Mild TBI in Contact Sports: are they really mild?

1. Mild Traumatic Brain Injury in Contact Sports: Are They Really Mild? Julian E. Bailes, M.D. Professor and Chairman Department of Neurosurgery West Virginia University School of Medicine

2. Disclosure Research Funded by and J. Bailes consultant for Martek Biosciences, Inc. Research Funded by BHR Pharma, Inc.

4. Roethlisberger’s Injury Highlights Nerve Center for Head Trauma By ALAN SCHWARZ Published: January 1, 2009

5. “The football fields of our nation have been a vast proving ground or laboratory for the study of tragic neurological sequelae of head and neck trauma in man” Richard Schneider 1967

6. What is a Concussion? Temporary disruption of normal brain function Also called Mild Traumatic Brain Injury (MTBI) Caused by a blow or motion to the head Results in brain movement inside skull From collisions, falls, striking objects/ground 90% occur without losing consciousness Continuing to play results in vulnerability to more injury, chronic disability or even death Brain scans usually normal

7. Cellular Injury from MTBI Neuronal membrane disruption opens voltage-dependent K+ channels Widespread release of glutamate Thru NMDA receptors, increase occurs in intracellular Ca++ Mitochondrial injury leads to impaired respiration, reactive O2 species, Oxid cellular injury, ATP failure, abnormal glucose metabolism Caspase-mediated apoptosis

8. Ultrastructural injury Neurofilaments and microtubules provide framework for axonal transport Anterograde/retrograde movement of membrane materials to/from somata Molecular motors kinesins/dyneins Both mechanical damage & delayed/progressive ultrastructural injury from proteolysis by intracellular calpains Axonal transport is interrupted

10. Mechanoporation Straight line forces do not cause MTBI Head motion, more than head contact causes MTBI Rotational, angular forces cause tension force vectors which affect the neuron A traumatic membrane defect occurs The brain attempts to “self-seal” these porations

12. Acceleration-Deceleration Injury: Brain movement within skull Rotation: Never prevented, perhaps increased, by helmets

13. KE=1/2M XV2 HIC= V1-V2/HD

14. Cumulative Effects in Collegiate Athletes 3 concussions: 3X’s risk of future events 1 in 15: 2nd concussion same season (usually within 7-10 days) Each concussion takes longer to recover Based on symptom duration, 69% moderate & 15% severe

15. Center for the Study of Retired AthletesKevin Guskiewicz, PhDJulian E. Bailes, MDUniversity of North Carolina at Chapel HillWest Virginia University School of MedicineNational Football League Players’ Association

16. Life After Football: Health of NFL Retirees Funded by: NFL Players Association Office of the Vice-Chancellor for Research, UNC-CH Department of Exercise & Sport Science, UNC-CH Injury Prevention Research Center, UNC-CH

21. Retire: Are Some Players Vulnerable to Dementia?

22. Chronic Traumatic Encephalopathy

23. DORSAL AND BASAL PERSPECTIVES OF CTE BRAIN

29. Concussion: Is There Any Hope for Prevention?

30. Fluid Percussion Model application of a fluid pressure pulse to the intact dura through a craniotomy replicates clinical contusion without skull fracture petechial hemorrhage in the brain parenchyma, axonal damage, subarachnoid hemorrhage, tissue tears followed by focal necrosis and cell loss, and characteristic vascular damage at the gray/white interface defined as “gliding contusion”

31. Impact Acceleration Injury Weight drop onto steel helmet affixed to skull Produces reliable and reproducible injury High yield of traumatically injured axons in white matter tracts

32. 32 Confidential Information Remyelination Vasogenic Edema Mitochondrial Recoupling ReducesCerebral Edema Progesterone Cytotoxic Edema Enhances GABA Increases Bcl2 AkT-P Antagonizes Sigma Receptor Possible Mechanisms of Action Reduces Inflammatory Cytokines Reduce Apoptosis Blocks Excitotoxicity Decreases free radicals & lipid peroxidation Study funded by BHR Pharma, Inc

33. Omega-3 Supplementation Recent evidence from animal studies suggests that supplementation with omega-3 fatty acids (particularly docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA)) improves functional outcomes following focal neural injury. Wu, A., Ying, Z. and Gomez-Pinilla F, “Dietary omega-3 fatty acids normalize BDNF levels, reduce oxidative damage, and counteract learning disability after traumatic brain injury in rats,” J. Neurotrauma 21:10 1457-67 (2004).

35. attention

36. memory

37. decision making

39. info processing, focus

40. info storage, recall, learning

41. adaptation/problem solving

42. coordination/language/communication= Cognition + Brain performance level

43. Immunohistochemistry Sham injured animals demonstrate paucity of APP positive axons with Retraction bulb morphology

44. Immunohistochemistry Animals subjected to impact acceleration injury demonstrate APP positive axons with retraction bulb morphology at 30 days

45. Immunohistochemistry Animals subjected to impact acceleration injury and supplemented with 10mg/kg/day DHA following impact injury demonstrate fewer APP positive axons with retraction bulb morphology at 30 days

46. DHA Post-Injury Treatment

47. AA/EPA Ratio % Change in AA/EPA ratio from baseline

49. DHA Pre-Injury Treatment

56. Are Helmets The Answer?

58. X Abating Traumatic Brain Injury A SLOSH Approach

59. SLOSH In fluid dynamics, the movement of a liquid or semi-solid inside another object First described by NASA, this sloshing effect can cause severe problems with vehicle stability/control due to a propensity to absorb external energy. In human anatomy terms, the vehicle or the container (skull) and its contents (brain) the semi-solid fluid-behaving matter Oscillation occurs only when the vehicle is partially filled

60. What is the Teleological Function of the Omohyoid Muscle?

61. Jugular Compression Device Failsafe: Non-compressible vertebrals The Quenckenstadt Maneuver has been safely used for nearly 100 years

62. Brainstem APP Region of Interest

63. RESULTS

64. Concussion-Changes Coming Brain Injury Assoc: 3.8 million sports and recreation-related concussions in U.S. yearly More concussions or greater recognition? Baby boomers want to prevent chronic injuries Increased awareness and structured approach at every level Congressional hearings Recognition: younger brains still developing State legislation: OK, TX, WA, NM, VA, others-pending in 26 states

65. Concussion Management Diagnosed concussion (certainly LOC) precludes RTP same day Player should be completely asymptomatic with normal neurological examination Neuropsychological testing Sometimes symptoms become more obvious later Treatment: physical and mental rest Rest period: 7-10 days, until no symptoms Avoidance of alcohol, caffeine, dehydration Omega-3 Fatty Acids-DHA Neck strengthening exercises