Dr. William Meehan - Concussion Updates 2017

you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you Right, so when I accepted to give the talk all that was true, I actually resigned from the football player's study a couple of weeks ago, so just to clarify and I get embarrassed by the long introduction. These are my disclosures. I don't really have anything much. I wrote a few books just to give you an idea. I got $34.20 for one of them last year, so I don't think it influences me much. When I do get some funding from the NHL Alumni Association, it's a former NHL player who's put on a little tournament, not just for my research, but for all brain injury research here at Boston Children. I'm not going to say anything for the next few minutes. I just want you to read this abstract and then look off when you're done. Right, so it looks like probably half the room or more has finished reading it. So somebody brave, just yell out the upshot of this thing, just in general terms, not even medical terms. What does it say basically? Learn to swim, okay, but why? Football is bad for your brain. Why is it bad? What does it say about the brain? It's smaller, right? Parts of the brain are smaller, right? And why would that be? Repetitive impacts. Okay, so trauma from football is bad for the brain makes the brain smaller. Okay, I'm going to move on from this, but we're going to come back to that later. So the talk is about concussion. I apologize if you've heard me give a talk before, but I'm going to go through the definition of concussion. Some of the biomechanics, some of the pathophysiology, and then we'll move on to some of the stuff you want. This is the international definition of concussion, the international consensus on concussion in sports. It's more like a list of characteristics, and so I'm going to go through them in a second, but I think for most clinicians, a working definition, something to think about it that actually contains all of what it is, is simply trauma-induced brain dysfunction. That's all it is. It is temporary dysfunction of the brain secondary to trauma. However, since it's an academic talk, I'll give you the international consensus definition. So number one, they say it is caused by trauma. We'll see in a few minutes the signs and symptoms of concussion are non-specific. And so really, you want a clear history of trauma triggering it to make the diagnosis. Number two, again, we'll see in a minute, it's not the trauma itself. It's a rapid rotational acceleration of the brain after impact that causes trauma. And because it's rotational acceleration that does it, you can get a concussion without trauma directly to the head. It could be trauma that transmits an impulse to the brain that spins it. And the classic example of this is outside of sports, but if you were in a car and you had a shoulder belt and a lap belt on and your car is going to wicket-fast and hits a wall or something stationary, your body starts to accelerate forward. It's restrained by the seat belt, but your head will spin forward and you can get a concussion that way. But most of the time in life and in sports, it's trauma to the head. The signs and symptoms of concussion, the pathophysiology, start immediately, right at the moment of impact, and they go away on their own over time. I mean, the best part of being a doctor that specializes in concussion is that even if the patient never saw you, they will get better. There's stuff you can do to sort of speed it up, but it goes away by itself. And lastly, it's a functional problem as opposed to a gross structural injury. There's no bruising or bleeding or cells dying or any gross structural problem. It's really a functional problem and we'll go through that in a minute. Now, it is due to a rotational acceleration of the brain. How we know that, to me, sort of how it laid out in time is fascinating. So I'm going to go through a little more than you used to and I apologize already if you've heard this before. But it turned out that outside of medicine, 120, 150 years ago, men working in slaughter houses knew that it was acceleration of the brain that led to concussion. This is not a pleasant thing to talk about, but it's reality. I apologize to vegetarians. It's really just to make the point of how we learned this. But 150 years ago, if you worked in a slaughterhouse, it was thought to be inhumane to walk up to an animal and sort of sacrifice it. Most of you know it was alive at one point and then somebody sacrificed it sort of wrapped it in plastic. That's how it ends up at the soup market. And it was inhumane. It started to be inhumane, just walk up and do that. And so they would stun the animal. They would concuss it first, ideally not get unconscious so that it wasn't aware of what was going on. And the way they did it was a large metal bolt would come down from the top of the ceiling and strike the animal in the head. And you held it in a little bit of a cage. And these men, 120 years ago, working in slaughterhouses noticed that if you held the head still, if your metal cage had a contraption that held the head directly under that bolt, when the bolt came down to hit the animal, you would last or ate the scalp, fracture the skull, you would get intracranial hematomas. But the animal would not be somalents or off balance or unconscious or days or any of the things we think of as concussion. If, however, you immobilized it at the torso so that the head was free to move after the impact. Often you got frank unconsciousness and when you didn't, you got somalents and imbalance you could go about your work of the day. And so it was widely known throughout the country. I mean, it's traveled east coast to west coast. That if you want to concuss an animal, you got to leave the head free to move. Now, concussion at the time was thought to be a trivial injury. And so physicians and scientists were not thinking about it at all. But around the 1940s, two things happened. One, a physiologist did a thought experiment. You used to be able to just sort of think of things and write them up and you get published in a Lancet. This was what Einstein did. He just sort of figured it out. If you're on a train, you got a flashlight in the mirror or whatever. And so this physicist named Holburn did a thought experiment. He said, look, the brain consists mostly of water. And therefore, I suspect its physical properties are similar to water. And if I took a flask of water and I put it on a table and put some cotton wool on top of it so you could see how it moved and I applied a purely linear acceleration, the glass beaker, the glass would start moving sliding along the surface. The water would then kind of go up against the edge of the glass and start coming with it. And then when the glass stopped, the water would slosh up to the front and then slosh up to the back and up to the front and ultimately you would get wave forms. And the cotton you put on top of it would bob up and down with the wave forms. And when it stopped, the relative relationship of the cotton would be about the same as where it started. It just kind of bobbed up and down. But if I took that flask and spun it, the glass beaker would start to spin. The water molecule is closest to the edge, would start to spin wicked fast. If you could identify one water molecule right in the center, it would spin on its axis and wouldn't move it all. And the cotton floating on top, the organization would be totally disrupted. And so he said, I bet you spinning the brain would be worse than applying a purely linear acceleration. And he made a wax model of a skull with a gelatin model of a brain and spun it. Cracked open the wax, took the brain out and had these lines of cleavage in it, this shearing injury in the brain. And he was the first to describe shearing injury, although at the time, totally theoretical. And people said, look, that's nice, jelly inside of wax, but the human brain is very complicated. And so people started studying it in the lab. And Denny Brown and Russell did an experiment where they struck laboratory animals in the head with a weight that was at the end of a pendulum, sort of came down and hit them, anesthetized. And if you held the head still, same thing is with the slaughterhouse. You'd last rate the scalp, fracture the skull, got hematomas, but no perceptible signs of concussion. If the brain is free to move after impact, you produced symptoms and signs of concussion. Still, people debated it. But really, the question was answered in 1974. Is linear acceleration or rotational acceleration worse for the brain? Omaean generally took squirrel monkeys. There's no trauma to the monkeys. But separated them into two groups of 12. All of them were wearing a helmet that was attached to a piston. In one group of 12, you hit about and then boom, the piston just moved the head forward one inch. And the other group you hit about and it rotated the head over an arc of one inch. Same distance traveled, same amount of force being used. But in one group, you got a purely linear acceleration and the other a purely rotational acceleration. Of the 12 monkeys that had a purely linear acceleration ahead of one inch, there was no perceptible signs of concussion. Of the 12 that had their head rotated over an arc of one inch, they were all immediately knocked unconscious. Without trauma to the brain. So Omaean generally said, look, a, it is acceleration alone, even without direct trauma, that results in concussion, and b, it's rotational acceleration, not linear, that causes the problem. Now in life, you get hit in the face, you usually get both. You get a rotational and a linear acceleration, but it's the rotational that causes the problem. And if you're going to try to prevent it, that's important. That's why I spend a lot of time on it. Okay. So why would spinning the brain hurt at all? And for this group, I feel like almost this is a little bit too simple, but I'm just going to show you as a way of conceptualizing why spinning the brain would be a problem. This is my depiction of a neuron. It's not meant to be accurate, but I'm just trying to say there's a cell body, an axon, an internal end, and then it's resting state. Flodium is the fluid surrounding the cell. Patassium is on the inside. And when it's time for the neuron to do something, for any nerve cells do something, it does, it asks by conducting an action potential. And the way the action potential works is that sodium channels embedded within the axonal membrane causes the cell body open. And when they open sodium rushes in down its concentration gradient, and once it's inside the axon, it triggers downstream sodium potassium channels to open, and then it triggers downstream ones to open all the way to the end of the cell. And when sodium rushes into the terminal end, it spits out a chemical, GABA or acetyl coolee, and that either inhibits the next nerve cell from firing or it causes the next nerve cell to conduct an action potential all the way down the spinal cord to my arm, it says points at the screen, and that's how it works, right? If you spin the brain fast enough and you deliver it that sheer strain that that over and thought about, high-positide, it must have opened the sodium potassium channel, sodium rushes in, because they're open, going down its concentration gradient. And once it does, it triggers the full action potential, regardless of whether or not that nerve cell was meant to do something. And more than that, in normal physiology, it's very tiny, micro-molecular amounts that are going back and forth. But if you apply enough sheer strain, it forms the channel and leaves it open longer than it's open in normal physiology, and so relatively massive amounts of sodium rushes into the cell. Normally, after you fire an action potential, the sodium potassium pump, pump, sodium back out. But the system is set up to these tiny micro-molecular amounts, and so when you allow it relatively massive amounts in, it takes a while to pump all that sodium back out, and as soon you do, just the neuron can't fire another action because you have to restore homeostasis before it can work again. And that delay results in dysfunction of the neurons in the brain, and that's what can be a question of. Functional problem is opposed to structural. There's loads of other stuff that goes on. I have to have given this talk probably 50 times, and every time I say, if you were interested in the rest of it, come up after and nobody ever has. So I'm just going to move past that, OK? But I'm simplifying it just to give you a way to sort of think about it, especially if you don't do this all the time. So what do you do? I mean, I'm thinking of myself. If I was a surgeon and an anesthesiologist, I'm in this room. What do I really want to know? Truthfully, I want to know this. I kid plays hockey. Everybody knows I'm a doctor. I show up at a game. Somebody goes down and I'll look at me to do something. So I would say, let's go through that first, OK? Because I expect you're not seeing a ton of it in clinic. So if that occurs to you, I would say, even though everybody's all stressed out about concussion because of the news, as a doctor, a kid goes down on the ice or on the field or wherever they are, if they have a concussion, so what? To fix that tomorrow in the office. Better yet, you can send them to somebody else to fix it tomorrow. And you have to send them to me, right? I'm happy to do it. But I would say, don't worry about that, quite frankly. Worry about everything else, like you always would, right? Are they conscious? Are they away? Is their airway open? Are they breathing? Are they going to be happy? Like start with all the regular stuff. And then, if you rule out all that stuff, bring them off to the sideline. You can sort of think about concussion and all that. Now, the history, so everything in medicine, everything. We always say it's the start with the history. The history is 85% of making your diagnosis, etc. And I do believe that's true. But it is more true for concussion than anything else that I do anyway. It's probably for most of us, right? If you're at that hockey game and somebody comes down and they speak, I don't know. So I hear Lee, but they got a humongous team at home with their hold and they're, I'm going to point at it. I don't know that I need a whole lot more, right? I said, I'm going to get an extra action figure out what's going on. Concussion's not like that in the slightest. We'll see in a minute. The signs of symptoms totally non-specific. So what you really want to hear on the history is I felt fine. I was coming over the blue line. I had to puck. I lost control of things. I looked down to regain it. And some big dude from Boston College, I'm hammering me. And I got a ton of symptoms. Headaches, dizzyness, nausea, I felt horrible. I came off my puke. And now I feel a lot better, but I'm still not 100%. That is the classic history for concussion. You don't always get it. But if you don't get it, you ought to think that there'd be something else going. I wouldn't automatically attribute the symptoms to concussion because it really is that classic most of the time. Your physical examination should focus on a screening neurological exam, which will just be normal for most people. I mean, the truth of the matter is we have things that we look for that can cause it's sort of particularly sensitive to concussion. But if you're not doing those specific things, some of which I'll talk about, it'll just be normal. And if it's not, you ought to think there's some other injury going on. You ought to send them to somebody who can figure that out. And lastly, I put imaging in parentheses because it does play a key role in people who don't have a classic history or the classic physical. But if you do an MRI or CT or whatever, you're just going to be normal. And so I would say if it's classic history, classic physical examination, overall reassuring story, I just wouldn't bother with the imaging. But if you do, and they have a concussion, it should just be normal. Now, maybe you can see some abnormalities on special types of imaging, but not the standard kind that you're going to get clinically. Okay. These are the signs of symptoms of concussion. I don't know. I mean, I look at that list, I'd say that could also be signs of symptoms of depression, dehydration, viral illness, hangover. I mean, you get, well, not so much loss of consciousness, but I got a headache. I'm having trouble constrain. I don't feel so good. I'm kind of sad. I'm drowsy, right? I just don't know. And that's why the history is so key. If you were playing a sport, you got hit and head and all this started. That's concussion. If not, if it's, I play basketball. And lately I've been having headaches and I don't feel so good. I don't know. Maybe your girlfriend dumped you. Maybe your on drugs. Maybe a dehydrated. I just don't know. And I'm not trying to be facetious. People think that, no, the first thing people think of when they're having issues now is concussion because on the way into work or listening on the radio and they hear some story about it. And so you really want to try to get at, is there a history of trauma, the trigger of it? And there are three main broad categories of tools that we use to try and help make the diagnosis and also monitor recovery of concussion. I'm going to go through them briefly. They're easy. They're free online. If you really want to do a lot of this in your clinic, but I expect most of you don't, so I'm just going to go through it. They're a symptom scale. So it happens with athletes. They get injured. This is classic. Let's skip the head for a second. Let's talk about the shoulder. They get injured. They come off. What happened? I got thrown up against the boards. I got pain in my shoulder. Somebody looks at it. There's no bruising. There's no deformity. It looks okay. Touch it hurt. Yeah, hurts a little. Okay. Sit down for a minute. Five minutes later. How do you feel? I feel good, coach. Can you play? Yep. Great. We put you back in. Right? That's reasonable. You got some sort of stable injury. Apparently you go ahead and try it. So when you ask an athlete, do you feel better? Or do you feel okay? Most of the time, they think you're asking, do you feel good enough to play? They play through pain all the time. And so if you don't ask about specific symptoms, and do you have it at all and what degree, you just get that, yeah, I feel better. I'm ready to go. It was the kind of answer. And so this was meant to sort of decipher out, are they having specific symptoms of cucutin or not? More than that, we use it in our clinic. So just like everybody at Children's, the simple thing gets taken care of somewhere else. And then there's five weeks out and they're not feeling better than they get sent in. And so we use it really to monitor recovery. If you add up all your stores, or you add up all the certifications, I got a one for this product that I have to remember. And you add it up in total 68. And you bring them back three weeks later, and it's 37, you say, look, you're getting better. Your simple score went down by a pretty significant amount. But they might not notice it if they live with themselves. I'm trying to think. Dr. Mooney's here. So when I was a resident, I was about 190 pounds, pure muscle at the time, okay? Now I'm like 230. Now I live with myself every day as does my wife. So I like to think that maybe she doesn't notice, because it was probably a couple of ounces every few weeks. But there's a guy named Enzo Maniace, did an ER fellowship here when I was doing my ER fellowship. And I was probably 195 then. And I saw him at a meeting two years ago, and he said, man, you got fat, right? First thing he said to me, because of course, last time he saw me, so when the time went by, I'm living myself, I know I'm a little bit bigger. I had a nice new pants, but it's dramatic to him because he hasn't seen it. So athletes the same way, if they're getting better a little bit every day, they just don't notice it. But if they disappear for a couple of weeks, come back to your clinic to score one way down. I say, look, you don't notice it. I tell them my fat story, and look, you're a lot better. So it's another secondary reason why we use it. You can measure balance, and I'm not gonna go over this at all, except to say, if you have a Neurocom smart balance machine, which Jacob Brodsky and EMT has here in Waltham, and you measure athletes' balance at the start of the season, you put them in a bunch of different positions each together with their eyes closed, and then I'm on one leg, so then I'm on one leg with your eyes closed, right, one foot front, the other with your eyes closed. And you monitor how much they sway. They sway a great deal more after concussion than they do before. And as they get better, as they recover, their balance returns. Now, not every, it's a very expensive machine, not every team's gonna do it, and so they invented a scoring system you can do in the office, and every time they commit an error, like I said, you know I gotta do it, but that's right, so I'm not gonna do that. They put their foot down, they take their hands off their hips, they bend more than certain amount at the waist, they get a point, points are bad. And you can use it as a gross measure of balance. It is a gross measure, but we do it for athletes, particularly athletes, we think might downplay their symptoms. It's not uncommon for athletes to wanna get back in the game, and just say, no, no, I'm fine, I got no symptoms. And so we have tests we do on the sideline to try and decipher that. Lastly, we measure their cognition. This is an ideal scenario, so I'll just go through the scenario, I guess. These are scores of brain function, of memory, of reaction time, of the amount of time it takes you to solve puzzles and problems, of a 12 year old female basketball player we saw in clinic. And her case was ideal, because she had a baseline assessment, performed before the season ever started. So we knew she's high-massive, while she's at risk for getting a finkusher. Let's think what her brain function is like now, so that if she gets one, we have something to compare it to. But why access is percentile, wherever she relates to other 12 year old girls throughout the country. Each bar of a different color represents a component, of course, so the different aspects of her test, put it into identify some area of cognitive function. And then the X-axis is different time points, she took the test. So at baseline, with regards to remembering her reaction time, the amount of time it takes her to figure out problems, she's 85 to 100% how every cat it was, right? So she's 12, but you know, something that should be a print then or wherever you go when you're smart like that, okay? She then got an injury, and when saw her athletic trainer six days later, and did her scores, now I gotta stop for a second, she's only 12, she's in the sixth grade, she's gonna get better fast, you're gonna see the second. But imagine she's not, imagine she's a junior in high school, and I wasn't joking, she is applying the print then, higher-bird, Yale, I don't know, wherever you go, when you're like this, right? And she gets a concussion, and this is what happens to her brain function. And maybe she doesn't get better fast, maybe takes her six weeks, five weeks, say. And it's first semester junior year, and they're gonna look very heavily at those grades. And she goes to her teacher, and she's got a note from somebody says, oh, she's got a concussion, give her a little extra time with her test, and put off big tests, she can make them up when she's better. And the teachers say, some of them, not all, no way, you're fine, I'm looking at you, you look fine, I don't see a cast or a bandage or anything. I saw you with your friend Suzy in the hallway today, and you were laughing hysterically, how bad could you be, and they make her take the test. How do you think she's gonna do? If this is her processing speed normally, she's the girl that turns it in 20 minutes or early walk out, and everybody hates it, right? She might not even finish, right? No matter what teachers say, I think school is memorizing them much as much as fucks fit in the back out. If this is what happens in her memory, even if she's given more time, how's she gonna do? Not great, right? And so now, all of a sudden, she's gotta go BC like me. Could have been Ivy League, now she's local Boston, right? I don't know. So in any case, I don't wanna be overly dramatic about it, but this is what happens to him, and that stress is around, because she's type A, which is why she's up there, doing all her stuff, right? And it's worse than that, because she sees some doctors that say, you can't go back to sports. And it calls all her friends or other girls on the basketball team. And when they talk about stuff, it's on the bus ride, too, in a way, a game or stretching before the game, or whatever it is. They say, oh Tommy, so cute. Are you gonna take him to the Winter Formals? He's just not there. And I don't, I don't, I don't want to work for girls, because then the next day they're at school, and some girls says something, you know, peanut butter, whatever, they all laugh, haha. She wasn't there for whatever makes peanut butter funny, but she tries to fit in so she laughs, and there's always the one mean girl who's like, what are you laughing at? You weren't there, right? So it affects her life, it isolates her socially. Her grades, she's not the person she thought she was. She's not an athlete, she's not smart anymore, and then her friends, she's just sort of alienated from her friends. So you have to treat all that stuff, otherwise she's not gonna get better. That's the point I'm trying to make, right? You can get, you can imagine if that happens to you, all of a sudden you're depressed, you got low energy, you got to hit it, all that too. So you got to treat all that too. Now, I don't want to be over with dramatic. So this girl came to see us 16 days after injury. And I remember it's the same thing, her mother said, look, I almost canceled the appointment. She's fine. Her head, her symptoms have gone away entirely. She started to make up her schoolwork. Last night she was on the driveway student who she felt totally fine, I think we're good. And I was like, this is awesome. The easiest thing I do all day. Let's repeat your test and clear it to go back to sports, right? And these are her scores now. Definitely better than they were, but not quite in her baseline yet. And that happens about 20% to 30% of athletes depending on what study you look at. Their symptoms go away, but their brain function is not 100% back to normal. So instead, I mean, this is one of the reasons we get the test. Instead, we say, I'll tell you what, make up all your schoolwork, go back to school, of course. Start doing the non-contact parts of basketball, dribble, shoot, do the play walkthroughs, but avoid doing two on two or three. If something were some of the girls in your face that avoid scrimmaging and play, and come back in a week, then we'll see how you're doing. And she came back in a week, those were her scores, we cleared her back to sports, never heard from her again, usually that's good news. So that's why we get the test. One, to show the dysmuntry and the brain, and hopefully say to the school, look, you gotta get some a little break here, extra time for their assignment, they could push off a major test, the test from Mark Prior, the great seven-sake people, and they're better. And two, to know when their symptoms are gone, are they totally recovered? Okay. Now, this is the best part. How do you manage concussion? Actually, it's quite easy. You put them at rest for a few days. There's two types of rest. There's physical rest. Most athletes get that. I shouldn't be running and lifting weights and sort of doing the stuff I do for my sport. But also, especially the first couple days after injury, if you were to do a lot of studying or video game playing or other things that demand concentration and focus and memory, it'll make your symptoms worse. So we also put them at cognitive rest. Last time I gave that this talk, the international recommendation would you do physical rest and cognitive rest until their symptoms are gone? Now, the recommendation is really 48 hours. We do sort of three to five days, but the recommendation is 48 hours. And after that, they start getting back to cognitive activity and back to exercise. I'll just give you the quick version. There's several reasons for it. Number one, athletes don't always do what you tell them. And so there was about nine papers that were cited as reasons for changing this. Five of them were published here at Boston Children's. The general idea was athletes don't always do what you say. So we just asked them when they came back, were you exercising, were you doing cognitive activity and they rated on the scale, how much they were doing. And it turns out the folks that were doing some got better than faster than the folks that weren't. Finally, and Wisconsin, the guy named Danny Thomas, just randomized people, rest until you're better or two days of rest and gradually get back to activity. And the people over here who did two days of rest and got back to activity got better faster. And then lastly, Grant Iverson over at MGH did this review of the literature and it turns out when you take somebody who's used to exercising regularly and you stop and he didn't look at, because you look at ACL tears and fractures and stuff like that. You used to exercising regularly and you stop, you get headaches, dizziness, low energy and sleep. Sleep disturbance, not everybody, but at a higher rate. And the thought, in this part I don't know, but this is what we're looking at, is that you disrupt the regulation of cerebral blood flow. And we did a study of 13 patients here and in that setting they had a disruption of regular cerebral blood flow regulation. We allowed them to exercise. It restored their cerebral blood flow regulation or something's one way around the same time. So I think that's probably it, if I would say I don't know for sure. But either way, the recommendations are to do that. Now, getting them back to exercise, still non-contact. So if you were a basketball player, I should stop. Sports have three broad categories, collision, which is football, men's ice hockey, rugby for both genders, lacrosse for men, things where you could purposely smash in to another guy or tackle them. There are contact sports where you can't do that, but you're gonna bump into each other as sort of playing it. And that would be soccer, basketball, women's ice hockey, women's lacrosse, things like that. And then there's non-contact, non-collision, tennis, cross country, swimming, things where incidental contact is even a non-issue. So you can't let them do contact even, certainly not collision, but also not contact. So even for basketball, soccer, and stuff, they can't scrimmage or do two on twos or something like that. But they could start dribbling, running, sprinting, working on their free throw, whatever else they got going on. Once they are symptom free or even now, before they're symptom free, you can start this return to play. It used to be if you sprained your ankle and you said you felt better rather than put you in a game, people would say, one of you run up and down on the sidelines a little bit. How does it feel? It's good. OK, why don't you cut side to side now? How does it feel? It's OK. Great. Give me a ball. OK, here it is. Try to get by me, right? And then it's OK. The ankle seems pretty good. But if you had a concussion, we would just say, how do you feel? Good. Great. Put you right back in. So finally, somebody said, look, why don't we do the same thing? We do for every other injury. Sort of test it out. And there are stages you go through before you get clear to go back to everything. And these are the stages. Fine. Now I got to say, looking in the room, I don't know, half of you or so, if there are some hard to or my age or older. OK. And if you are, you have to have asked yourself, at some point in the last five years, why do we care? I mean, truthfully, nobody cared about concussion at all during the 1980s and 90s. You'd be watching a game and some guy would get a clear concussion. And the announcer would be like, you know, McTavish is just shucking up on the play. And he'd be in the next line change. He's just nobody did anything about it whatsoever. And if you got a concussion, if you were lucky, it was dramatic and they moved you out of the game. Some guy would come over, some father volunteering at the game, he'd say, how many fingers am I holding up to? Who's the president, you know? And it didn't really. You say Abraham Lincoln. And they'd be like, and then a few minutes later, how you feel? I feel good. Put your back in the game, right? And now, people want to end sports, right? Well, what happened? Why all of a sudden, we talk about ending soccer because we head to ball or football because it's tackling. So there's just a couple of main reasons. Number one, if you get a concussion in sports, you're a risk of getting another sport related concussion is higher than the players on the field who never got one. Now, still, if it's a trivial injury, who cares if you're a risk in higher? So there must be more. And the fact is, concussions are cumulative. Every time you get one, it leaves some effect on the brain that never goes away. That effect is wicked small. So much so that is researchers, if we have athletes usually who've had two or three concussions, can't find any difference between them and people who haven't had any. But we know it's there because if they go on to get another one, they're more likely to lose consciousness. They're symptoms last longer. They're symptoms are a little more severe than the guys just having as first. And the third is called second impact syndrome. I'm not going to get into it too much, but if you sustain a concussion and you are incompletely recovered and you go back to sports and sustain another blow to the head, often something that looks trivial. Typically, we wouldn't expect to cause any problems at all. You are at increased risk of massive cerebral edema, herniation and death. It's rare, but it happens a handful of times every year around the country and almost every year in Massachusetts, usually during football season. And you just don't want that to happen. So it's another reason why we take them seriously, we try to monitor them better. And last, which gets all the attention, so I'm going to focus on a little bit is what's called chronic traumatic encephalopathy. I'll go through the pathology of them. And a chronic traumatic encephalopathy is defined as an abnormal form of a normal brain protein called tau, as well as some secondary features. In certain parts of the brain, perivascular distribution, depths of the cell size, it is believed that it is either due to repeated concussions, sustained during sports or army service, or something else where you get a lot of trauma. But lately, people have said, oh, you don't even need to have a concussion, it's just sub-concussion trauma. It's just increased my risk. So we'll go through a little bit of the data. But that's what's led to, geez, maybe we should just fan sports altogether. The pathology, I'm going to skip for a second, because I thought I had loads of time. I'm running a little bit short. This is what, but I'm going to focus on this because this is what I bet most of you have heard about CTE. First of all, it's common in football. 90% of this time, 90% of NFL players have it. It causes aggressive behavior. The results in suicide. I mean, that one for sure, Massachusetts, I think everybody has heard that. And as a result, football is dangerous. We ought to ban it. We shouldn't let kids play it. Maybe we shouldn't ban it. Just every sport, rugby and lacrosse, I talk, you football, soccer, all of it, because you can hit your head. So let's ban them all. And that's gain and traction now. That's gain and traction. And you have been influenced by this. And so by, I mean, it's impossible not to be because every time you listen to the news, or the radio paper, every day at least, there's something about it. OK. How do I know you've been influenced? Because this is the abstract that I showed you at the beginning of the talk. And I replaced the word ballet dancer with football player. And I replaced the word non-dancer with swimmer. And I did this too, so I'm not picking on you. But we all made three assumptions. One, any difference between football player and a swimmer has to be due to trauma, and it has to be bad for the brain. Is there anybody in this room who thinks that ballet dancers have smaller volume and certain areas of the brain due to repeated trauma? Is there anybody who's so sure that it's bad for the brain to do ballet? Anybody wants to ban ballet? No, right? Not for this reason, anyway. Now, I picked that abstract because of the striking difference between a football player and ballet dancer. But truthfully, I could have done bad knit and players. I could have done long distance runners. There's loads of studies out there that you never heard of because they don't make the news that show a difference in the brain between some athlete who's in a non-contact non-collegiate sports and some of those are not an athlete. But when it's football, it's all over the news. And we assume it's bad. It's bad for the brain, it's due to trauma, and maybe we ought to ban it, right? Now, there is no benefit to athletes or to sports to have repeated trauma to the brain. That's not what I'm saying. I'm just saying as scientists and physicians, we got to look at the truth and the data and try our best not to be influenced by what we hear in the media and so far. We're doing a four job of it. This is what the medical literature says, by the way. It is unlikely that concussion is a risk factor for neurodegenerative disease. And if it is a risk factor, it likely has a trivial effect that is offset by the increase in lifespan. Number two, the association between this abnormal form of the protein town and clinical signs and symptoms is unclear, and I would just say unestablished, no idea. Number three, suicide among former NFL players has a lower incidence than it does among age-matched men in the general population. God forbid I knocked myself off today. Nobody would hear, is that maybe you, my wife, or your people. But if I were a former football player, the whole country would know about it and potentially most of the world, right? Now this might change, by the way. Now that we have them convinced that they have a neurodegenerative disease about which they can do nothing, I have to believe that if a very weak that has impact their quality of life negatively, it's not leading to despair and potentially suicide, which is why I think there's a downside to all this media craze and we ought to sort it out in the literature first before we go putting it out there. I'm not going to believe at the point, I think you get it. So what do we really know about it? So the 90% of you sometimes magazine comes from this. So far, my colleague at BU had seen 100, this should be, sorry, this should be like 101, at 100, 100, 100 months. But they have seen 101 brains, the former NFL player, the 100-rowman had CTE, so almost all of them, right? There has been about 24,000 men who played the National Football League over the years, and so far we know 101 of them have CTE. So I would say really, the prevalence of it is somewhere between 99 and 100, 0.5%. Now I think it is unlikely that all the rest of them would stay negative, of course, not about saying that. At the same time, I know that the brains that haven't seen suffer from a selection bias. This is not as default to the investigative, they call every single person they hear about and ask the family to donate the brain. But if your loved one played in the NFL, and went on to own his own company and had a slew of grandchildren, I had this wonderful life, and they call and say, hey, we want to sacrifice the brain and chop it up and look for St. Godby, you say, look, I'm burying my, could you back off please? I'm burying my loved one. I don't want any part of this work fine. If your loved one went on to have a horrible life and couldn't get a good job, and was miserable, and had multiple divorces, and was the views and preferences of the homeless, you say, yeah, Sam, right, I think it's come to football, and I want you to show it and you donate your brain. And so there's clearly gonna be a selection bias there. Still, there was no benefits. So the sport of football or ice hockey, soccer, a repeated trauma to the brain, that's how I'm saying. I'm just saying before we convince all these men that they are doomed and there's nothing they could do about it, not at least now, but they're an increased risk of something. Now, a pathologist in Canada said, look, if you only stay in football players, you're gonna think it's something to do with football. So let me stain, everybody just shows up at the morgue in Manitoba, Canada. Men, women, athletes, non-athletes, guys who serve in the military, people who are school teachers, everybody, just whoever shows up. And 35% of them had hyper-phosphorylated towel with the depths of the cell sign, a perivascular distribution. One out of three people. And they weren't people who had dimension, had some of them probably did, but they were just people who showed up in the morgue under the age of 65. It's normal to develop hyper-phosphorylated towel later in life so that they were younger people. If they had a history of head trauma, the risk was higher. Of course, went from 35% to 48%. If they had no history of head trauma, but a history of substance abuse, and they included alcohol in that definition, the risk was 42%. If you took away people had a history of head trauma, and people had a history of substance abuse, still 20% of them, and that criteria for the diagnosis of CTE. And there was no selection bias, because it wasn't people whose families were concerned about them and who had major issues. I bet you, have they still left it for people like that? When I'm higher than 35%? Still, there's no benefit to repeated trauma to the head and sports. It's not what I'm saying. I'm just saying, you have to think about the effects you're having on people when you go out there with this story. So I think campaign to get rid of head trauma sports. Of course, but don't mislead people and think that they have something they can't do anything about when many of them don't. Lastly, there's a cohort study in Wisconsin that was sort of like the Framingham cohort. They clicked on a bunch of data on people starting when they were school children, and they followed them all the way up until I think now they're in their 70s or 80s. But recently, they took a group of almost 4,000 men. 3,905, they were 65 years old, and they separated them in a guy's duplicated football, and guys who were like in the band and did something else that had no trauma to the head. And they said, are there any difference between these guys with regards to dementia, headaches, mild cognitive impairment, depression, substance abuse, blah, blah, blah, blah, they went through the list. And the only difference, significant difference, was that if you played football, you were less likely to suffer from depression at the age of 65 than if you didn't. Okay, now I'm gonna prove to you, I think trauma to the head is bad. I got 13 minutes and I'm on a leave time for questions, so I'm gonna stop in three, eight, somewhere between three and eight. So, this is a math frame that's in section and state and the blue thing that's represented the nucleus of the neuron. Okay, if you deliver a mild traumatic brain injury, one concussion, much more severe than a typical four related concussion. But if you deliver it, you get some pink stain which represents this towel, the abnormal 14 protein, the abnormal form of the protein towel that's used to diagnose CTE. And you get it, it shows up by about 48 hours. By two weeks, it's almost gone, by month it's gone. So, every time you get a concussion, you probably convert from normal towel to bad towel and a week or two, three, four later, it's gone. You clear, your body gets rid of it by itself. If you give a severe injury, 20% of these my thighs, the other 80% are unconscious for like 11 minutes, they cease for the first three or form as a major, major injury. But if you get it, you make towel, you make it abnormal towel, six towel, you make it sooner, back forever, at least six months out. I don't know about the age of that. Mouse life in a lab is about a year and a half if you're lucky in the wild, it's about two to three. So, six months is pretty, there's a lot of life. If you take this injury here and you repeat it, this is a mild thing, because you repeat it, give it to seven times over the course of nine days, make it the lab test, and then on the weekend. You make the towel and it stays, you don't get rid of it, at least out to six months. Okay, what does it mean if you have it? Well, sorry. When you initially do it, you get the time, it's mostly at the surface of the brain. If you're not supposed to use it, look at it in a mouth brain, this is the cortex, this is the cancer. Yeah. You make the abnormal form mostly at the cortex. If you leave the mouth alive for six months, don't hit it anymore, don't do anything. Eventually, it spreads on its own. I don't know how, kind of like a pre-hot, the proteins are spreading on its own, but it spreads on its own. And what does that abnormal form of towel do? It results in the breakdown of microtubules. Forget that, let's have a look at that. This is an axon on the electron microscopy in cross-section. There are microtubules, these gold spots are actually long sort of areas of train tracks that transport proteins one end to the self-tune other, and they're distinct and beautiful again on this slide. If you deliver trauma, or even if you take cist-pow, the abnormal form of towel, and put it in a mic that has never had trauma, you break down those microtubules. You saw a few good ones, but all this diffused gray are microtubules that have broken down. So cist-pow is induced by trauma, and it's toxic for the brain. And it changes your behavior. This is something called the elevated plus-haze. Mice, in general, don't let me get out of the open. Evolutionarily, you're probably over, you can eat mine out or something, right? But they stick to enclosed areas where they feel hidden. If I took this and oriented it this way, this is the closed eye of the wall, this is out in the open. And normal shamise just stick in the closed bottom. Every time you get a reddle, you'll get a little bit, but mostly even he's in the closed bottom. Okay? If you injure them, and you get them in some inert substance, they start walking out, they're wicked bold, right? They're walking out in the open arm off. So you, they've lost their natural ability to hide inhibition. We got increased risk taking behaviors, what we really call it. Okay. Ping Lou is a scientist at the best as your Elegum of Medical Center who was studying an anti-touch antibody for Alzheimer's disease. And Rebecca Mannix, who's my partner in the lab, and an ER physician here and a genius, said, hey, man, this thing might be good for trauma when we should walk over there, ask him the viral list. And he gave it to him. And we injured these mice and we gave them the antibody. And when we gave it to him, they protect their microtubules. It's not perfect like it was, but it's a lot better than here. And let's hit this, but let neurons go on to die when you protect microtubules. I think most people get that. But more than that, you change their behaviors and you give them the antibody and they're not perfectly same. But boy, they wander around the open on a lot less than when you injured them and when you didn't do it. Now we've expanded. There's a lot more changes in behavior, but I'm getting close to my three to eight-minute mark here. So I'm just gonna say, this is the theory we're working on, okay? It bostons childrens in the BI. If you get a key question in sport, probably, you make this towel and you clear it and you're fine. If you get them repeatedly, at a high enough intensity, remember much more so in these mice and in sport, they're the question. And in a close enough time interval basically every day, then you don't close it clear. You start to clear home, do you get another injury, or do you get another, and eventually you just got it. Or if you just get one severe injury, you got it. And once you have it, you can't get rid of it because it's neurodegeneration and changes in behavior. I think that's it, okay? I don't know, but that's where we're going. These are my collaborators. I'm gonna throw one shameless plug because we all work at the same hospital and I bet most of you have never heard of the McKayley Center for Sports injury prevention. But we are on the law firm campus. The whole goal is to stop injuries in sports before they happen. If you're an athlete and you come to see us, we take a massive amount of data on you. Three up to, not everybody gets all of them. It's up to 318 variables. And with that, we can predict the injuries your highest risk of sustaining. I give you a prescription of steps you can take to not get injured in the first place. I'm gonna stop there and take questions and I'll leave these slides up. Thank you for listening. Dr. Perrara. Summary of what we know today. It's important for us not only for our kids and our grandkids, but also for all of the patients and the parents that are asking us questions all the time. So hopefully we can give more informed answers. They're already hands waving in the back. So I'll start with Dr. Perrara. Hi, Bill. Thank you. I'm gonna ask you the question that we've been asking you for years. As you know, we have tried to do some investigation in our operating room about looking at obvious and covert concussion and sports trauma patients in the operating room. The anesthesia community has been asking for years. The child comes in, has an injury, has to go to the operating room. Is it safe to administer general anesthesia? In our colleagues in the anesthesia community really can answer this. And we need some guidance as to, is it reasonable to delay? How long should we delay? We're looking for return to sports and function that might be too long. Is there anything you can really help us with with that? Not until, is there only, but I'll tell you the way it came out. So we had a case like this. They came and asked me, can I have anesthesia? It was for an elective surgery, whatever was I don't remember. I said, I have no idea. You gotta talk to the anesthesia. And anesthesiologists here told me, hey, man, most of the anesthetics we use are associated with some amount of cerebral edema. It's mild and we manage it. But I really am reluctant to give it to a guy who's got head trauma. And I said, geez, that sounds reasonable. It's an elective surgery where I'm just waste. And then it led to this is what we have now. So I have no intelligence to say, I will say, the way I think about it, just trauma patients come in all the time. Got a concussion, got an open femur fracture, got some other, and we just think of the surgery, of course. You don't even think about it. And I don't know that anybody clinically has observed negative effects of that, but maybe I just don't know. So I don't worry about it too much. At the same time, if you're getting your wisdom teeth pulled or so, I say, why don't we just wait to hear better. So I look at it as how urgent is the surgery. In my mind, well, I can't say anything intelligent. I guess I'm sorry. I just don't know. Yeah. He's here at that anesthesia. I don't want to out. He's not in the room, but like he's here at children. I don't want to out him out, but it's political. There's no questions here, Dr. Meade. I can't believe this didn't generate any more questions. Dr. Jack. So given the. Oh, sorry. It's a great. So the question was, how can we combat this sort of campaign against what seems like against sports without the fin of evidence? It comes up a lot actually here at Children's and the thing is nobody wants to do it, especially me. The contract I'm supposed to sign today says that they could take this lecture, put it out on the internet and all this stuff. And I change it so you could do it only internally if Boston chose to. Nobody wants to be the person saying that, hey, man, there's some good sides to sports, especially sports like football, I'm talking across one besiege. At the same time, the truth is I didn't put this slide up. I took it off. There are well established, massive benefits to organize sports participation, health wise, social wise, mental health wise. And for an injury that most of the time is trivial, 98% of concussions sustained by high school students are totally recovered from within a month. So to think that we're going to get rid of these options for something like that to me makes no sense. The same time you don't want to be the public face of the guy saying that because, you know, mothers you'd be protesting in your house and everything. It'll affect the clinic and everything else. The second thing I would say, which now is escape my brain, I got to think about her second brain, how was I going with this? I can't remember, it was important, so give me a sec. I don't know, it'll come back to me, but somebody's got to do it. I will say there's a guy named Jim McDonald is an MD in Ohio and Greg Myers, next size physiologist who made this point in the medical journal. But it doesn't get picked up by the lay media. So if you ask any doctor in neurology, neurosurgery, sports medicine who manages concussion patients, they will almost all give you the same answer. I have with few exceptions, give you the same answer. I'm giving you. If you ask ironically, you know, the letters to the editors and all this stuff from doctors saying we should band sports are almost always from hematologist, surgeons, obstetricians, and maternal child health specialist. If people just really have no idea about it, and I think they're well-intentioned. I think they're listening to NPR on the way in the work that read NPR on so like holy crap, how could we let this happen? But I can think of two, maybe, I can think of one, actual clinician and a specialty that deals with concussions regularly who feels that way, and he only feels it about children. So I don't know how to combat it. If somebody's got to do it, just can't be me. Sorry, Dr. Jackson. So just a question about public policy. Giving those lovely data that you showed regarding recovery from concussions. Our children in Massachusetts who play contact and collision sports mandated to have a baseline neurologic exam. It's a great question, and then I thought up what I was gonna say. So the great question I got to get to before I forget it again, I have to talk about certain kids who can't switch to cross-question. Okay, so are they mandated? No. And that was a purposeful decision. So we pay in order to get the online version of that cog and the thing, we pay $10,000 a year. And what we didn't want, we said, look, it is truthfully, now you got the experts, it is truthfully trivial injury most of the time. And so I don't want sports canceling a program because they can't need a mandate, so they can't come up with $10,000 or something. Now it's cheaper for some sports, so in my heart, I just think everybody should get it. And in Massachusetts, there's no reason not to. So Boston Children's Runs, MCMC, which is a Massachusetts coalition for the management of concussion, and we offer free baseline testing to any school in Massachusetts, and we'll do it for you, and they don't have to pay a penny. And along with that, you get an education for your teachers, students, athletic trainers, some by Dan Sartana, which is an athletic trainer who runs the program for us. So they should, we have made it so they can all get it, but it's not yet mandatory. The other thing I was going to say to get back to your original question, people always bring this up. Well, if you ban football and soccer, they could run cross-country. There's no doubt that there are kids who play football and soccer who could run cross-country. There's no doubt. But if you take a guy like me, say, I was never going to run cross-country. I could, I could, but I wouldn't. I wouldn't be good. I'd be slow. I wouldn't feel good about doing this, right? But you put me in rugby. I feel good about myself. I go to school. I got good friends. I'm respected, even though I'm a little bit heavy. Did you see that guy? I love him. He was awesome. He scored two tries last Saturday, right? You take that away from me. I don't got it. I exercise less. And by the way, I'm already the guy who's at risk for obesity and high blood pressure and cardiovascular disease and stroke and type two diabetes, all of which are wicked common. And now you're going to increase my risk of things I'm already likely to guess. In order to decrease my risk of getting something I'm unlikely to get anyway, C-P-E, right? Unless I play for Texas FAMM and go to the NFL for tenure, to me just doesn't make sense. That was where I was going, that's hard. Other questions? Time for one final question. To find it out. Yeah. Yeah. Great talk. Thank you. The question I have for you is sometimes adolescents would get a concussion. And it takes them long time to recover. It could be six months. We see them up to one year. And then the question comes, can they go back to contact sports? So what do you tell? There's a couple of things to your questions. One is it depends on the mechanism. So I believe in my heart, of course, I got no way of proving it. That a sport-related concussion is unlikely to cause, if we are right about the fluctuation, oh, and I'll put up the other reading list, the fluctuations of sodium and potassium and glutamate and calcium, some things I didn't talk about. There's no way that that's still going on, six, seven, eight, nine months after sport-related concussions. Just no way. It's not going to take that long to pump all the sodium out. So restore homeostasis. Now that we know, when you take somebody to exercising regularly, and I didn't say this, but also the same thing happens with cognition. They're used to studying, and all of a sudden you stop them, and you put them in a dark room, and you pull them out of school and stuff, that they get all these symptoms. I bet you that over the last several years, many, if not most, of the long duration of symptoms if your question was atrogynous. We were following the guidelines, but I think the guidelines were resulting in symptoms that had nothing to do with the physiology of concussion, but rather the lack of physical deconitioning, cognitive deconitioning, social isolation, the things we imposed on them. So I think we'll see a lot less of that by restoring them to exercising cognition sooner, and I would say clinically, I think I've observed that. Now, there's definitely people get, because they tell out a window they got a carcorder, it's much higher force. And for them, it's hard to know. I think probably if physiology does have a lot to do with it, and I maybe there is some not-grow structural, but micro-structural damage, it's just not going away. And again, I don't have great evidence for this, but usually when they get about a year out, many studies suggest that very few people are going to recover lost function after a year. Some do it out to two, there's a couple cases of guys waking up from a coma seven years down there, but mostly after you're not getting a lot of function there. Dr. Taster probably talked more about this than I could. So around then, if they have some subtle loss in cognition or some sense of we can't figure out, we start talking about the risks and benefits. If they're miserable because they're not playing sports, if they're getting heavier, if they got predi-be, we say, look, maybe it's better for you to get back to a little something. And usually it's not collision sports, but it's sports with risks, cycling, or basketball or something where you could get it. And oftentimes we'll clear them, and I have to say, have the ones we have, nobody's had any untoward outcomes, and they're all feeling a million times better. So it's hard, you don't want me to do it, because it's a tough thing, but it's probably best for the patients who are allowed on the plane that way. Dr. Ian, thank you so much for updating this. Thanks for listening, and I'm happy to say for the guy who wants to- no. through the materials. no. yeah. think You know, it's interesting that we know whether or not there's some other reasons for people of those being described in the calcium challenge. Right, right. They have a calcium challenge. Yeah. But they've got some of the reasons just happening to the calcium challenge. Yeah. Okay, so things thought, and they got there. Right. Just because they're the frequency of this, just to see jobs to be played. I'm with them. I'm with you. I think you're right. And I hadn't thought that it would do. Okay.