April 11, 2018 With growing neuroscientific research on sports concussions, states have revised their policies and statutes. Yet at present we have limited research on how these state sports concussion laws are working. This panel explored the intersection of neuroscience and law in the context of preventing, detecting, and treating youth sports concussions. For more information, visit our website at: http://petrieflom.law.harvard.edu/events/details/how-to-fix-youth-sports-concussion-laws

1. Sport-Related Concussion
Bill Meehan, MD
Director, Micheli Center for Sports Injury Prevention
Division of Sports Medicine, Boston Children’s Hospital

2. Abstract: We investigated brain volumes using
magnetic resonance imaging (MRI) in 10
professional American Football players compared
with 10 swimmers. In football players compared with
swimmers, decreased brain volume was observed in
the left premotor cortex, SMA, putamen, superior
frontal gyrus, corticospinal tracts, both internal
capsules, corpus callosum, and left anterior
cingulum. Hum Brain Mapp 31:1196–1206, 2010

3. Definition
• Trauma induced brain dysfunction
• Rotational acceleration

4. Normal Physiology

5. Normal Physiology

6. Normal Physiology

7. Normal Physiology

8. Signs and Symptoms
• Loss of Consciousness
• Amnesia, retrograde or
antegrade
• Disorientation
• Appearing dazed
• Acting confused
• Forgetting game rules or play
assignments
• Inability to recall score or
opponent
• Inappropriate emotionality
• Physical incoordination
• Imbalance
• Seizure
• Slow verbal responses
• Personality changes
• Headache
• Dizziness
• Nausea or vomiting
• Difficulty balancing
• Vision changes
• Photophobia
• Phonophobia
• Feeling “out of it”
• Difficulty concentrating
• Tinnitus
• Drowsiness
• Sadness
• Hallucinations

9. Specific Assessment Tools
Assessment
– Symptoms
– Balance
– Neurocognition

10. Symptom Inventory
None Mild Moderate Severe
Headache 0 1 2 3 4 5 6
“Pressure in head” 0 1 2 3 4 5 6
Neck Pain 0 1 2 3 4 5 6
Balance problems or dizzy 0 1 2 3 4 5 6
Nausea or vomiting 0 1 2 3 4 5 6
Vision problems 0 1 2 3 4 5 6
Hearing problems / ringing 0 1 2 3 4 5 6
“Don’t feel right” 0 1 2 3 4 5 6
Feeling “dinged” or “dazed” 0 1 2 3 4 5 6
Confusion 0 1 2 3 4 5 6
Feeling slowed down 0 1 2 3 4 5 6
Feeling like "in a fog" 0 1 2 3 4 5 6
Drowsiness 0 1 2 3 4 5 6
Fatigue or low energy 0 1 2 3 4 5 6
More emotional than usual 0 1 2 3 4 5 6
Irritability 0 1 2 3 4 5 6
Difficulty concentrating 0 1 2 3 4 5 6
Difficulty remembering 0 1 2 3 4 5 6
Sadness 0 1 2 3 4 5 6
Nervous or Anxious 0 1 2 3 4 5 6
Trouble falling asleep 0 1 2 3 4 5 6
Sleeping more than usual 0 1 2 3 4 5 6
Sensitivity to light 0 1 2 3 4 5 6
Sensitivity to noise 0 1 2 3 4 5 6
Other: _______________ 0 1 2 3 4 5 6

11. Balance Assessment
1. Double Leg Stance – Feet together, hands on
hips, eyes closed for 20 seconds.
2. Single Leg Stance – Non-dominant foot, 30
degrees hip flexion, 45 degrees knee flexion,
hands on hips, eyes closed for 20 seconds.
3. Tandem Stance – Non-dominant foot in back,
hands on hips, eyes closed for 20 seconds.

12. Balance Errors
1. Hands off iliac crest
2. Opening eyes
3. Step, stumble or fall
4. Moving hip into >30 degrees abduction
5. Lifting forefoot or heel
6. Remaining out of position > 5 seconds
• Errors counted.

13. Neurocognitive Testing
0
10
20
30
40
50
60
70
80
90
100
Baseline Post Injury
1
Post Injury
2
Post Injury
3
Verbal Memory
Visual Memory
Processing Speed
Reaction Time
6 Days Post 16 Days Post 23 Days Post
Percentile

14. Management
• Management
– Physical rest (24-48 hours)*
– Cognitive rest (24-48 hours)*
– RTP stages
– Contact only after
• Sx-free at rest, with exertion
• Caught up in school, sx-free with full cognitive exertion
• Pre-injury data back to baseline
McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport-the
5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports
Med. 2017 Apr 26. [Epub ahead of print]
*

15. Step Level of activity
1. No activity, complete rest. Once asymptomatic, proceed to
level 2.
2. Light aerobic exercise such as walking or stationary cycling,
no resistance training.
3. Sport specific exercise - for example, skating in hockey,
running in soccer; progressive addition of resistance
training at steps 3 or 4.
4. Non-contact training drills.
5. Full contact training after medical clearance.
6. Game play.

16. Complications & Referral Indications
• Prolonged recoveries
• Intractable symptoms
– Insomnia
– Post-traumatic headaches
– Cognitive dysfunction
– Balance problems / dizziness
• Ocular issues
• Vestibular problems
• Multiple injuries

17. Impetus Behind Policies
• Risk
• Second Impact Syndrome
• Cumulative
‒ Chronic Traumatic Encephalopathy

18. More Recent Policy Proposals
• Risk
• Second Impact Syndrome
• Cumulative
‒ Chronic Traumatic Encephalopathy

19. Second Impact Syndrome
• Saunders and Harbaugh 1984

20. Cumulative Effects
• Gronwall 1975
• Collins 1999
• Guskiewicz 2003
• Schultz 2004
• Omalu 2005, 2006, 2007
• McKee 2009, 2010, 2015, 2016, 2017

21. Chronic Traumatic Encephalopathy:
What We See and Hear
• CTE is common in
Football Time

22. • CTE is common in
Football
• CTE causes
aggression
Time
Chronic Traumatic Encephalopathy:
What We See and Hear

23. • CTE is common in
Football
• CTE causes
aggression
• CTE causes suicide
Time
Chronic Traumatic Encephalopathy:
What We See and Hear

24. Chronic Traumatic Encephalopathy:
What We See and Hear

25. Chronic Traumatic Encephalopathy:
What We See and Hear

26. Chronic Traumatic Encephalopathy:
What We See and Hear

27. Chronic Traumatic Encephalopathy:
What We See and Hear
Effects Us!

28. Structural Neuroplasticity in the Sensorimotor Network of
Professional Female Ballet Dancers
Jurgen Hanggi,* Susan Koeneke, Ladina Bezzola, and Lutz Jancke
Abstract: We investigated brain volumes using
magnetic resonance imaging (MRI) in 10
professional ballet dancers compared with 10 non-
dancers. In ballet dancers compared with non-
dancers, decreased brain volumes were observed in
the left premotor cortex, SMA, putamen, superior
frontal gyrus, corticospinal tracts, both internal
capsules, corpus callosum, and left anterior
cingulum. Hum Brain Mapp 31:1196–1206, 2010

29. What Medical Community Says
• Risk of neurodegenerative
disease unlikely
• Association between trauma
and pathology unclear
• Suicide less common

30. What Medical Community Says
• Association between
pathology and symptoms
unclear
• International Conference on Concussion in Sports

31. What We Should Say

33. What We Should Say

34. Why It Matters?
• Goals
– Preserve football
– End football
– Be seen as an expert
– Get some attention
• Athletes
– Make decisions
– Treatment
– Prevention
• Truth

35. Benefits of Sports Participation
– Decreased risk of mortality
– Lower risk of obesity
– More likely to exercise
– Decreased risk of heart
disease
– Decreased risk of obesity
– Decreased risk of stroke
– Decreased risk of obesity
– Decreased risk of depression
– Decreased risk of metabolic
syndrome
– Increased life expectancy
– Decreased risk of chronic
fatigue syndrome
– Greater self esteem
– Less likely to join gangs
– Decreased illicit drug use
– Later age of first sexual
encounter
– Less likely to have unprotected
sex
– Lower risk of teen pregnancy
– Greater occupational success

36. Risk factors for CTE
Noy et al. Chronic Traumatic Encephalopathy-Like Abnormalities in a
Routine Neuropathology Service. J Neuropathol Exp Neurol . 2016

37. Risk factors for CTE
• 35% of bodies in routine neuropathology service
Noy et al. Chronic Traumatic Encephalopathy-Like Abnormalities in a
Routine Neuropathology Service. J Neuropathol Exp Neurol . 2016

38. Risk factors for CTE
• 35% of bodies in routine neuropathology service
• 48% of those with h/o head trauma
Noy et al. Chronic Traumatic Encephalopathy-Like Abnormalities in a
Routine Neuropathology Service. J Neuropathol Exp Neurol . 2016

39. Risk factors for CTE
• 35% of bodies in routine neuropathology service
• 48% of those with h/o head trauma
• 42% of those with h/o substance abuse
Noy et al. Chronic Traumatic Encephalopathy-Like Abnormalities in a
Routine Neuropathology Service. J Neuropathol Exp Neurol . 2016

40. Risk factors for CTE
• 35% of bodies in routine neuropathology service
• 48% of those with h/o head trauma
• 42% of those with h/o substance abuse
• 55% of those with h/o both
Noy et al. Chronic Traumatic Encephalopathy-Like Abnormalities in a
Routine Neuropathology Service. J Neuropathol Exp Neurol . 2016

41. Risk factors for CTE
• 35% of bodies in routine neuropathology service
• 48% of those with h/o head trauma
• 42% of those with h/o substance abuse
• 55% of those with h/o both
• 20% of those with no h/o of either
Noy et al. Chronic Traumatic Encephalopathy-Like Abnormalities in a
Routine Neuropathology Service. J Neuropathol Exp Neurol . 2016

42. Risk factors for CTE
• 35% of bodies in routine neuropathology service
• 48% of those with h/o head trauma
• 42% of those with h/o substance abuse
• 55% of those with h/o both
• 20% of those with no h/o of either
Noy et al. Chronic Traumatic Encephalopathy-Like Abnormalities in a
Routine Neuropathology Service. J Neuropathol Exp Neurol . 2016

43. – 3,904 men (65yo) -Wisconsin Longitudinal Study
– Measured depression and cognition
– Football players vs 1)non-collision and 2) non-sport
– Football players lower depression scores than non-
collision
– No other significant associations on any outcomes

44. Weigh the Risks Against Benefits

45. Summary – Evidence So Far
Suggests
– No benefit to repeat trauma to the brain
– Concussions can have a cumulative effect
– Concussion risk factor for abnormal tau, harmful
– Furthermore, risks in sports besides concussion
– Preliminary studies do not support an effect of
subconcussive blows, but research not conclusive
– Benefits of sports are substantial
– Athletes need to weigh risks against benefits and
decide

46. Options
– Ban sports or high risk sports
– Ban certain high risk aspects of sports
– Try to decrease risk
– Allow parents and athletes to weigh
risks vs. benefits
– Re-evaluate as time goes on

47. Options
– Ban sports or high risk sports
– Ban certain high risk aspects of sports
– Try to decrease risk
– Allow parents and athletes to weigh
risks vs. benefits
– Re-evaluate as time goes on

49. Further Reading
1. Deshpande SK, Hasegawa RB, Rabinowitz AR, et al. Association of playing high
school football with cognition and mental health later in life. JAMA Neurol. 2017 Aug
1;74(8):909-918.
2. McKee AC, Cantu RC, Nowinski CJ, et al. Chronic traumatic encephalopathy in
athletes: progressive tauopathy after repetitive head injury. J Neuropathol Exp Neurol
2009;68:709-35.
3. Carson A. Concussion, dementia, and CTE: Are we getting it very wrong? J Neurol
Neurosurg Psychiatry. 2017 Jun;88(6):462-464
4. Noy S, Krawitz S, Del Bigio MR. Chronic Traumatic Encephalopathy-Like
Abnormalities in a Routine Neuropathology Service. J Neuropathol Exp Neurol .
Epub ahead of print 2016.
5. Meehan WP III, Taylor AM, Berkner P, Sandstrom NJ, Peluso M, Kurtz MM, Pascual-
Leone A, Mannix R. Division III Collision Sports Are Not Associated With
Neurobehavioral Quality-of-Life. Journal of Neurotrauma 2016;33(2):254-9.
6. Non-Medical: Kids, Sports, and Concussion: A guide for coaches and parents. 2nd
edition. Praeger Publishing © 2018

50. Questions?