Editor: Roland Torres, MD, FAANS, FACS Spring 2012  
In this Issue...
Message from the Chair
Neurotrauma and Critical Care Web Page Update
Sports Medicine Committee
Clinical Research Update:
When the Cameras All Are On You
  Sports Medicine Committee

Anthony L. Petraglia, MD; and Julian E. Bailes, MD

Over the past few years, increased attention has been focused on the neurological sequelae of sports-related traumatic brain injury (TBI), particularly concussion. One only has to turn on the TV, listen to the radio or pick up any newspaper to catch a glimpse of what has become front and center in medicine and society today. Many consider 2009 the "Year of the Concussion" — a year filled with major cultural and scientific shifts in the way athletes, coaches, parents and physicians viewed concussions. With new research initiatives and skyrocketing levels of public awareness, 2010 marked a year where society came to a better understanding of concussion and mild TBI, while we as a medical community came to learn that we have a long way to go.

An explosion of interest and research regarding the underlying pathophysiology of concussion and the possible long-term effects of repetitive mild TBI (mTBI), coupled with the potential link to the development of chronic neurodegenerative disease such as chronic traumatic encephalopathy (CTE) and possibly amyotrophic lateral sclerosis (ALS), has resulted in increased attention from members of Congress as well as society. In general, people are coming to understand how this is a large public health issue that extends far greater than what we watch on TV every week. Additionally, within the scope of professional sports, there were some notable athletes who sustained concussive injuries. The combination of these numerous events has led to changes in rules, policies and the way we manage concussion, while simultaneously opening up a multitude of avenues for biomedical research.

Football probably has spent more time at the forefront this past year than any other sport, particularly at the professional level. With regards to TBI, the landscape of the National Football League (NFL) underwent many alterations between 2007 and 2010, implementing multiple changes to its concussion policies aimed at better protecting and treating its players. In 2007, the NFL hosted a medical conference consisting of team physicians, athletic trainers, medical experts and even team members to discuss concussions and their effects on the players. After that conference, the NFL released a set of guidelines on return-to-play rules, distributed an informational pamphlet to all players on the causes and effects of concussions, and also created a hotline for reporting situations in which players might feel pressured to play with concussion symptoms. That first set of guidelines in 2007 stated that "a player could not return to a game or practice in which he [has] lost consciousness and that a player must be asymptomatic and pass his neurological tests normally before returning to play."

In October of 2009, NFL executives and lawmakers joined at the House Judiciary Committee meeting to discuss the effects of head injuries in the sport. At that meeting, critics accused the NFL of not doing enough to protect players from the long-term effects of concussions. Shortly thereafter, the NFL’s concussion committee co-chairmen resigned, and the path to a clearer, expanded and stricter set of guidelines was forged. On March 16, 2010, the NFL announced the formation of a new committee (the NFL Head, Neck and Spine Medical Committee) and named two neurosurgeons, Drs. Hunt Batjer and Richard Ellenbogen, the new co-chairmen. Other neurosurgeons also are serving various roles on the committee. A new set of guidelines was formed and implemented this past year:
Once removed for the duration of a practice or game, the player should not be considered for return-to-football activities until he is fully asymptomatic, both at rest and after exertion, has a normal neurological examination, normal neuropsychological testing, and has been cleared to return by both his team physician(s) and the independent neurological consultant. A critical element of managing concussions is candid reporting by players of their symptoms following an injury. Accordingly, players are to be encouraged to be candid with team medical staffs and fully disclose any signs or symptoms that may be associated with a concussion. — National Football League statement on Return-to-Play, 2009
In addition, the NFL Player’s Association (NFLPA) has created the Second Opinion Network, which consists of independent board-certified neurosurgeons throughout the U.S., in every NFL city. Also, during the 2010 season, in an effort to crack down on helmet-to-helmet hits and ultimately reduce the amount of concussions suffered by players, the league began to issue larger fines to players, particularly repeat offenders, and mentioned that suspensions would be considered for those who continued to commit illegal hits. Change certainly takes time, but the results thus far have been promising. Also, players seem to be more educated about the issues, and there seemed to be an overall increase in the number of concussions reported during the 2010 season. One of the most important byproducts to come from all of this change has been the effect it has had on the millions of young football players across the country who look up to professional athletes as heroes. Such influence has even trickled down to the Pop Warner youth football programs and other levels of youth football.

The effort to address concussion-management policies in collegiate athletes began more broadly at the end of 2009 through the National Collegiate Athletic Association (NCAA). The Competitive-Safeguard and Medical Aspects of Sports Committee issued a revision to the NCAA Sport’s Medicine Handbook guideline advising on appropriate response to concussions and procedures for returning student-athletes to competition of practice. The NCAA also had a conference in April of this past year where certified athletic trainers and physicians met to discuss concussion management practices. A few months later, the organization adopted legislation that required its member institutions to adopt a written concussion management plan to ensure that any athlete who shows symptoms of a concussion will be removed from competition. In addition, member institutions also were required to have a written emergency plan. According to the NCAA’s new rules, college athletes now are required to have baseline neuropsychological testing performed, as well. The student-athlete sustaining a concussion should be removed from play for the remainder of that day, evaluated by a proper health-care provider, and returned to play only after following and completing a medically supervised stepwise plan. The NCAA also has collaborated closely with the Centers for Disease Control (CDC) to develop educational materials for distribution to student-athletes, coaches and parents.

The National Federation of State High School Associations (NFHS) is the national leadership organization for high school sports. Among its many tasks, the NFHS writes playing rules for 17 sports for boys and girls at the high-school level. Through its member state associations, the NFHS reaches upwards of 7.5 million high school athletes in more than 19,000 high schools across the country. In keeping with the management changes seen at other levels of athletics, the NFHS Football Rules Committee met in February of last year and accepted a revised concussion rule effective for the 2010 season. The previous rule directed officials to remove an athlete from play if "unconscious or apparently unconscious." Now, officials are charged with removing any player who shows signs, symptoms or behaviors consistent with a concussion and ensuring that a player does not return to play until cleared by an appropriate health-care professional. Such rule changes also are being expanded to cover all high school athletic programs where contact or collision could occur. In May of last year, as a part of the NFHS Coach Education Program, the NFHS began offering an online education course devoted to concussion entitled "Concussion in Sports — What You Need to Know." The 20-minute online course is designed to help educate interscholastic teachers, coaches, officials, parents and players on the importance of understanding, recognizing and properly managing sports-related concussions.

Neurological injury prevention and control is occurring even at the most junior level. Pop Warner Little Scholars, Inc. is the largest and oldest youth football, cheer and dance organization. In November of 2010, Pop Warner formally announced the formation of the inaugural Pop Warner Medical Advisory Board. This board is led by four physicians with expertise in neurological sports medicine; it includes Dr. Lawrence Lemak (orthopedic surgery), Dr. Stanley Herring (physical medicine & rehabilitation) and two neurosurgeons — Drs. Julian Bailes and Arthur Day, with Dr. Bailes serving as its first chairman. In addition, Pop Warner updated its rules in 2010 to reflect the most safety-conscious and comprehensive approach to concussion prevention and management. These rule changes echo those principles exhibited by the higher organizations, but specifically emphasize and maintain that the return-to-play decision must be made by licensed medical officials, as opposed to parents or guardians.

This important aspect is in alignment with the "Lystedt Law" passed in 2009, in the state of Washington. The law was named after Zackery Lystedt, who was critically injured during a high school football game. He struck his head on the ground after a big play and subsequently grabbed his helmet in obvious pain as he struggled to get up. After making it to the sideline, he sat out for about 15 minutes, and then went back in for the remainder of the game. Another hit late in the game resulted in an intracranial hemorrhage, neurosurgical intervention and a prolonged hospitalization. Ten other states have created similar laws, while many others have them under consideration. Congress now is looking at the Lystedt Law as a template from which to set national standards for recognizing and treating head injuries in young athletes.

These changes are not being made exclusively in the football world. A concussion can occur in just about any sport, and the CDC as well as organized neurosurgery have been instrumental in promoting education to that extent. The CNS has sponsored webinar sessions to promote concussion education (as detailed below), and seminars and talks at the CNS and AANS meetings are increasing awareness. Organized neurosurgery also has stressed the importance not only of awareness and diagnosis, but prevention and preparation, as well. Key steps to ensure the best outcome for athletes includes educating athletes and parents about concussion, first and foremost, and the potential long-term consequences of not allowing the brain to heal following injury. Insisting that safety comes first is paramount.

As evidenced above, many neurosurgeons certainly are on the frontlines in these national changes. However, the work is far from done. There is a continued need for neurosurgeons to be involved from leadership standpoint. We must continue to work with our colleagues from other disciplines of medicine in order to deliver comprehensive care to athletes with neurologic injuries. Concussion care falls within the scope of neurosurgical practice, and neurosurgeons need to become versed in computerized neuropsychological testing and its interpretation. For neurosurgeons, this realm of medicine is by no means foreign territory; however, formal, in-depth training in treating sports-related neurologic injuries is not as commonplace. In an effort to help bridge that gap, the Congress of Neurological Surgeons — as a part of its University of Neurosurgery Webinar series — hosted a webinar in January of 2011 entitled "Football Injuries and Concussion: Assessment, Return to Play, Long-Term Sequelae and the Neurosurgeon’s Role." The following were some of the highlights from that webinar given by Dr. Julian Bailes and Dr. Joseph Maroon:
"While we all have learned the definition of concussion to some degree in our training, the definition has continued to evolve as we have learned more over the recent years. In keeping with the consensus statement on concussion, which was generated from the 3rd International Conference on Concussion in Sport held in Zurich 2008, a concussion can be defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Simply put, it is a temporary disruption of brain function that typically resolves spontaneously. It can be caused either by a direct blow to the head, face or neck, or a blow elsewhere on the body with an “impulsive” force transmitted to the head. While concussion does result in neuropathological changes at the ultra-structural level, the acute clinical symptoms largely are a reflection of a functional disturbance, and typically there is no abnormality on standard neuroimaging studies. It was emphasized that while loss of consciousness can occur, the majority (upwards of 90 percent) do not involve a loss of consciousness."
Acutely, with concussion, there is a disruption of the neurofilaments and microtubules that provide a framework for axonal transport, compromising the anterograde and retrograde transport of molecular proteins to and from somata. This mechanical damage, as well as delayed or progressive ultra-structural injury due to proteolysis, subsequently affects axonal transport. Also, at the cellular level, we have come to learn that there is neuronal membrane disruption (or mechanoporation) that leads to ionic shifts and an increase in intracellular glutamate and calcium. Glucose metabolism is altered, and mitochondrial injury leads to a failure in ATP and an increase in reactive oxygen species. The brain may try to heal these membrane defects and seal these porations as a part of the repair process; however, cells may ultimately undergo caspase-mediated apoptosis as a result of these cellular changes.

The chronic effects of cumulative concussions have been demonstrated at all levels of athletics. It has been shown that with a concussion, an athlete is at an increased risk for a second concussion in the same season, and that each subsequent concussion requires a longer recovery period. If an athlete were to sustain three concussions, that player has a three-fold increased risk of a future event. Epidemiological studies have suggested an association between repetitive sports concussions during a career and late-life cognitive impairment. Similarly, there has been an increased number of cases where neuropathological evidence of CTE has been observed in retired athletes.

As we progress through 2011 and beyond, we will continue to collect more data and information that will help us manage athletes that sustain neurologic injuries. Most clinical and scientific studies have focused on severe TBI, but concussive and sub-concussive head injuries affect more people, occur more frequently, and are a silent epidemic of increasing importance. Future research should investigate the use of virtual reality tools in the assessment of injury. The role of neuroimaging should be further expanded as we explore novel imaging modalities, in addition to better defining the role of current neuroimaging techniques in clinical assessment. While we likely won’t ever eliminate concussions from sports, we can continue to lead the charge for finding ways to reduce their incidence and improve the way in which we manage them.

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