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Concussion Research Update…Why Our Patients Need OMT Concussion Research Update…Why Our Patients Need OMT AAO Convocation March 13-17, 2019 P. Gunnar Brolinson, DO, FAOASM, FAAFP, FACOFP Discipline Chair, Sports Medicine Director, Primary Care Sports Med Fellowship Team Physician, Virginia Tech Team Physician, US Ski Team Funding and Disclaimer DOT: National Highway Traffic Safety Administration American Osteopathic Association 1051715717 National Science Foundation Toyota Central Research and Development Labs, Inc NIH: R01HD048638 NIH: 1R01NS094410-01A1 NCAA-DoD Care Consortium I do not have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within this presentation. Concussion evaluation, treatment and research is a “team game”! • Stefan Duma • Mark Rogers • Mike Goforth • Lauren Leslie • Brett Griesemer • Natalie Hyppolite • Rick Greenwald • Al Kozar • Jonathan Beckwith • Shawn Kerger • Joel Stitzel • Peter Fino • Steve Rowson • Murray Nussbaum • Bethany Rowson • Erik Tahkounts • Jillian Urban • Gerry Gioa • Chris Whitlow • And there are many others…. • Logan Miller Introduction • The human brain possesses functional complexity far beyond that of any other organ or body part • When injured, it is this complexity that creates tremendous clinical challenges for both diagnosis and treatment • Recognizing concussion and differentiating it from other diagnoses can be a daunting task, but one of critical clinical importance • Understanding the intersection between research and clinical care • Returning the athlete to play safely is of fundamental importance for the clinician • Understanding the role of Equipment, Rules Changes, Coaching and other “countermeasures” is vitally important No health topic in recent memory has captured the public’s attention as much as the debate on sports related traumatic brain injury. The deal calls for the NFL to pay $765 million to fund medical exams, concussion-related compensation, medical research for retired NFL players and their families, and litigation expenses, according to a court document filed in U.S. District Court in Philadelphia. So what have we learned…. Concussions misunderstood and feared by most Americans Sponsor UPMC, 10/05/2015 The national survey of 2,012 Americans age 18 and over was conducted in April by Harris Poll on behalf of UPMC. The survey further showed that, despite a lack of knowledge and understanding, there is a high level of concern and even fear across the country. A fear of concussions may be impacting parents’ decisions to let their kids play contact sports This survey was conducted online within the United States by Harris Poll on behalf of UPMC between April 16 to 23, 2015 among 2,012 U.S. adults age 18 or older, 948 of whom are parents. For complete survey methodology, including weighting variables, please contact Deana Percassi, Harris Poll, 585-214-7212. “Concussion”…the movie • Concussion is an American sports drama film directed and written by Peter Landesman, based on the 2009 GQ article Game Brain by Jeanne Marie Laskas. The film stars Will Smith, Alec Baldwin, Gugu Mbatha- Raw and Albert Brooks. The film focuses on a forensic pathologist and neuropathologist, Dr. Bennet Omalu played by Smith, who discovers Chronic Traumatic Encephalopathy (CTE) in the brains of two NFL players. • Principal photography began on October 27, 2014, in Pittsburgh, Pennsylvania. Village Roadshow Pictures, Scott Free Productionsand The Shuman Company are producing the film. Columbia Pictures will release the film as scheduled for an opening December 25, 2015 date. What is a Concussion? • Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces • Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: – 1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head – 2. Concussion typically results in the rapid onset of short lived impairment of neurologic function that resolves spontaneously, however in some cases symptoms may evolve over minutes to hours – 3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury – 4. Concussion results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course; however, it is important to note that, in a small percentage of cases, post-concussive symptoms may be prolonged – 5. No abnormality on standard structural neuroimaging studies is seen in concussion Consensus Statement on Concussion in Sport; 5th International Conference on Concussion in Sport McCrory, P, et al. Br J Sports Med 2017; 0: 1-10 doi:10.1136/bjsports 2017-097699 Incidence of Concussion • 1.6 to 3.8 million traumatic brain injuries/year – 300,000 sport-related concussions • Concussions represent an estimated: – Up to 9% of all high school athletic injuries – 3-6% of interscholastic football athletes – 4-8% of collegiate athletes – 7.7% of National Football League (NFL) athletes • 53% of concussed high school athletes go unreported Langlois JA,Rutland-BrownW,WaldMM.The epidemiology and impact of traumatic brain injury: a brief overview. McCrea et al, 2004 J head Trauma Rehabil. 2006; 21:375–378. What is a concussion? • Not all athletes have the same threshold for concussion – But every athlete, whether previously concussed or not, walks on to the field of play with some inherent risk of being concussed • If different athletes receive the same type and magnitude of mechanical force applied to their brains, some will be concussed while others will not • Athlete’s past concussion experience, concurrent diagnoses, physiologic state, and family history may play roles “Yep, I’m flying through the air, this is not good” Ricky Bobby Current Research and Clinical Considerations for Concussed Athletes Must be managed in on individualized basis and multiple factors taken into account. For this talk we will synthesize research findings and clinical practice into an integrated approach…. “The current literature is unclear and contradictory regarding specific therapeutic approaches. Sports clinicians are left to develop an approach to management of concussion that is based on currently available best practices that have little scientific evidence to support them.” P.G. Brolinson; management of sport related concussion review and commentary; Clin J Sport Med Journal Club issue 24(1) -Jan 2014. Concussion Biomechanics • Heading a soccer ball can result in head accelerations – From 16 to 20g lasting 25 ms • The average collegiate football impact – From 21 and 32g lasting 14-15 ms • Impacts to the top of the head yielded the greatest linear acceleration and impact force magnitude – Improper tackling techniques • Offensive and Defensive line players sustained the lowest-magnitude impacts but the highest number of impacts during games and practices Rowson, S et al. Presented at Rocky Mountain Bioengineering Symposium & International ISA Biomedical Sciences Instrumentation Symposium 17-19 April 2009, Milwaukee, Wisconsin, www.isa.org Halsted, M and K Walter. Pediatrics, 2010; 126 (3): 597-615 Broglio, SP, et al. Journal of Athletic Training 2009;44(4):342–349 Concussion Biomechanics • Over 250,000 head impacts recorded at Virginia Tech – Games (30%) – Practice (70%) – 15 years of data collection: 2003- 2018 • Clinically diagnosed concussive impacts recorded for instrumented players • Unbiased exposure data – Previous football work over-sampled injury data Example MTBI Event Example MTBI Event Peak G = 136 G Clinically diagnosed concussion Another Example MTBI Event Another Example MTBI Event Peak G = 139 G Clinically diagnosed concussion Concussion Biomechanics and Brain Modeling • Appreciate computational models • Brain deformation varies widely by impact of the brain and their potential to location (or direction of motion) and even counterintuitively compared to impact study impact exposure magnitudes • Observe variations in response of • Important implications for quantifying the brain under different loading concussion risk and long term exposure to directions and severities concussive and subconcussive impacts • Investigators using imaging to identify • Understand value and necessity of potential biomarkers for injury predictive of brain models to connect sensor long-term outcomes based exposure with imaging and • Imaging includes advanced structural clinical outcomes techniques to evaluate brain microstructure and advanced functional techniques (fMRI, • Sensor-driven biomechanical MEG) and molecular imaging like PET modeling holds the key to • Imaging is limited now because target of pinpointing areas in brain at most TBI in brain is elusive due to injury risk from TBI or impact exposure. heterogeneity Brain Finite Element Models ABM SIMon GHBMC SUFEHM Miller et al. (2016)Takhounts et al. (2003) Mao et al. (2013) Sahoo et al. (2014) THUMS 4.01 KTH WHIM UCDBTM Kimpara et al. (2006) Kleiven et al. (2002) Ji et al. (2014) Horgan and Gilchrist (2004) Brain Motion... And Sulcal strains (Ghajari, 2017) http://www.cap.org/ The promise of modeling…. Head Injury Criteria typically relate: linear and rotational kinematics (motion) to injury risk . 1 퐻퐼퐶 = 푎 푡 푑푡 푡 −푡
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