1. Concussion Update The State of Play Terry Coyne BrizBrain & Spine Sunshine Coast Brain & Spine

2. Aims Identify concussion Appropriately advise players/other stakeholders re management, return to play Access resources

4. NFL, RETIRED PLAYERS RESOLVE CONCUSSION LITIGATION; COURT-APPOINTED MEDIATOR HAILS “HISTORIC” AGREEMENT Thousands of Retirees and Families to Benefit Medical Testing; Research; Compensation and Promotion of Safety All Part of Agreement Former United States District Judge Layn Phillips, the court- appointed mediator in the consolidated concussion-related lawsuits brought by more than 4,500 retired football players against the National Football League and others, announced today that.

5. NFL would pay $765 million plus legal costs, but admits no wrongdoing. Individual awards would be capped at $5 million for players suffering from Alzheimer’s disease. Individual awards would be capped at $4 million for deaths from chronic traumatic encephalopathy (CTE).

6. Greg Williams has said that multiple concussions in his career resulted in permanent damage. The Age, September 2013

7. NRL legend Mark Geyer set to have a brain examination and wants to other players who suffered concussion to be tested for potential trauma James Hooper The Sunday Telegraph March 15, 2014

10. In partnership with: What is concussion? Subset of mechanical brain injury Can be direct or transmitted force to head Typically rapid onset of neurological impairment which resolves spontaneously, but may evolve over minutes/hours Acute symptoms usually due to functional disturbance rather than structural May or may not involve LOC Occasionally symptoms may be prolonged BrizBrain & Spine St Andrews Education Meeting 2006

11. In partnership with: AFL – 5-6/1000 player hours Equals 6-7/season per team on average BrizBrain & Spine St Andrews Education Meeting 2006

12. In partnership with: Symptoms & Signs Symptoms - somatic (eg headache) - cognitive (eg “feeling foggy”) - emotional (eg lability) Signs eg loss of consciousness, amnesia Behavioural change (eg irritability) Cognitive impairment (eg slowed reaction times) Sleep disturbance (eg insomnia) BrizBrain & Spine St Andrews Education Meeting 2006

13. In partnership with: On field/Sideline evaluation If ANY features of concussion: Player requires evaluation; if none available, remove from play and arrange assessment Standard emergency evaluation (ABC’s), Cx spine assessment Assessment using appropriate tool (eg SCAT 3) Player not left alone If concussion – no return to play that day BrizBrain & Spine St Andrews Education Meeting 2006

14. In partnership with: Diagnosis is a medical decision based on clinical judgement Traditional questions to assess orientation (T,P, P) unreliable Can be delayed BrizBrain & Spine St Andrews Education Meeting 2006

15. In partnership with: In Emergency Room/Surgery Good history, detailed neuro exam (including mental status, cognition, gait, balance) Improving or deteriorating? Assess need for neuroimaging if need to exclude structural injury (prolonged disturbed LOC, focal deficit, deteriorating) (SCAT 3) BrizBrain & Spine St Andrews Education Meeting 2006

16. In partnership with: Other Investigations Balance Error Scoring System (BESS) – postural stability correlates well with overall neurological motor function Biomarkers – genetic (eg Apo 4) - cytokines (eg IGF-1, S-100), in serum, CSF Electrophysiological – EEG, evoked responses) - interesting, but significance unknown BrizBrain & Spine St Andrews Education Meeting 2006

17. In partnership with: Neuropsychological Assessment Useful, but not practical except in professional setting Symptoms usually resolve first, so when used usually after player asymptomatic No evidence to support baseline neuropsych testing BrizBrain & Spine St Andrews Education Meeting 2006

18. Concussion

27. In partnership with: Management Key Points – physical and cognitive rest until acute symptoms resolve - then graduated exertion to normal play No return to play on day of a concussion, esp school age, where cognitive deficits may not be present on the sideline, but may be delayed, more so than in adults BrizBrain & Spine St Andrews Education Meeting 2006

29. In partnership with: Graduated RTP Usually 24 hrs for each level, so 1 week to progress to RTP from when asymptomatic at rest If symptoms recur, rest 24 hrs, and restart one level back, where was asymptomatic Elite v non-elite – elite may have more resources, but their brains are the same, so management no different BrizBrain & Spine St Andrews Education Meeting 2006

31. In partnership with: Persisting symptoms (>10 days) 10-15 % of concussions Consider other pathologies (imaging) Maybe multi-disciplinary approach – physio, psychologist, neuropsychologist, vestibular rehab etc Pharmacology – specific symptoms (eg sleep disturbance, anxiety) - modify pathophysiology to shorten symptoms - methylphenidate (Ritalin), amantadine. But……. BrizBrain & Spine St Andrews Education Meeting 2006

32. In partnership with: Children (<13 yrs) Ist step is successful return to school, prior to physical activity, even physical ADL’s Increased risk of cerebral swelling Need to be entirely symptom free before return to sport May take longer to recover than adults Child SCAT – neuropsych more difficult as brain not mature, so hard to standardise tests Generally be more cautious BrizBrain & Spine St Andrews Education Meeting 2006

33. In partnership with: Risks of too soon RTP Impaired performance, re-injury due to slower reaction times, for example 2 nd impact – acute severe cerebral swelling - ? disturbed auto regulation - case report level ?CTE – seems to be greater risk of cognitive impairment, depression/other mental health issues amongst NFL players with multiple concussions; but we don’t know the type, number or severity of concussions required, and why a small # only get CTE. So, err on the side of caution BrizBrain & Spine St Andrews Education Meeting 2006,

34. In partnership with: Chronic traumatic encephalopathy (CTE) Distinct tau-opathy Incidence in athletes unknown Cause and effect unknown ?Genetic disposition Other factors – age, mental health, alcohol/drug use, medical co-morbidities – largely not accounted for in studies to date BrizBrain & Spine St Andrews Education Meeting 2006

35. In partnership with: Prevention Unfortunately, little evidence for protective gear. Mouthguards, football helmets good for dental, facial protection, but no evidence they decrease concussion. Also “risk compensation”, esp children, adolescents Skiing, snowboarding – evidence, so recommended Cycling, equestrian, motor sports - prob protect against falls against hard surfaces, less skull #’s BrizBrain & Spine St Andrews Education Meeting 2006

36. In partnership with: Thank you Visit BBS Website to download: Pocket Concussion Recognition Tool SCAT 3 Child SCAT 3 Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport, held in Zurich, November 2012 BrizBrain & Spine St Andrews Education Meeting 2006