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More Hard Knocks: TBI and Concussion at the American Academy of Neurology Annual Meeting

Op-Med is a collection of original articles contributed by Doximity members.

Traumatic brain injury (TBI) and concussion were once considered the “silent epidemic.” At the recent 2018 American Academy of Neurology meeting in Los Angeles, it’s clear that these topics are no longer silent, but up front and center in the consciousness of thousands of neurologists who attended.

On the opening Friday, the Academy held a Brain Health Fair to inform and educate the general public about neurological conditions, ways to protect the brain and how to keep the brain healthy. Booths dedicated to pre-sport neurological exams, demonstrations of post-TBI visual/balance impairment and proper activity during recovery were attended by many local students and adults as well. Even at the end of the day, a sports concussion talk was followed by 20 minutes of questions from the attentive audience.

There were multiple sessions on mild (concussion), moderate, and severe TBI during the week, with the primary focus being on management of clinical sequelae such as headaches and the role of biomarkers. In addition, a special plenary lecture was delivered by Dr. Bennett Omalu, who talked about his career and the challenges he faced when he first reported the pathological findings of chronic traumatic encephalopathy (CTE). Dr. Omalu also encouraged the audience to be willing to fight for what you believe in. Lastly, Dr. Omalu participated in a panel discussion with Dr. Steve DeKosky.

Youth Contact Sports Debate

The Controversies in Neurology Plenary Session was a highlight this year, with debate topics selected by the Academy membership. The final debate pitted TBI/concussion experts Dr. Jack Tsao and Dr. Christopher Giza at opposite ends of the question “Would you let your child play contact sports?” After introductions, the pair met with a quick fist bump at center stage and the debate was on!

Dr. Tsao began by presenting a list of sports and polling the audience to see what attendees agreed upon was and was not a contact sport. Football and ice hockey were felt to be contact sports, while swimming, volleyball, and tennis were viewed as non-contact sports. Dr. Tsao then discussed the on-going U.S. Department of Defense-National Collegiate Athletic Association sports concussion study. Although sports-related concussions often target football as a main cause of injury, concussions are prevalent in non-contact sports as well, such as volleyball, lacrosse, soccer, basketball, cheerleading, and ballroom dancing.

Dr. Tsao also highlighted the benefits of youth athletics cannot be underestimated. Participating in sports yields health, psychological, and social benefits, including greater fitness, learning the value of discipline, teamwork, and leadership, and a higher likelihood of being hired for a job after college graduation. In addition, living a sedentary lifestyle may be more dangerous than playing sports as there is increased chance of obesity in children leading to greater risk for diabetes and multiple sclerosis. Prevention strategies, such as education, protective gear, safety rules, and technique training, have been implemented in recent years to protect players from concussions. Scientific data has not definitely shown that participation in contact sports increases risk of developing CTE. CTE has 4 stages and behavioral and memory complaints can be seen even while pathology is in early stages. CTE has been reported primarily in retired professional athletes who have a history of multiple concussions and repetitive subconcussive head trauma exposure over many years, and the recent publications have been from case series, demonstrating selection bias. The true incidence and prevalence of CTE in the general population as well as contact sports playing population has yet to be defined and risk factors identified. Thus, “Let Children Play Sports!”

Meanwhile, Dr. Giza countered with 5 reasons NOT to allow kids to play contact sports:

  1. Danger of catastrophic injury;
  2. Danger of chronic problems;
  3. Vulnerability of the young brain;
  4. Unfavorable risk-benefit; and
  5. Need for improved safety.

With videos of a young hockey player being body checked into unconsciousness and children practicing helmet-to-helmet hits, he argued that such risks outweighed any benefits. He talked about second impact syndrome and showed images of CTE in 110 out of 111 autopsy brains from NFL players. Dr. Giza argued that the younger brain was more vulnerable to TBI, with thinner skulls, greater apoptotic cell death, less myelination, different energy metabolism and cerebral blood flow, and distinct synaptic plasticity. He showed a tipped balance with risk for TBI, overuse injuries, burnout, use of performance enhancing drugs and lack of monetary gain against questionable benefits. His last point was that changing the culture of youth sports was hard; but offered hopeful data from youth hockey’s restriction of early body-checking resulting in a 64% reduction in concussions. In his final slide, Dr. Giza exhorted “Don’t Hurt Kids” by using proper equipment, practicing good technique, avoiding unnecessary contact, enforcing rules, educating players/coaches, and identifying and treating concussions.

In rebuttal, Dr. Tsao discussed the possibility that many concussions could be due to poor technique resulting in contact with the head rather than inherent risks from the contact sports. He also emphasized that it is possible to change sports to emphasize learning proper technique of play rather than focusing on contact. In addition, second impact syndrome has not been reported from the military battlefields and improvement in automated neurocognitive testing was reported after concussion, possibly due to practice effects.

After that, Dr. Giza pointed out 6–7 catastrophic injuries occurred in high school football players every year. He cited studies indicating 30–50% of youth players admitted hiding concussion symptoms. Since young athletes have difficulty in understanding the long-term risks of these activities, adults are obligated to protect them through rules and policies.

Before and after the debate, the audience was 67% against contact sports vs 33% in favor. Both speakers argued strongly for their assigned positions, and both disclosed that their debate and professional opinions differed. Drs. Tsao and Giza agreed there were substantial benefits to youth sports participation and that the decision to engage in a particular sport should be an informed individual choice.

Sports Neurology/Neurotrauma Wrap Up

Every day there were sessions covering TBI, concussion, sports and military neurology. From severe TBI in the ICU to the effects of sleep on elite athletes, there was didactic learning and open discussion for all. Platform presentations highlighted the newest data in Neurotrauma & Sports Neurology. From chronic consequences of combat sports, to issues of geriatric TBI, to complex relationships underlying cognitive post-concussive symptoms, the broad range of TBI was covered. Posters, even up to the last session on the last day, highlighted multidisciplinary care and education for TBI, network changes in anxiety circuits, new data on diagnostic modalities and innovative treatments.

Fortunately we have come a long way from the mid-1990s where symptomatic recovery within 15 minutes of injury might allow a player to resume playing a contact sport, to the current motto, “When in doubt, check it out.” The AAN is actively working with other concerned stakeholders to raise awareness of TBI/concussion risks and the number of program offerings continues to increase each year.

Dr. Christopher Giza is currently a professor of Pediatric Neurology and Neurosurgery at the David Geffen School of Medicine and Mattel Children’s Hospital-UCLA. He is the director and founder of the UCLA Steve Tisch BrainSPORT Program. He is also part of the UCLA Brain Injury Research Center and the UCLA Mattel Children’s Hospital, Los Angeles, CA

Sarah Shore is a research assistant at University of Tennessee Health Science Center.

Dr. Jack Tsao is a professor at the Department of Neurology, University of Tennessee Health Science Center, Memphis, TN. He is part of the Children’s Foundation Research Institute, Le Bonheur Children’s Hospital, Memphis, TN

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