ACSM on Sports Concussions - Two Steps Forward, One Step Back

The American College of Sports Medicine (ACSM) released the following information on sports concussions. I appreciate them raising awareness of brian injury. With all due respect to my colleagues, their advice on "brain rest" is neither biologically possible nor data based. 


They write "

Like any other injured body 

part, the concussed brain should be 

rested in order to recover. D

uring recovery, athletes should have no physical exertion that will raise the heart rate, and they should also perform no mental work, such as school or other tasks, that require concentration. Doctors commonly prescribe periods of reduced schoolwork and tests after a concussion, but they may need to start with complete brain rest, including no thinking, texting or video games." 

If you or your child get a prescription for total "brain rest", you should ask why. 

I still recommend that people with a brain injury should seek a BRAIN specialist.  JR


WHAT IS A CONCUSSION?
A concussion is an injury to the brain caused by a sudden acceleration or deceleration force, and concussions occur in many different sports. While an athlete does not need to hit his or her head to suffer a concussion, hits to the head— against another person, a ball, or the ground—are a common cause. The brain moves inside the skull, and the sudden movement can cause the brain to swell. Helmets protect against more serious head injuries, but they do not necessarily prevent concussions. It may not be obvious to parents, coaches, trainers and athletes immediately how bad the head injury is, so if a concussion is at all suspected, the athlete needs to stop with the practice or the game.

SYMPTOMS OF CONCUSSION

The most serious concussion symptoms could be associated with a more severe head injury, such as bleeding into the brain. People with the following “red flag” symptoms need emergency care:
• Increasing confusion or headaches;
• Vomiting, double vision or unequal pupils;
• Irritability or behavior change; and
• Drowsiness or fading in and out of consciousness.

Other concussion symptoms are less obvious and are split among four categories:

• Physical symptoms—headache; nausea; dizziness; vision or balance problems; sensitivity to light or noise.
• Cognitive symptoms—feeling mentally slow or foggy; trouble concentrating; trouble remembering.
• Emotional symptoms—irritability; sadness; nervousness; feeling more emotional than usual.
• Sleep-related symptoms—sleeping more or less than usual; drowsiness; trouble falling asleep.

CONCUSSION DIAGNOSIS

Assuming the injured athlete does not have any of the most serious symptoms, he or she will not need a head CT scan or MRI. There is currently no imaging test that can diagnose a concussion. The doctor will ask about symptoms, complete a neurological physical exam and possibly balance testing, and may opt to perform mental agility testing known as neuropsychological testing. These tests are best if there is a pre-injury baseline for comparison, and this may be a service offered by your local school, club or hospital.

CONCUSSION TREATMENT

Unfortunately, people with a concussion usually look and act normally, so it is difficult for them and their family, teachers and coaches to tell they’ve suffered a concussion. Like any other injured body part, the concussed brain should be rested in order to recover. During recovery, athletes should have no physical exertion that will raise the heart rate, and theyshould also perform no mental work, such
as school or other tasks, that require concentration.

Doctors commonly prescribe periods of reduced schoolwork and tests after a concussion, but they may need to start with complete brain rest, including no thinking, texting or video games. As the brain recovers, cognitive activity can be gradually returned. Only when the brain is working normally at rest, with no recurrence of the symptoms listed above, is the athlete ready to return to play.

Most people with concussions recover in 7-14 days. Some individuals require significantly longer times, and some are never quite back to normal. Repeated concussions can be associated with more
severe injury and longer recovery. A repeated concussion before the brain is fully recovered can be fatal, causing rapid brain swelling and second impact syndrome.

RETURNING TO PLAY

A progression of return-to-play after a concussion begins only after all symptoms have cleared at rest and with mental exertion. Then an athlete can begin a five-day gradual return, stopping and waiting
at any point when exertion causes symptoms to return.

• Day 1: Low-level activity, such as walking or slow jogging.
• Day 2: Increased intensity of jogging, running or biking.
• Day 3: Heavy non-contact activity, including sprinting.
• Day 4: Contact activity in controlled practice situation.
• Day 5: Full participation.

Read more here

• Article

Neurodegenerative causes of death among retired National Football League players

1. Everett J. Lehman, MS, 
2. Misty J. Hein, PhD, 
3. Sherry L. Baron, MD and
4. Christine M. Gersic

+Author Affiliations

1. From the Centers for Disease Control and Prevention, The National Institute for Occupational Safety and Health, Division of Surveillance, Hazard Evaluations and Field Studies, Cincinnati, OH.

1. Correspondence & reprint requests to Mr. Lehman: elehman@cdc.gov

View Complete Disclosures

ABSTRACT

Objective: To analyze neurodegenerative causes of death, specifically Alzheimer disease (AD), Parkinson disease, and amyotrophic lateral sclerosis (ALS), among a cohort of professional football players.

Methods: This was a cohort mortality study of 3,439 National Football League players with at least 5 pension-credited playing seasons from 1959 to 1988. Vital status was ascertained through 2007. For analysis purposes, players were placed into 2 strata based on characteristics of position played: nonspeed players (linemen) and speed players (all other positions except punter/kicker). External comparisons with the US population used standardized mortality ratios (SMRs); internal comparisons between speed and nonspeed player positions used standardized rate ratios (SRRs).

Results: Overall player mortality compared with that of the US population was reduced (SMR 0.53, 95% confidence interval [CI] 0.48–0.59). Neurodegenerative mortality was increased using both underlying cause of death rate files (SMR 2.83, 95% CI 1.36–5.21) and multiple cause of death (MCOD) rate files (SMR 3.26, 95% CI 1.90–5.22). Of the neurodegenerative causes, results were elevated (using MCOD rates) for both ALS (SMR 4.31, 95% CI 1.73–8.87) and AD (SMR 3.86, 95% CI 1.55–7.95). In internal analysis (using MCOD rates), higher neurodegenerative mortality was observed among players in speed positions compared with players in nonspeed positions (SRR 3.29, 95% CI 0.92–11.7).

Conclusions: The neurodegenerative mortality of this cohort is 3 times higher than that of the general US population; that for 2 of the major neurodegenerative subcategories, AD and ALS, is 4 times higher. These results are consistent with recent studies that suggest an increased risk of neurodegenerative disease among football players.

• Received April 24, 2012.
• Accepted July 9, 2012.

• Copyright © 2012 by AAN Enterprises, Inc.

Football players more likely to develop neurodegenerative disease, study finds

Football players more likely to develop neurodegenerative disease, study finds(CNN) -- Just hours before the 2012 NFL season kicks off, a new study suggests that professional football players are three times more likely to have neurodegenerative diseases than the general population.

When researchers specifically looked at Alzheimer's disease and ALS -- amyotrophic lateral sclerosis, also known as Lou Gehrig's disease -- that risk increased to four times greater than the rest of us.

The study, published Wednesday in the medical journal Neurology, surveyed nearly 3,500 retired NFL players who were in the league between 1959 and 1988.

The National Institute for Occupational Safety and Health, a division of the Centers for Disease Control, had been following this group of players since the early '90s, when the NFL asked the institute to evaluate them for their risk of cardiovascular disease.

This time, the authors decided to look at the neurological outcomes of the players by specifically evaluating the autopsies of 334 players.

CNN article here

Academic effects of contact sports on college athletes

Cognitive effects of one season of head impacts in a cohort of collegiate contact sport athletes

While it is known that concussions can harm an athlete’s ability to learn, a new study has found evidence that even one season of contact sports can affect how well some athletes acquire new information, according to the study’s lead author and Director of Neuropsychiatry at the Geisel School of Medicine Thomas McAllister.

The research was part of a multi-institution study that has been working for five or six years to understand the biomechanical basis and effects for concussions, McAllister said.
The study, which was published by the American Academy of Neurology, found that contact sport athletes did not perform worse than non-contact sports athletes on cognitive tests before their seasons began. These results were “reassuring,” McAllister said.

“We did not find any systematic widespread adverse affects on cognition,” he said. “The two groups on average looked pretty similar at the end of the season.”

The study did find that a larger subgroup of contact sport athletes than non-contact sports athletes performed worse than expected on tests taken immediately after the season. Taking into account how well the athletes tested before their season began and controlling for other indicators of general test performance and the interval between tests, the authors predicted how well the athletes should perform after their season and compared this to their actual results.

“We found that about 22 percent [of contact sport athletes] did worse than 1.5 standard deviations below what we would have predicted,” McAllister said. “This was a significant difference from the non-contact group.”

McAllister said that this raises the possibility that some individuals are particularly vulnerable to suffering negative effects from hitting their heads repeatedly during contact sports.
“This changes the emphasis of the debate a little bit,” McAllister said. “It’s a new direction for us to be thinking about the risks or lack of risks for contact sports. There may not be the same risk for everyone.”

The researchers also used the tests administered at the beginning of the season to see whether athletes who had been playing contact sports for most of their lives and had presumably hit their head more often had lower cognition than non-contact sport athletes.
“We did not find any systematic differences between the two athlete groups at the beginning of the season,” McAllister said. “We think this is good news. We were unable to detect widespread significant differences in their cognitive capabilities.”

To measure their results, researchers administered two tests to male and female contact and non-contact sport athletes from the College, Brown University and Virginia Polytechnic Institute and State University at the beginning and end of their seasons. Contact sport athletes played football or ice hockey while non-contact sport athletes participated in track, Nordic skiing or crew.

Participants that sustained a documented concussion during the season were not included in the study results because researchers were primarily interested in the effects of “repetitive impacts to the head not apparently causing a concussion,” according to McAllister.
A 20-minute computerized test measured cognition, memory attention and reaction time. The other neurological test, administered to a sub-group of athletes, was more extensive and used “paper and pencil.” Researchers compared the results of the contact sport athletes’ tests with the non-contact sport athletes’ tests, which were used as a control.
Contact sport athletes wore special helmets during practice and games equipped with a Head Impact Telemetry System designed by Richard Greenwald, the president of Simbex, a technology company in Lebanon. The helmets have been in use since 2004 around the United States, according to Greenwald.

“The helmets contain a system that monitors head impacts automatically and wirelessly,” Greenwald said. “They measure how often, how hard and where on the helmet gets hit.”
Jessica Gagner ’13 plays women’s ice hockey and participated in the study as a contact sport athlete. She said she was not more cognizant about hitting her head when wearing the helmet.

“To me, if you’re playing a contact sport, you’re obviously going have a bigger effect on your head,” Gagner said. “It’s really inevitable that you’re going to have more of an issue with head impacts if you are a contact sport athlete.”
Cara Vernacchia ’13 runs track and was a non-contact athlete who participated in the study. She said she was glad to be able to take part to help researchers learn more about concussions and how to prevent them.

“Being able to be part of the study made me realize that concussions do occur,” Vernacchia said. “It’s interesting to see how prominent head impacts are, even on our campus.”
The researchers hope to continue observing the effects of contact sports on the study’s participants. Many students agreed to undergo neuroimaging before and after their seasons and researchers hope to examine these results.

“We’d love to be able to revisit with some of these athletes four or five years down line and get a second set of test results to see how they’re doing after a whole collegiate career,” McAllister said.

The researchers also hope to learn more about why certain athletes performed worse than expected on tests after a season of contact sports.
“I think the second theme of ongoing research would be to try and understand what individuals are at risk to be in that ‘not doing as well as we would have thought’ category,” McAllister said.

Greenwald said that the researchers hope to learn more about the effects of contact sports on youth and women in the future.

Read more here:

Cognitive effects of one season of head impacts in a cohort of collegiate contact sport athletes

1. T.W. McAllister, MD, 
2. L.A. Flashman, PhD, 
3. A. Maerlender, PhD, 
4. R.M. Greenwald, PhD,
5. J.G. Beckwith, MS, 
6. T.D. Tosteson, ScD, 
7. J.J. Crisco, PhD, 
8. P.G. Brolinson, DO,
9. S.M. Duma, PhD, 
10. A.-C. Duhaime, MD, 
11. M.R. Grove, MS and 
12. J.H. Turco, MD

+Author Affiliations

1. From the Departments of Psychiatry (T.W.M., L.A.F., A.M., M.R.G.), Community and Family Medicine (T.D.T.), and Medicine (J.H.T.), Dartmouth Medical School, Lebanon; Simbex (R.M.G., J.G.B.), Lebanon; Thayer School of Engineering (R.M.G.), Dartmouth College, Hanover, NH; Bioengineering Laboratory, Department of Orthopaedics (J.J.C.), The Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI; Edward Via Virginia College of Osteopathic Medicine (P.G.B.), Blacksburg; Virginia Tech-Wake Forest (S.M.D.), Center for Injury Biomechanics, Blacksburg; Pediatric Neurosurgery (A.-C.D.), Children's Hospital at Dartmouth, Dartmouth Hitchcock Medical Center, Hanover, NH; and Pediatric Neurosurgery (A.-C.D.), Massachusetts General Hospital, Boston.

1. Correspondence & reprint requests to Dr. McAllister: thomas.w.mcallister@dartmouth.edu

View Complete Disclosures

ABSTRACT

Objective: To determine whether exposure to repetitive head impacts over a single season negatively affects cognitive performance in collegiate contact sport athletes.

Methods: This is a prospective cohort study at 3 Division I National Collegiate Athletic Association athletic programs. Participants were 214 Division I college varsity football and ice hockey players who wore instrumented helmets that recorded the acceleration-time history of the head following impact, and 45 noncontact sport athletes. All athletes were assessed prior to and shortly after the season with a cognitive screening battery (ImPACT) and a subgroup of athletes also were assessed with 7 measures from a neuropsychological test battery.

Results: Few cognitive differences were found between the athlete groups at the preseason or postseason assessments. However, a higher percentage of the contact sport athletes performed more poorly than predicted postseason on a measure of new learning (California Verbal Learning Test) compared to the noncontact athletes (24% vs 3.6%; p < 0.006). On 2 postseason cognitive measures (ImPACT Reaction Time and Trails 4/B), poorer performance was significantly associated with higher scores on several head impact exposure metrics.

Conclusion: Repetitive head impacts over the course of a single season may negatively impact learning in some collegiate athletes. Further work is needed to assess whether such effects are short term or persistent.

Teenagers Fare Worse After Concussion Than Children or Adults

Teenagers and children are not little adults. Its a basic premise of all pediatric medicine. If a teen or child is hurt, see a pediatric specialist. JR

Teenagers who suffer a concussion are more sensitive than adults or children to its aftereffects, Canadian researchers report.

Concussions can affect short-term memory in adolescents, which is essential for reading and calculating, and those effects can last for six months or longer, the study authors found.

"Contrary to the belief by some parents and coaches that children can play through a concussion because their brains are more resilient, we find that children are more vulnerable to the effects of a brain injury than adults," said lead researcher Dave Ellemberg, a neuropsychologist at the University of Montreal.

And, teenagers suffer greater symptoms than either children or adults, he added.

"It's not that surprising," Ellemberg noted. "We know the adolescent's brain, more specifically the areas affected by the concussion, the frontal lobe areas of the brain, are growing in spurts and when something is developing rapidly it is even more fragile to injury."

The report was published Feb. 28 in the journal Brain Injury.

To come to its conclusions, Ellemberg's team worked with 96 male athletes who had suffered a concussion three to nine months before testing. The athletes were divided into three groups: adults (30), kids aged 9 to 12 (32) and teens aged 13 to 16 (34). These athletes were then compared with similar people who had not had a concussion.

All of the study participants were given neuropsychological tests used by the U.S. National Hockey League. The researchers then compared the results of those tests with the results of electrophysical evaluations that measured working memory, attention and inhibition while participants worked on a computer. Electrophysical tests are considered more sensitive than neuropsychological screens, the study authors noted.

The researchers found all the athletes who suffered concussions had results on their electrophysical evaluations that indicated injurious effects, compared with similar people who had not had a concussion.

Among teens, there were also problems with short-term working memory that lasted six months to a year, they noted.

"We find that most concussions are similarly severe, whether or not there is loss of consciousness," Ellemberg said.

Immediate symptoms after an injury are not a way to know how a child is doing, he said. "You, typically, have to wait for a couple of days, or even weeks, after the injury to see the symptoms," Ellemberg explained. "Concussions are severe, and do have consequences. We need to have a systematic system to evaluate these children."

After a suspected concussion, the child or teen should be seen by a medical professional who can assess the patient and make a plan for when the child can go back to playing, he said.

"We can't be afraid to have our kids play sports. We know that it's good for the child's physical health and mental health," Ellemberg stressed. "So, we want to encourage sports, but we want to make sure that we do it in a safe way."

Teams need to have an adult trained in what to do if a child has a concussion. In addition, an effort should be made to eliminate violence and situations that can lead to concussions, Ellemberg added.

Commenting on the study, Gillian Hotz, director of the concussion program at the University of Miami Miller School of Medicine, said that "kids have developing brains, so issues may not show up until a year later when they are stressed to do more frontal lobe activities."

Concussions are preventable, she said, and there needs to be education about concussion directed to parents, coaches and children. "Of course, wearing helmets properly is important," Hotz noted, adding that more communities are taking a proactive approach to dealing with concussions.

For example, high school athletes in Miami are given tests of mental functioning before they can play. These give professionals a baseline with which to compare their symptoms after a concussion to see if there are changes, she explained.

These and other measure can make a difference in identifying and treating concussions, Hotz said.

Read more: http://www.nlm.nih.gov/medlineplus/news/fullstory_122391.html

Computerized Tests For Concussions May Be Unreliable

Concussion testing is a neuropsychological test. Schools are collecting this data on children at baseline often using non-standard methods.  I have been advocating using post-concussive testing as one component of an expert medical examination. The results must be interpreted in light of the individuals neurologic examination.  Are you going to trust your child's brain to a computer program alone?  JR

Schools worried about concussions increasingly use computerized tests to tell if a student athlete has a brain injury. But new research says those tests aren't reliable enough to diagnose concussion, or to tell if it's safe to return to play.

The researchers looked at research on one computerized neuropsychologist test, called ImPACT, that is widely used by colleges and high schools. (Here's one NPR story on how high schools use ImPACT to assess concussions.)

It's also used by the National Football League and National Hockey League.

But very few studies have been done on the reliability of these tests in real-world situations.

So Lester Mayers, a sports medicine doctor at Pace University in Pleasantville, N.Y., and Tom Redick, an assistant professor of psychology at Indiana University-Purdue University in Columbus, Ind., surveyed the data. They weren't happy with what they found. They say computerized tests aren't reliable enough to serve as the sole measure of brain health.

"I'm not suggesting abandoning the whole practice," Redick told Shots. "But I do think that we want to be sure we're not using something just because it's popular." Theirwork is published in the current Journal of Clinical and Experimental Neuropsychology.

One issue with the computerized testing is the length of time that passes from when a healthy athlete takes a baseline test, and when they're tested after a suspected concussion.

After a few weeks, the test becomes increasingly unreliable, the review found. That's an issue because the manufacturers recommend testing athletes twice in high school, and once in college. "This increases the likelihood that a true cognitive impairment will be missed," the authors write.

Another issue is how reliable the tests are in determining when it's safe for an athlete to return to play without risking further brain damage. Just three studies looked at that. Those studies were very small, and the results inconsistent, the authors report. They write:

"We therefore question the rationale of using ImPACT for clinical management of sport-related concussion and specifically for determining the time of return to play."

There is no gold standard for figuring out when an athlete is safe to return to play, Redick says, which makes it hard for coaches, parents, and athletes to know what to do. But computerized testing is not the solution to that problem.

The U.S. military has invested millions into computerized testing service members for traumatic brain injury, but that program has been a debacle, according to aninvestigative report last November by NPR and ProPublica. Researchers say the computerized test used, called ANAM, isn't robust enough to screen for problems that could continue weeks or months after a brain injury.

Last August, the American Academy of Pediatrics said that parents shouldn't let children box, urging parents to recommend sports "that do not encourage intentional head injuries."

More here

Some NFL players still willing to hide concussions

Ask Jacksonville Jaguars running back Maurice Jones-Drew whether he would try to play through a concussion or yank himself from a game, and he'll provide a straightforward answer.

"Hide it," the NFL rushing leader said.

"The bottom line is: You have to be able to put food on the table. No one's going to sign or want a guy who can't stay healthy. I know there will be a day when I'm going to have trouble walking. I realize that," Jones-Drew said. "But this is what I signed up for. Injuries are part of the game. If you don't want to get hit, then you shouldn't be playing."

In a series of interviews about head injuries with The Associated Press over the last two weeks, 23 of 44 NFL players — slightly more than half — said they would try to conceal a possible concussion rather than pull themselves out of a game. Some acknowledged they already have. Players also said they should be better protected from their own instincts: More than two-thirds of the group the AP talked to wants independent neurologists on sidelines during games.

The AP spoke to a cross-section of players — at least one from each of the 32 NFL teams — to gauge whether concussion safety and attitudes about head injuries have changed in the past two years of close attention devoted to the issue. The group included 33 starters and 11 reserves; 25 players on offense and 19 on defense; all have played at least three seasons in the NFL.

The players tended to indicate they are more aware of the possible long-term effects of jarring hits to their heads than they once were. In a sign of the sort of progress the league wants, five players said that while they would have tried to conceal a concussion during a game in 2009, now they would seek help.

"You look at some of the cases where you see some of the retired players and the issues that they're having now, even with some of the guys who've passed and had their brains examined — you see what their brains look like now," said Washington Redskinslinebacker London Fletcher, the NFL's leading tackler. "That does play a part in how I think now about it."

Read more: http://www.usatoday.com/sports/football/nfl/story/2011-12-26/concussions-players-hide/52231024/1

NFL steps up concussion detection

There will always be Colby Armstrongs – players who hide concussions or other injuries from club medical staff in order to keep playing or out of fear of losing their job.

But what happens when trainers and team physicians paid by professional clubs err in detecting concussions? When they let down their guard or vigilance is impaired because they’re attending to other tasks? The NFL isn’t taking any chances. Not any more.

Chris Mortenson of ESPN reported Wednesday morning that effective this week, an independently-certified trainer will be assigned to monitor all suspected concussion-related injuries at every NFL game.

The decision was made after the Cleveland Browns failed to test quarterback Colt McCoy for a concussion after an illegal helmet to facemask hit by Pittsburgh Steelers linebacker James Harrison in a nationally-televised game on Dec. 8. The Browns president, Mike Holmgren, claimed they did not test McCoy, who went back into the game after two plays, because trainers did not see the hit and because they were attending to other injured players.

McCoy, one of 11 Browns players to have sustained concussions this season. has not been cleared to return to the practice.

The NFL, and particularly commissioner Roger Goodell, deserves credit for seizing this opportunity. Goodell sent a medical team last week to meet with the Browns and chaired a four-hour conference call that involved the team and representative of the NFL Players Association. The NFLPA may still file a grievance on McCoy’s part, Mortenson reports.

This does not mean that we are seeing a move towards eliminating one of the biggest and longest-running conflicts of interest in professional sports: the role of trainers and physicians paid by the club. But maybe it is the next step.

Read more: http://www.theglobeandmail.com/sports/football/nfl-steps-up-concussion-detection/article2279052/