Concussion (the movie):

the science behind the acting

James MacDonald MD, MPH
Division of Sports Medicine
Nationwide Childrens Hospital
@sportingjim
james.macdonald@nationwidechildr
ens.org

Disclosures
MomsTeam Institute, 501(c)(3) BOD
Wolters Kluwer
CJSM Associate Editor
UpToDate Author

COIs???

Bias

Not pro-football, not anti-football

Pro-safety
Pro-science
Pro-Active Kids
Pro-sports

Im not a doctor but I play one in

the movies

The Movie: An Overview

Concussions (movie) isnt about
concussions
Its about the NFL not about kids
Safe for kids PG-13
CTE--discovered by Dr. Omalu?
CTE is not yet fully understood
League of Denial PBS FrontLine
http://www.pbs.org/wgbh/pages/frontline/oral-hi
story/league-of-denial
/

What well cover

Concussions
Short vs. long-term riskswhat we know 2016
Current research/knowledge

Chronic Traumatic Encephalopathy (CTE)

Are our kids at risk?
Youth Footballwhat is the evidence of its
dangers
Directions where this is heading?
Should we ban football

Concussions -epidemiology
3.8 million pediatric SRCs /yr 1
50% of HS football players
dont report/season2
Rates in HS sports3:

Football 6.4/10000 AEs

Boys Ice Hockey 5.4/10000 AEs
Boys LAX 4.0/10000 AEs
Girls LAX 3.5/10000 AEs
Girls Soccer 3.4/10000 AEs
Boys Soccer 1.9/10000 AEs

Almost 9% of HS sports
injuries4
Youth sports data are lacking
1.9% of Youth Soccer injuries

2015 Concussion Total

Sports Medicine

JanJun

JulDec

Total

New
Patients

421

689

1110

Follow Up

810

1054

1864

1743

297
4

Grand
Total

1231

AJSM 2012
CJSM 2004
3
AJSM 2012
4
Pediatrics 2010
1

Concussionswhat are
they?
Complex pathophysiologic
process affecting brain
Caused by Impulsive force

direct or indirect

Resulting in new
neurological sign/symptom
2016:
Concussionclinical
diagnosis
Objective gold standard still
lacking

Signs
LOC
Amnesia
Ataxia

Symptoms
Lots!!!!

Cognitive
Affective
Postural
Sleep

Diagnosis

Zurich Consensus Statement CJSM

2013

SCAT-2 (3)

Prospective
SRCs in College
Athletes
SCAT 2 (0 100)
Baseline & Postconcussion

Decline > 3.5

Sens = 0.96
Spec = 0.81
LR+ = 5.1

CJSM 2013 4th Intl Concussion Consensus

Statement
2
Putukian et al., CJSM 2015

Objective Measures of Concussion -- 2016

Objective Biomarkers
Blood S100B, amyloid, tau, NSE, glial fibrillary acidic protein,
neurofilament polypeptide, SNTF, APOE 4
Video oculography - eye tracking, portable
Pupillometry peak velocity, latency
Visual/auditory evoked potential
Objective balance portable force plate (Biodex Biosway),
accelerometers, app (Sway)
Cranial accelerometry skull movement caused by cerebral blood
flow reactivity
Cerebrovascular reactivity Doppler US
Functional Near Infrared Spectroscopy (fNIRS) cerebral oxygenation
as function of cognitive workload
Hit sensors for helmeted (HIT, Gforce) and unhelmeted (Gforce,
Triax), patch (X2)
Injury risk curves dependent on accuracy of concussion diagnosis and
biomechanical measure

Christina Master MD, CHOP

Concussions (cont.)
HS Football
players1
75% Sx free in 3
days
65% RTS in 9
days

Younger take
longer

Return to Sport
Return to Learn
Return to Drive

80% RTS in 21
days
1

Jrnl Athl Training 2007

How much cognitive

rest?
Brown et al. Pediatrics 2014

Pros cohort (N = 335; Age =

8 23)

Patient self-report of cognitive

activity
Divided into quartiles
Mean duration of symptoms 43d
Associated with slower
recovery
Initial PCSS level
Cognitive activity

Thomas et al. Pediatrics 2015

RCT (N = 88, Age = 11

22)
Strict rest 5 d
Usual care

No difference in neurocog
or balance measures
Intervention group
had more daily post
concussive symptoms
& slower resolution

Physical Activitypostconcussion

Published Ahead of Print 2/2/16

AJSM (N = 364; Age = 15)
Cohort study LOE 2
Post-concussion symptom duration
Female, initial PCSS score associated with length
Physical activity level post injury no association

Ages 13 18
HIGHER levels of physical activity associated
with SHORTER symptom duration

CTEwhat is it?
Clinical Characteristics
No prospective, longitudinal
studies demonstrating these

Mood/Impulsivity
Suicidal Ideation
Cognitive impairment
Headaches
Motor (Parkinsonian)

Pathological
Tauopathy
amyloid inconsistent feature

Levels of Evidence (LOE)

Case Reports/Case Series
Retrospective
VI, VII

Diagnosis
Post mortem autopsy

Biases:

Found in
Football/rugby/wrestling/rodeo/
circus clowns
Not found in those with no
exposure to head impacts

Referral/recall/selection/
sampling

Correlation not
causation

Neurology 2013
Univ. of Wisconsing Library LOE
Guide

Boston University

CTEpractice & research

gaps

Castellani, Laboratory Investiation

2015

Causes for Concern?

Frank Gifford

Tyler Sash

Cause for Concern?

Cumulative Head Impacts
(Subconcussive blows)?
HS/College 1000 head impacts/season
Youth (age 6) 100 head impacts/season
Can generate impacts equivalent to
collegiate athletes

Animal Models
Changes in White matter
Concussion Dose/Response Model

Animal Models
Outcomes

Mouse model
2 3 mo old

Weight drop rmTBI

(7 injuries/9 d)
Cognitive deficits
w/o structural injury

Injured (N = 32)
vs. sham injured (N =
21)
Assessors blinded

Tests of balance, spatial

memory (e.g. Morris water
maze), exploratory
behavior
Post-mortem brain exam

rmTBI mice
3 months
Increased exploratory
behavior
Impaired balance
Worse spatial memory

Increased astrocytosis and

microgliosis

J Neurosurg 2014

No volume changes

Corpus Callosum White

Matter s
DETECT study
NFL players [(N = 40), Age 40 65]
Age at first exposure (AFE) to Repetitive Head
Impacts (RHI)
2 groups:
< Age 12
Age 12

Magnetic resonance diffusion tensor imaging (DTI)

Dependent measures fractional anisotropy, axial/radial
diffusivity
Whole CC and five subregions

Significant changes in several dependent measures in

earlier AFE group
Journal of Neurotrauma 2015

Dose Response Model

NCAA Athletes (N = 100 male/88 female; diff.
schools)
Self-reported concussion history 4 groups

0 concussions
1 previous concussion
2 previous concussions
3 previous concussions

CNT testing (visual/verbal memory, simple/choice RT)

Performance decrements beginning at 2
concussions
Females > males

T Covassin et al. J Neurol Neurosurg Psychiatry. 2010

Countervailing Evidence

Youth football:
the scope of the sport

CJSM 2013

Making Football Safer

Helmets:
Well fitted, reconditioned

Mouth Guards?
No

Neck Strengthening?
Qualified yes
(N = 6704)
Adjusted for gender/sport
1 # increase neck strength :
OR = 0.95

Rule changes in
games/enforcement?
Maybe

Practice changes?
Promising

Collins et al. Jrnl of Primary Prevention 2014

Snake Oil
Can a dietary supplement treat or
prevent concussion?
Chocolate milk!
Omega-3 fatty acids!
Turmeric!

As amazing as the marketing claims are,

the science doesnt support the use of any
dietary supplements for the prevention (or
treatment) of concussions.

--Director of FDAs Division of Dietary Supplements

Tackling in football
Tackling is most common
activity at time of injury
Majority of concussions
result from tackling/being
tackled
Incidence of concussion
lower in practice than
games
But there are many more
practices
In youth (not HS/College)
measured head impact
forces are higher in
practices

Recommendations
Decreasing # of contact
practices decreases
overall number of head
impacts over the course
of a season
Emphasis on proper
tackling
technique/enforcing rules
?Delay onset of tackling
until a certain age?
Importance of having ATCs
present at schools

Pediatrics 2015
AAP Policy Paper on Tackling

Helmetless tackling???!!

NCAA D1 Athletes
25 cases/25 controls
Impact sensors
Intervention:
5 min 2x week
preseason, 1x week
in season, helmetless
tackling drills

Outcome: 28% less

head impacts
JATA 2015

Concussion reporting
HS Football Players with possible concussions
Do they report?

MA & OH HS FB at seasons end

[(N = 692), (Age = 16.0 +/- 1.2)]
104 players with 155 concussions
Only 56% reporting rate (2004 47%)
1st string 49.3%
Non 1st string 73.3% (P < 0.05)

Freshman 78.9%
Sophomores 62.5%
Juniors 51.6%
Seniors 42.3% (P < 0.05)
Presented at AAP 2015

Putting concussions in
perspective

Relative
Risks

Doug Casa, Korey Stringer Institute

[N = 243 (1990
2010)]

Relative Risk
2694 children/teens died from guns 20101
638 children < 12 died in MVAs 20132
17 Football Season Fatalities, 20153
Indirect: 10 (Mean = 7/last decade)
4 head
2 spinal cord
1 organ

Direct: 7 (Mean = 3/last decade)

SCD = 6
EHS = 3
Sickling crisis = 1

First, Lets Kill All the Lawyers

the Bard

Crystal Dixon, et al v. Pop Warner

Little Scholars, Inc.
.. about the failure to coach the
injured plaintiff in proper tackling
technique and whether there was a
conscious disregard for his safety
based on the evidence presented.

Lawmakers in MD
Bill to suspend coaches who return
players suspected of concussions on to
playing field

Social Media & Hornets

Nests
Gun safety
Hands Up

Concussions/CTE
Vaccines
Paleo Diet
Bike Helmets
Cross-Fit
Open Access

Weve been talking about this a

long time

Football has become soft like

our country has become soft

You dont need a weatherman to

know which way the wind blows
Survey by the Sports and Fitness Industry
Association and the Physical Activity
Council:
2012 participation in organized football by
players aged 6 - 14 was 4.9 percent below that
in 2008.

National Federation of State High School

Assns:
Participation in high school football was down
2.3 percent in 2012-2013 compared to the
2008-2009 season.
WSJ 2013

The concussion crisis:

If it bleeds, it leads

Science
Advocac
y

Media

Business

Crisi
s

Litigatio
n

Risk
Percepti
on

Scientific Evidence Disseminated =

NCH: Doing Something

About It
Stuart EA, Rodenberg RE, Dotson ML, et al.
Reliability Measures of the Balance Error Scoring
System as Administered by Certified Athletic Trainers.
Heyer G, Fischer A, Wilson J, et al. Orthostatic
Intolerance & Autonomic Dysfunction in Youth With
Persistent Postconcussion Symptoms: A Head-Upright
Tilt Table Study.
MacDonald J, Wilson J, Young J, et al. Evaluation of
a Simple Test of Reaction Time in Baseline Concussion
Testing.
MacDonald J, Duerson D. Reliability of a
Computerized Neurocognitive Test in Baseline
Concussion Testing of High School Athletes.

@Pediacast
iTunes
PediaCast
PediaCast CME

2/3/16

Back to the movie or

Reading the tea leaves
Dont let kids play
football.

.football is safer
than its ever been.

Which is the pediatric public health

crisis of our times?

Conclusions
Concussions and exposure to contact sports
associated with CTE but NO cause/effect yet
Far too early to draw definitive conclusions
about what this means for youth football
Precautionary principle lets work on
making football safer
Put in the balance the benefits of youth sport
Theres more to the concussion crisis than
science
We have A LOT more science to do

Conclusions cont.
Consensus to limit overall head impact
exposure
Maintain integrity of game
Avoid unintended consequence

Most initiatives related to lessening frequency of

contact
e.g. helmetless hitting drills

This ought not to be the end of youth contact

sports (e.g. football)

Having a concussion wont

destroy your life

Resources
SCAT 3
CJSM 2013; 23: 89 117 http://
bjsm.bmj.com/content/47/5/259.full.pdf

AAP Tackling Statement (see references)

Concussion Policy & Law Blog
http://concussionpolicyandthelaw.com/

NCH Sports Med

http://
www.nationwidechildrens.org/sports-medicine-conc
ussion-clinic

CDC Heads Up
http://www.cdc.gov/headsup/youthsports/training/

References

McCrory P, Meeuwisse W, Aubry M. Consensus Statement on Concussion in

Sport Held in Zurich, November 2012. Clin J Sport Med. 2013; 23: 89 117.
Stamm JM, Koerte IK, Muehlmann M, et al. Age at first exposure to football is
associated with altered corpus callosum white matter microstructure in former
professional football players. J Neurotrauma. 2015; 32: 1768 1776.
Meehan WP, Landry GL. Tackling in Youth Football; AAP Council on Sports
Medicine & Fitness Policy Statement. Pediatrics. 2015; 136: e1419 e1430.
Castellani RJ. Chronic Traumatic Encephalopathy: A Paradigm in Search of
Evidence? Laboratory Investigation. 2015; 95: 576 584.
Putukian M, Echemendia R, Dettwiler-Danspeckgruber A, et al. Prospective
Clinical Assessment using SCAT-2 Testing in the Evaluation of Sport-Related
Concussions in College Athletes. 2015; 25: 36 42.
Gessel LM, Fields SK, Collins CL, et al. Concussions Among United States High
School & Collegiate Athletes. J Athl Training. 2007; 42: 495 503.
Savica R, Parisi JE, Wold LE. High School Football & Risk of Neurodegeneration:
A Community-Based Study. Mayo Clin Proc. 2012; 87: 335 340.
Meehan W, Mannix R, Zafonte R, Pascual-Leone A. Chronic Traumatic
Encephalopathy and athletes. Neurology. 85: 1504 1511.