October 16, 2011
- Hello, ladies and gentlemen, and thank you for joining us for another session of the Operative Grand Rounds. For this session, we're honored to have with us, Dr. Gail Rosseau, a neurosurgeon from NorthShore Health System in Chicago. She's also a board member of the double-ANS and has done tremendous work in terms of public awareness for compression and protection of our children. Gail, I would like to thank you for joining us and we're all very excited to listen to this very important topic.
- Thank you Aaron, it's nice to be here. Well, first, let me tell you a little bit about the background on this slide program that we're getting ready to present to our colleagues. As you know, Aaron, over the last year, you could hardly open a newspaper without there being a report or a story about a concussion related to sports. And of course, the AANS and CNS, America's neurosurgeons always have shown leadership in this. But the topic has become one that is just in the hearts and minds of everyone in the viewing public. And so our national organizations thought that this was the right time for us to gather together what is known, what the best scientific evidence is, what the best available consensus is, and present that as a united group of neurosurgeons to the public in an effort to be able to be as helpful as we can to our patients, our future patients and to do the responsible, important things that we can do to aid in improving the public health. So this slide set was developed in the summer of 2011, by a consensus of a large number of experts in the field. In fact, Aaron, I think this may be the first time that we have such a slide set that has been agreed upon, like a neurosurgical topic in which an entire slide set has been vetted by the AANS leadership, the Congress of Neurological Surgeons leadership, the Joint Section on Trauma, the ThinkFirst board of directors, the leadership of the Council of State Neurosurgical Societies, as well as the individuals who represent organized neurosurgery on the NFL Head and Spine Injury Prevention Committee. So, this consensus is what we'd like to present to our colleagues today in the hope that they will download it from the websites of the organizations I've just mentioned. AANS, CNS, ThinkFirst, in order to use it in their own communities. So concussion and sports information for your community from America's neurosurgeons. And we framed this in terms of questions that the public and the media have; what is a concussion? Why is there an increased focus recently on sports concussions? How are sports concussions treated? What programs are available to help prevent these concussions? And where could a member of the general public or the media go for further information? So, first of all, what is a concussion? And I'd like to draw the attention of our viewers, to the fact that all of the slides that have neurosurgical information are referenced, and you'll see those references at the bottom of each slide. I would also draw the attention of each neurosurgeon to the fact that there are a select group of references that are listed on the website for reading, about a dozen current and important papers that can bring even the neurosurgeon who does not normally treat sports concussions, up to speed on this topic so they can feel comfortable addressing this public health concern. A concussion is defined as you see there, a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. and this comes from the consensus statement on concussions at the most recent international conference on concussions in sports. For the purposes of the general public, it's usually defined as any change in neurologic function that's the result of a mild traumatic brain injury. What's new is that by definition, only about 10% of concussions involve a loss of consciousness. When they are performed, a CT and MRI are often normal. But about 15% of those individuals suffering a concussion may have symptoms that last longer than one year. So this is an example of the deceleration injury that occurs, the forceful motion of the head that causes a brief change in mental status for less than 30 minutes, which is what our current definition is of a concussion. Now, this is valuable and it was-- This is a locker room poster that the CDC and the NFL came up with, it's downloadable and you'll be able to find it at the websites I'll list at the end of this program. It encourages the recognition and reporting of sports concussions. And I highly recommend it to all of our colleagues. In the fine print on that poster, you see concussion symptoms, they are various. And these are the common symptoms that are well-known to everyone in the neurosurgical community; confusion, headache, difficulty remembering, balance problems, feeling sluggish or irritable, all of these things on both left and right are the things that neurosurgeons deal with day in and day out. And I'll just bring your attention to down at the bottom here, cdc.gov/concussioninyouthsports, which is a very useful program. Well, why has there been an increased focus recently on sports related concussions? And why are we now advocating that neurosurgeons play a role in public health education? Well, first of all, there's been this evolving definition of concussion, so that now only one in 10 events that we call concussions involve a loss of consciousness. I don't know about you Aaron, but that's different than what the concussion definition was when I trained in my residency. A concussion is common in sports and appears according to the best evidence to be increasing. There is the potential for catastrophic outcomes. And we're all asked about these when they're reported in the broadcast media. And then finally, there's the development of some tools with more to come, that describe post-concussive dysfunction and help us evaluate how badly a patient's been injured and what we need to do in order to help them return to play. Why the increased focus? Well, again, this evolving definition. And you'll see down at the bottom of the screen, some of the more recent articles that bring together the consensus statements about what we now as the sports medicine community, define as a sports concussion. Why they increased focus? Well, look at these numbers, they're simply astounding. If you compare the number of sports and recreation related concussions in the US, where there are anywhere from one and a half to nearly 4 million a year, with any other neurosurgical condition, it just clearly outnumbers any other condition we neurosurgeons treat. So concussion is common, it's common in youth sports. And it appears that just under 10% of high school athletes will have/will sustain a concussion during the time that they play sports during their high school years. And this number appears to be increasing especially among high school athletes. Well, this is important not only for high school athletes, but for the even larger numbers of kids who are playing youth sports. And here's some examples on this slide, the top corner, sports, there's thought to be as many as 4 million young kids, mainly young boys playing football, and they of course are inspired by what's happening in the NFL. But it's not just football. Football is one of the major national pastime, but this affects other sports as well. And it affects not just our young boys, but our young girls. Among high school soccer players, concussions are more commonly reported in girls and boys. Girls competing in soccer and basketball are more susceptible to concussions than are boys in the same sports. And according to some studies, for example, this one we've cited in The Journal of Athletic Training, in high school soccer, girls sustained concussions 68% more often than boys did in the same sport. So, this is very common. Why should that be? Well, there are two main reasons we think why girls and girls high school sports and especially soccer, leads to more reported concussions than boys sports. This seems to be, number one, that girls are more likely to report a concussion. And number two, there does seem to be a difference in the strength of the neck musculature, such that the whipping motion or the momentum of the head on the neck is just more significant in girls than in boys. Therefore, allowing the potential for a concussion to be more serious with a girl a blow to the head like that. Why the increased focus? Well, you've seen the media reports as have we all, that highlight the potential for rare, but really catastrophic outcomes in young healthy individuals. And I'd like to call the attention of every one of our neurosurgical colleagues to the Lystedt Laws, which have now been passed in 30 states plus the district of Columbia, these laws are designed to prevent repeat injuries and their tragic consequences. In 2010, there was an increase in reported concussions. And this led to a new NFL concussion policy, which you see here. This comes from that NFL concussion guidelines, that, "Once removed for the duration of a practice or a game, a player should not be considered for return-to-football activities until fully asymptomatic." And here's the new part. "At rest, as well as after exertion, they need to have a normal neurologic exam, normal neuropsychological testing." And here's another new element to this. "Until they're returned-- Cleared for return-to-play by not only the team physicians, but by an independent neurological consultant." And these kinds of changes in policy, Aaron, are already being seen at the collegiate, high school and youth sports levels. There were additional directives regarding the need or usefulness of neuropsychological testing, that rules relating to the use of the helmet will continue to be closely enforced. And the NFL has made a major commitment to research and study on all elements of concussion with a particular focus on the long-term effects. And as you know, this is being studied and will continue be studied and neurosurgeons are leading the way. Again, why the increased focus? Well, there's been the development of tools to describe post-concussive dysfunction. Joe Maroon and his group at the university in Pittsburgh, working with the Steelers have put 25 years into developing ImPACT. This is an example of ImPACT testing and there are several vendors available that do this type of pre and post-concussive testing with many more tests, both psychological and biomarkers to come in the years to come. Well, what community groups will want to know from the neurosurgeons using a slide set such as this are, what can they do to help minimize the risk factors in sports concussion? Well, they need to teach safe practice. They need to encourage the recognition and reporting of symptoms. Be aware that injuries are more common in the younger athletes, even though they're more likely to be reported in the NFL. And we hear a lot about them on Sunday nights and Monday mornings and the news, that they're much more common in the younger players. We need to use the available assessment tools that we have, monitor the developments that neurosurgical leaders are contributing to at the very highest levels of play at the NFL. And then finally, endorse and participate in neurosurgery's own head and spine injury prevention programs like ThinkFirst. Now, many neurosurgeons are volunteering their time as coaches and team physicians. And greater emphasis needs to be placed on the teaching of the fundamentals and techniques, especially safe, blocking and tackling. In practice and in games, spearing should never be allowed. Encourage the recognition and reporting of symptoms. This can be downloaded, again, you'll see the website where you can download it at the end of this program. Use these kind of... A set of recognition and reporting posters to encourage a new culture, a culture of protecting the brain among all players of contact sports. Work smart, use your head, don't lead with it. We need to be extra vigilant with younger players because they are more likely to be injured. Use the available tools. And again, these are heads up, downloadable tools that can be passed out by neurosurgeons when they give community lectures to the local university, local trainers, local high school, or groups, they're all available. And again, they'll be listed at the end of this talk. We wanna encourage the passage of Lystedt Laws in all 50 states. As I mentioned earlier, as of October, 2011, these laws have been passed in 30 states, plus the district of Columbia. These laws were named in honor of Zachery Lystedt, who in October of 2006, at age 13, was returned to a football game after a concussion and was permanently injured. And young Zach Lystedt and his parents have made it their mission to help prevent such a tragedy from ever happening to another young athlete. So there are aspects to the Lystedt Laws that affect coaches, affect parents and guardians and affect athletes. And I would encourage every neurosurgeon to be familiar with the details of these three elements of the laws and to be a force for change in your community if these laws don't exist. They protect our young athletes and protect our sons and daughters. Well, how are concussions treated? With the current time, our recommendations are based on the best of their available science and consensus. But as you well know, this is an evolving topic. Physical rest, while you should not only refrain from strenuous aerobic exercise, but also minimize activities that require concentration and attention. Now, we've been talking a lot about football, we've mentioned soccer, but traumatic sports related injuries affect all the sports that we see here. Cycling, far and away is the recreation related activity that's most likely to result in a traumatic brain injury. So we need to be aware that as neurosurgeons, all of these activities are potential causes of traumatic brain injuries. And we need to be playing our part in educating the public in order to help prevent these injuries. The use of the helmet while biking could prevent one injury every four minutes in the United States. So as neurosurgeons, we need to practice what we preach. I hope that neither you, nor I, or any of our colleagues, Aaron, will ever be seen out on a bike without a helmet. It turns out the bicycle helmets are effective in reducing 85% of traumatic brain injuries. Yet only 40% of cyclists wear them. So the message is wear them, wear them properly and so many injuries can be prevented. What programs are available to help neurosurgeons help the public be safe? Well, we all know that ThinkFirst is the pride of neurosurgery. It's our national injury prevention foundation. Currently, there are 135 US chapters offering evidence-based presentations on prevention of head and spine injury to youth and teens. The programs discuss the dynamics of brain and spinal cord injuries and the importance of making correct choices. It was founded in 1986 by the AANS and CNS together, the same people who are with the ThinkFirst were behind the creation of this slide set for the use of all neurosurgeons. It decreases neurological trauma by prevention, education and advocacy. And ThinkFirst is the premier neurosurgical, neuro-trauma prevention organization. The elementary school program includes these six elements; brain and spinal anatomy pertinent to the age group, vehicle and bicycle safety, playground and water safety and violence prevention. The program for teams is new and was partially co-funded by the Christopher & Dana Reeve Foundation. It includes very important and teen specific educational programs such as distracted driving, drinking and driving, violence prevention and the use of appropriate helmets during sports. So what are some of the future directions? What neurosurgical research is going on right now that we might be able to hint at or share with the viewing public, the community that we'll be seeing programs such as this one? New game rules. Well, we just had the opportunity to ask Roger Goodel, the NFL commissioner this week about what might be coming down the pipe in football. And the answer is everything and every idea is on the table. The NFL and organized football is serious about making football and by extension, all sports safer. So we can continue to have our athletes as well as our spectators enjoy the sports we love while making it safe. What might be some of the new return to play directives? And evidence is being amassed on a daily basis with accelerometers in practice and play that hopefully will give us data to... Upon which to base some of our return-to-play directives. What about new equipment? And this is a huge issue. You may have seen that one of the MacArthur Foundation genius grants last week was awarded to someone who is looking at just this topic, how to make helmets safer in contact sports. And finally, genetic and biomarkers. Might there be a genetic marker that allows us in the future to direct a young athletes to or away from contact sports, if they have certain genetic markers which indicate that they may be more likely to be permanently injured with a concussion based on their own genetic makeup. And then finally, might there be a biomarker that would allow us in the future to detect how serious a concussion is with some type of blood tests, just as we now can evaluate the evolution of a myocardial infarction based on a blood test. So these are exciting future directions that neurosurgeons are working on as we speak. And we hope that we'll be able to report to the public in the months and years to come. So let me conclude by summarizing what every neurosurgeon knows. All concussions are serious. We want to encourage young athletes to not hide it, to report it and to take the time to recover. Because as they say in the NFL, it's better to miss one game than to miss the whole season. Traumatic injuries, particular in sports affect more patients than all other neurological/neurosurgical conditions combined. At present, our best treatment is prevention. Neurosurgeons are experts in the treatment and prevention of concussion and traumatic brain injury. We have and will continue to as a specialty lead the way in this very important element of the national public health. So let me leave you with some very useful websites where you can go for further information on this topic. And with that, I'll close. Aaron, thank you so much for asking me to present this. It's a pleasure to be with you and to be with our colleagues, talking about the important topic of sports concussions.
- Well, Gail, I want to, on behalf of all the neurosurgeons, thank you for all the great work you have done in this area. This is a great purpose. This is really community service. This is what neurosurgeons are supposed to be doing. And I think you have led the way and we all are very, very appreciative. I would like to ask you a common question neurosurgeons run into. And I know this is very generic, but I thought still I can ask that question. We often see a family in the clinic, in the office, and the child, the boy or... He's maybe in high school early on and he's playing football and has a head concussion. And they come to you and say, "Well, the coach asked us and the family doctor asked us, we have to come see you and you tell us what to do and how long should the patient should the child or the boy stay out of the game?" What's your thought process? And how do neurosurgeons need to be more active to learn how to manage patients with concussion?
- Well, that's a very good question and it's a very topical one. The last patient I saw this evening before I joined you was a high school football player, the quarterback on his team. He's a junior, he was the starting quarterback. He's out with his third concussion in one year and he wants to go back to the basketball season and obviously, for football next year. So we... There is no hard science on this, but we're accumulating data that allows us to go with consensus and best available evidence. And so, in an injury like that, where there's clearly been a concussion and the student is kept out of school and practice until their symptoms break. Now, typically the student, the individual, the athlete, will become symptom free at cognitive rest first. So in the case of the students that I just saw, when I saw him three weeks ago, he was one week, which was the most recent time. He was a week post concussion, still having dizziness, having some increased symptoms with use of computer screens, television, texting, et cetera. We removed those things and he felt better two weeks later. Now we reintroduced some concentration with some computer games and some computer work and he is now symptom free with full cognitive activities. So he will go back to mild aerobic exercise with very little Valsalva. So light... Multiple reps with light weights. Then he will be released to the trainer to go back for a graduated program that will be first individual exercise with increasing weights. And then that will increase to reps independently of sports simulations. And only when he's able to do that, so, be symptom-free at exertion with walkthroughs, can that individual go back to full practices. So it's a graduated program that we release them, we as the neurosurgeons released them to the trainers to begin the graduated program back to full participation and practice and then in games.
- Okay. Thank you for your great thoughts, Gail and we look forward to having you with us for other very important, such as the topic today. Thank you.
- Thank you. It's our hope that every neurosurgeon will go to the AANS, CNS or ThinkFirst websites where they can download these slides and we can become 3,000, 4,000 points of light in the nation on this subject. These are meant for neurosurgical use, they're consensus slides. They're also a great way to introduce your practice into the community. And we encourage everyone to use them.
- Very well said. Thank you, Gail.
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