Jeffrey S. Kutcher, MD, FAAN National Director Sports Concussion and Athlete Brain Health

National Director, The Sports Neurology Clinic ™ Team Neurologist, US Ski & Snowboard Team Director, NBA Concussion Program Consultant, NHLPA Consultant, NFLPA Consultant, ElMindA, Ltd. Dr. Kutcher Disclosures

1. Neurological insults from playing sports 2. Neurological conditions in athletes 3. Neurological benefit of exercise 4. Neurological substrate of performance Sports Neurology

Concussion: transient alteration of brain function as the direct result of a biomechanical force. Days to weeks. Post-concussion syndrome: complex pathophysiology, both biological and psychological, that occurs after the concussion is over. Months to years. Chronic effects: unknown pathophysiology, unclear epidemiology. Chronic Traumatic Encephalopathy (CTE), depression, cognitive decrement. Lifetime Athlete Brain Health

Not every injury to the brain causes a clinical syndrome Not every brain symptom or clinical sign following exposure to mechanical force is due to concussion During the clinical syndrome of concussion, symptoms may be from something other than than the injury itself Concussion axioms

Clinical manifestation of a functional brain injury Caused by physical forces acting on the brain What is a concussion?

Common Symptoms Kutcher and Giza. Continuum, December, 2014

Migraine Symptom spectrum Encephalopathy Affective TGA headache neck pain nausea photophobia slowed disoriented Inattentive dizzy clumsy amnestic manic depressed psychotic Vestibular vertigo  tracking imbalance

“Peripheral” symptoms 1. Cortical spreading depression 2. Peripheral activation 3. Peripheral sensitization 4. Central sensitization THALAMUS

Giza and Hovda, JAT

Giza & Hovda, 2001

Increased energy demand Decreased energy supply

1 1 1: Injury Threshold 2 2 2: Symptom Threshold Injury vs. effect

SCAT 3

The initial approach No InjuryConcussionEmergency

Emergency action required Safety first… ABCs C-spine Seizure Level of consciousness Focality

Components of a Baseline Concussion Evaluation Neurologic history: Recurrent symptoms Relevant comorbidities Brain trauma history Neurologic physical exam: Screening neuro exam Focused concussion exam

Augmenting the Neurologic Exam Cognitive testing (computerized or paper) Balance testing Vestibular and ocular-motor testing

Tenants of Baseline Testing Good idea to measure brain function prior to an injury Results should be useful to the provider managing the concussion Tests should augment the neurologic history and exam

Diagnostic uncertainty Kutcher and Giza. Continuum, December, 2014

TIME INJURY RTP Process: R.R.E.S.D R Rest (physical) R Rest (mental) E Eat S Sleep D Drink

Kutcher and Giza. Continuum, December, 2014

TIME INJURY RTP Process: B.R.A.I.N. BikeRunAgility “In Red” No restrictions

Get a sense of the timing Look for inactivity related symptoms Past medical history Psychological factors & personality TIME INJURY Concussion vs. PCS

TIME Concussion and PCS Migraine Mood ADHD Neck Sleep

Post-Concussion Syndrome Peel back the layers… Unplugged Syndrome Primary headache Mood Sleep Neck ADHD

Post-Concussion Syndrome Lodestone vs. Keystone problems

Chronic Traumatic Encephalopathy Martland H. Punch Drunk. JAMA Described 23 cases of professional boxers who had: behavioral changes cognitive decrement slurred speech and/or clumsiness …labeled them “punch drunk” or “slug nutty.”

Chronic Traumatic Encephalopathy Tau protein deposition, like Alzheimer’s Disease, but in different locations Presumed to be from repeated contact Unclear clinical effects NORMALCTE

Chronic Traumatic Encephalopathy Reggie Fleming Bob Probert Red Berenson Rick Martin

Sports Concussion and Suicide

Wade Belak Rick Rypien

Sports Concussion and Suicide

“The no it all Rog goodell [sic] lied to every player and told us concussions will not effect us in life that a LIE!” Jeremy Shockey (Getty Images) “Science tells me I'll be dead time in 54yrs old!! What would U do?”

Sport Concussion and Suicide

“All parties should understand that a scientific basis exists for concern that news coverage of suicide may contribute to the causation of suicide.” Things that promote suicide: Presenting simplistic explanations for suicide Engaging in repetitive, ongoing or excessive reporting Providing sensational coverage of suicide Glorifying persons who commit suicide Focusing on the suicide completer’s positive characteristics Sport Concussion and Suicide

Observed Expected SMR

Thank you!