportant acute management principles (next slide)

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MANAGEMENT

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OBJECTIVES


CONCUSSION

CONSENSUS STATEMENTS – MANAGEMENT (CONT’D)

1. Remove the player from the current game or practice (if event occurred during sport)

2. Do not leave the player alone; monitor signs and symptoms

3. Do not administer medication4. Inform parent or guardian5. The player should be evaluated by a medical doctor6. The player must not return to play in that game or

practice

.

CLINICAL

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CONCUSSION


B. Later ManagementThe 6-step Graduated Return to Play ProtocolStep 1 - physical and mental rest.

No return to activity until all symptoms have resolved, and do not recur even after provocative exercise during Steps 2-5.

If any Symptoms or Signs Return, Stop the Process, and Return to Step 1

.

CLINICAL

PREVENTION

MANAGEMENT

COMPLICATIONS

Never return to play if symptoms persist or recur with exercise!

OBJECTIVES


CONCUSSION

Step 2 - Light aerobic exercise, such as walking or stationary cycling. Monitor for symptoms and signs. No resistance training or weight lifting.

Step 3 - Sport specific activities and training (e.g. skating).

Step 4. Drills without body contact. May add light resistance training and progress to heavier weights.

Step 5. Begin drills with body contact. Step 6. Game play.

.


CLINICAL

PREVENTION

MANAGEMENT

COMPLICATIONS

The time needed to progress from non-contact to contact exercise (45) will vary with the severity of the concussion and the player. Only go to step 5 after medical clearance. Again, go back to Step 1 if symptoms recur.

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OBJECTIVES


CONCUSSION

MANAGEMENT – CLINICAL SUMMARY

The return to play process is gradual, and begins after a doctor has given the player clearance to return to activity.

If any symptoms/signs return during this process, the player must be re-evaluated by a physician. No return to play if any symptoms or signs persist.

Remember, symptoms may return later that day or the next, not necessarily when exercising!

CLINICAL

PREVENTION

MANAGEMENT

COMPLICATIONS

Each step should take at least one day. Therefore, the minimum time for return is one week, and double that for children

OBJECTIVES


CONCUSSION

INDICATIONS FOR CONCERN

Permanent Termination “Modifiers”

Continuing neurological symptoms and signs, especially cognitive deficitsMultiple concussions over short period of timeLong duration to recover e.g. monthsLesions seen on imaging-CT or MRI

CLINICAL

PREVENTION

MANAGEMENT

COMPLICATIONS

OBJECTIVES


CONCUSSION

RETURN TO PLAY GUIDELINES IN SPORTS

Two aspects:

1.When to Return2.When to Never Return or Terminate?

CLINICAL

PREVENTION

MANAGEMENT

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OBJECTIVES


CONCUSSION

Criteria Can Return To Play

Never Return to Play

1. Neurological Examination

No neurological deficits Presence of any neurological deficits or significant symptoms

2. Number, pattern and severity of previous concussions

Small number, dispersed in time, low severity and complete recovery

Multiple, over a short period of time, high severity

3. Length of time to achieve recovery

Short duration (days) Long duration (several months or years)

4. Neuropsychological

evaluation- detailed

No cognitive deficits Presence of cognitive deficits

5. MR/CT findings No abnormalities Presence of lesions

CLINICAL

PREVENTION

MANAGEMENT

COMPLICATIONS

CRITERIA AND GUIDELINES FOR RETURN OR NEVER RETURN TO PLAY

OBJECTIVES


CONCUSSION

Much More Complex than RTPNeeds to be Individualized“Accomodations” are Usually NecessaryTeam Interaction/CommunicationBased On Clinical EvaluationNO HELP FROM ANY IMAGING BIOMARKER!!!Very time-consuming-provision of

notes/feedback to schools/employers

RETURN TO LEARN AND RETURN TO WORK GUIDELINES

OBJECTIVES


CONCUSSION

THE CONCUSSION SPECTRUM - SUBSEQUENT AND LATE

EFFECTSSecond Impact SyndromePost concussion SyndromePsychosocial problems – Depression, Anxiety, Behaviour Change, Suicide

EpilepsyCognitive Deficits and Dementia

Chronic Traumatic Encephalopathy (CTE)

CLINICAL

PREVENTION

MANAGEMENT

COMPLICATIONS

OBJECTIVES


CONCUSSION

Results from a second head hit a few days later when there has not been full recovery from the first head hit

Can be catastrophic, and even fatal.Exact mechanism unknown (?loss of autoregulation

leading to cerebrovascular congestion, brain swelling, increased intracranial pressure, herniation of the brain).

Is completely preventable.Treatment is poor.Can also occur without an identifiable first injury.

SECOND IMPACT SYNDROME ORMALIGNANT BRAIN SWELLING

OBJECTIVES


CONCUSSION

CLINICAL

PREVENTION

MANAGEMENT

COMPLICATIONS

Death of a young hockey player due to second impact syndrome

Fekete, JF in CMAJ, 1968

Hemorrhages in brainstem due to herniation of the brain

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OBJECTIVES


CONCUSSION

POSTCONCUSSION POSTCONCUSSION SYNDROMESYNDROME

1. Debilitating condition affecting a large number of people, difficult to diagnose, with no clear pathophysiology and with only symptomatic treatment available.

2. Does PCS lead to CTE??

OBJECTIVES


CONCUSSION

PATIENT CHARACTERISTICS IN OUR SERIES OF 221 PATIENTS WITH PCS

Mean age: 27.0 yearsRange 10-74 years123 (55.7%) of all patients were ages 10-22

Sex ratio: 127 (57.5%)male: 94 (42.5%) female

Can occur after any cause of concussion: sports, work, MVC, etc

OBJECTIVES


CONCUSSION

AGE OF PATIENTS WITH PCS (AT LAST CONCUSSION). (N=221)

M=27.0

OBJECTIVES


CONCUSSION

PERSISTENT SYMPTOMS

Mean number: 8.1 Range of 3-23 symptoms

Most common symptoms:1.Headaches (89.1%)2.Memory Problems (61.5%)3.Concentration Problems (54.8%)4.Balance problems (52.0%)5.Dizziness (51.6)6.Fatigue (45.7%)7.Nausea (43.0%)8.Sensitivity to light (38.9%)9.Irritability (31.7%)10.Depression (30.8%)

OBJECTIVES


CONCUSSION

# OF CONCUSSIONS PERPATIENT (INCLUDING MOST RECENT). (N=221)

M= 3.3

OBJECTIVES


CONCUSSION

DURATION OF PCS. (N=221) M=7 MONTHS,

RANGE: 1 MONTH TO 26 YEARS

(In most patients, the actual duration is longer as PCS had not resolved at time of last examination.)

OBJECTIVES


CONCUSSION

TREATMENT OF PCS

1.No proven therapy2.Graduated Return to

school, play, work3.Thus, prevention is

essential.

OBJECTIVES


CONCUSSION

CHRONIC TRAUMATIC ENCEPHALOPATHY (CTE)

Was called Dementia Pugilistica because it was first described in boxers by Martland, HS (JAMA, 1928)

Also known as the “punch drunk syndrome” because of intellectual decline, balance impairment, slurred speech, tremor

Variable latency after repetitive concussions Too many “dings”, cumulative effects of

“mild concussions”

CLINICAL

PREVENTION

MANAGEMENT

COMPLICATIONS

Brain of boxer with Dementia Pugilistica

CT Scan shows

atrophy of the brain.

OBJECTIVES


CONCUSSION

CTE PATHOPHYSIOLOGY

CTE Is a tauopathy due to repeated blows to the brain

Accumulation of tau protein in neuronal cell bodies.

Tau is normally present in axons and functions to stabilize microtubules

In CTE, deposition of tau damages neurons CTE has been seen in boxers and football,

soccer and hockey players Research needed to determine its

prevalenceCLINICA

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www.solveconcussions.ca

Retired CFL Players

CTE Pathophysiology (continued)

NormalNerveCells

AbnormalNerve Cells

First CFL Brain Donation to the Canadian Sports Concussion ProjectKrembil Neuroscience Centre, Toronto Western Hospital

Diagnosis of CTE *Arrows indicate nerve cells filled with Tau protein*

Jay Roberts (age 67), Ottawa Rough Riders

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Jay Roberts,Ottawa Rough Riders

Age 67

First CFL Brain Donation To The Canadian Sports Concussion

Project,Krembil Neuroscience Centre.

Toronto Western Hospital

NormalNerveCells

AbnormalNerve Cells

Nerve CellsFilled

with Tau Protein

DIAGNOSIS:C.T.E.

OBJECTIVES


CONCUSSION

Clinical Exam Non-Specific

Routine CT and MRI Non-Specific Atrophy

Functional MRI ??DTI MRI ??BOLD MRI ??MRS ??Maxi-Neuropsych Tests

Non-Specific

PET ??Event Related

Potentials (ERP) ??Electrical

Connectivity ??MEG ??Blood Biomarkers ??CSF Biomarkers TauMechanical Tests ??AUTOPSY-

TAUOPATHY-the only proven Biomarker!!!!!!!!

POTENTIAL BIOMARKERS FOR CONCUSSION INDUCED BRAIN DEGENERATION SUCH AS CTE

CLINICAL

PREVENTION

MANAGEMENT

COMPLICATIONS

OBJECTIVES


CONCUSSION

HOW TO DETECT CTE IN THE LIVING?

OBJECTIVES


CONCUSSION

OBJECTIVES


CONCUSSION

THE YOUNG BRAIN - IS IT MOREVULNERABLE TO INJURY?

Modern Research Says, YES!Therefore, the emphasis must be on prevention To prevent long-term deficits such as permanent memory loss

CLINICAL

PREVENTION

MANAGEMENT

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OBJECTIVES


CONCUSSION

CONCUSSION PREVENTION STRATEGIES IN SPORTS AND RECREATION

Concussions are serious injuries - can end careers and cause permanent brain injury

Follow the established guidelines for management

Promote safer play and respect – get rid of fights, elbows, illegal play and the “enforcer” role

Reduce head contact in football practicesKnow that helmets do not prevent

concussionCLINICAL

PREVENTION

MANAGEMENT

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CLINICAL

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OBJECTIVES


CONCUSSION

PREVENTION OF CONCUSSIONS AND THEIR COMPLICATIONS

CLINICAL

PREVENTION

MANAGEMENT

COMPLICATIONS

PrimaryPreventi

on

•Prevent the concussion from occurring

SecondaryPreven

tion

•Recognize and manage the concussion properly

TertiaryPreventi

on

•Prevent the long-term complications

• No Hits/Checks to the Head Rule, No Hits from Behind Rule, No Fighting Rule, and their Enforcement. Teach Respect.

• Diagnose and manage concussions properly to prevent worsening e.g. Second Impact Syndrome

• Prevent the long-term complications. Termination. Advise “Never return to play” to prevent CTE

EXAMPLES IN HOCKEY

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OBJECTIVES


CONCUSSION

PREVENTION OF CONCUSSIONS OF CONCUSSIONS IN HOCKEY (CONT’D)IN HOCKEY (CONT’D)

MULTIFACETED APPROACH:EducationCoaching - Attitude, Prevention StrategiesTrainingRefereeingRules Changes - NO HITS TO THE HEAD, NO HITS FROM BEHIND, NO FIGHTINGEquipment – Helmets, MouthguardsRemoval from Play and Terminating

CLINICAL

PREVENTION

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COMPLICATIONS

Every hockey player should see this video!

Download free at thinkfirst.ca

Who Do You Recognize Here??

1953-54

SENIOR HOCKEY 1953-54

Download free at thinkfirst.ca

HELMETS PREVENT SKULL FRACTURES, BRAIN CONTUSIONS AND LACERATIONS,AND BLOOD CLOTS IN AND AROUND THE BRAIN

HOCKEY and FOOTBALL PLAYERS ARE CONCUSSED WHILE WEARING HELMETS!

Protective equipment is essential… But helmets do not protect against all concussions

OBJECTIVES


CONCUSSION

Now in all of the 50 US states

Includes two main elements: 1.mandatory education about concussion for participants in

collision sports in schools or in community leagues, their families, coaches, and teachers

2.Mandatory management of concussion, especially removal from the game or practice, advice to see a doctor, and no return until a signed approval from a doctor

Bill 39 introduced in Ontario in 2012 for schools received 1st reading but died when the legislature was prorogued.

CONCUSSION LEGISLATION

OBJECTIVES


CONCUSSION

Ontario Ministry of Education: Announced in March, 2014 and implemented in Jan. 2015

Directs School Boards to have concussion education, management and prevention policies

For players, parents, teachers, coaches, referees, etc.

Well written and resourced.Will save brains and livesFirst of its kind in CanadaBravo!!!

POLICY AND PROCEDURES MEMORANDUM 158

OBJECTIVES


CONCUSSION

Concussions can be prevented by helmetsConcussions can be diagnosed by CT and MRIThere is a proven treatment for concussionsResume your activities as soon as possible, and you will get

better quickly It’s just a concussion, and everybody gets betterBaseline testing prevents concussionBaseline testing is good treatment for concussionPostconcussion syndrome is what malingerers get and only

occurs when liability is an issueDepression and anxiety after a concussion are psychogenic,

and due to sadness

CONCUSSION MYTHOLOGY

OBJECTIVES


CONCUSSION

CONCLUSIONS

The term “Mild Traumatic Brain Injury” or mTBI is an oxymoron

Concussions can produce lasting symptoms, especially repetitive concussions

Prevention is the only cure. There is no drug or other therapy to accelerate recovery from concussion or to prevent the next concussion, or to prevent the long term consequences of concussion.

More concussion research is necessary

CLINICAL

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CONCUSSION

PARACHUTECANADA.ORG

CLINICAL

PREVENTION

MANAGEMENT

COMPLICATIONS

THANK THANK YOUYOU

charles tator april 23, 2015 niagara falls what is new in concussion? summit 2015 niagara parachute...

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