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

2. 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

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

4. 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

5. 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

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

7. Common Symptoms Kutcher and Giza. Continuum, December, 2014

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

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

11. Giza and Hovda, 2001. JAT

12. Giza & Hovda, 2001

14. Increased energy demand Decreased energy supply

15. 1 1 1: Injury Threshold 2 2 2: Symptom Threshold Injury vs. effect

16. SCAT 3

17. The initial approach No InjuryConcussionEmergency

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

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

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

22. 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

23. Diagnostic uncertainty Kutcher and Giza. Continuum, December, 2014

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

25. Kutcher and Giza. Continuum, December, 2014

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

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

28. TIME Concussion and PCS Migraine Mood ADHD Neck Sleep

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

30. Post-Concussion Syndrome Lodestone vs. Keystone problems

31. Chronic Traumatic Encephalopathy Martland H. Punch Drunk. JAMA. 1928 Described 23 cases of professional boxers who had: behavioral changes cognitive decrement slurred speech and/or clumsiness …labeled them “punch drunk” or “slug nutty.”

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

33. Chronic Traumatic Encephalopathy Reggie Fleming 1936-2009 Bob Probert 1965-2010 Red Berenson 1939 - Rick Martin 1951 - 2011

34. Sports Concussion and Suicide

35. Wade Belak 1976-2011 Rick Rypien 1984-2011

36. Sports Concussion and Suicide

37. “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?”

38. Sport Concussion and Suicide

39. “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

41. Observed Expected SMR 9 21.8 0.41

43. Thank you! 248-485-7041 jeffrey.kutcher@thesportsneurologyclinic.com