6/22/2011 1 Tad Seifert, MD Norton Neuroscience Institute Louisville, KY Case Presentation Football player No chronic medical issues Two documented concussions during current season 1 st event ○ Last offensive series of game ○ Cleared to play following week 2 nd event ○ Appx 2 months after 1 st event ○ Appx 2 months after 1 event ○ Suffered during 2 nd quarter ○ Did not return for remainder of game ○ Held out the following week ○ Started next game 14 days later
Transcript
6/22/2011
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Tad Seifert, MD
Norton Neuroscience Institute
Louisville, KY
Case Presentation Football player No chronic medical issueso c o c ed ca ssues Two documented concussions during current
season 1st event
○ Last offensive series of game○ Cleared to play following week
2nd event○ Appx 2 months after 1st event○ Appx 2 months after 1 event○ Suffered during 2nd quarter○ Did not return for remainder of game○ Held out the following week○ Started next game 14 days later
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Case presentation
3rd event (appx 6 wks after 2nd injury)4th t h l t t h l t hit (fl d 4th quarter helmet-to-helmet hit (flagged as illegal)
Appears unsteady
Transient “dazed” appearance
Not pulled from game
R i d f i i ff ti Remainder of game is ineffective
Next scheduled game is 2 wks
Case Presentation
Should this player sit?
Be retested with ImPACT?
Be reinserted in the “gradual RTP protocol?”
None of the above?
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15 yard penalty assessed
Julius Peppers fined $10,000,
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Aaron Rodgers
“It hurt, I can tell you that He hit methat. He hit me pretty good. I know what a concussion feels like. I’m just grateful this wasn’t hard enough to give me another one ”me another one.”
The Capital TimesMadison, Wisconson
Shawn Doherty writes of a “consipiracyof silence”of silence” “After all the drama over Rodgers suffering
two concussions and getting pulled out of one game and missing the next last fall, why haven’t there been more questions about what most of us saw Sunday, even if some y,of us don’t want to admit it?”
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Shawn Doherty of The Capital Times:“I’m talking about how Rodgers looked and
acted right after Bears DE Juliusacted right after Bears DE Julius Peppers’ illegal helmet-to-helmet whack to his head. Rodgers was woozy and wobbling about with dazed eyes. If you didn’t notice he was wobbling, surely you noticed his football was. His magic was gone for the rest of the game. He couldn’t even hit the mark with a couple of short passes…”
Aaron Rodgers
3 days postgame:“N t h t t lk b t I did ’t h “Not much to talk about. I didn’t have a concussion. I want to dispel that rumor. No concussion. I was fine. Yeah. Helmets are designed to prevent concussions, I think.”
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“Helmets are designed to prevent concussions I think ” A R dconcussions, I think. -- Aaron Rodgers
Robert Cantu, MD Boston University Medical School
Senior Advisor to NFL Head, Neck, and Spine Medical Committee:○ “His confidence about helmets preventing○ His confidence about helmets preventing
concussions is misguided. They are made primarily to prevent skull fractures and subdural hematomas. Do they prevent concussions? Probably they do, but just a small fraction.”
Let’s talk about helmets…..
“That was lucky. As much as the new helmet feels uncomfortable and I’m stillhelmet feels uncomfortable and I’m still getting used to it, I’m really happy I was wearing it on that (Peppers’) hit. ----Aaron Rodgers on his switch to a new model after suffering
two known concussions earlier in the season
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Schutt AiR XP “The Schutt AiR XP™ is
a traditional shell helmet with that familiarwith that familiar, spherical shape that so many players have grown up with. A unique combination of tradition with state-of-the art technology in a helmet that’s small in appearance but packs pp pthe BIGGEST protection of any traditional shell helmet on the field.“
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Packers statement: “ wearing a specifically modified helmet ….wearing a specifically modified helmet
with extra padding to reduce the risk of sustaining another concussion….”
SI.Com’s Will Carroll: “…it’s neither special or that advanced. The
Schutt design is said to be better than the t d d d i th t R dmore standard design that Rodgers wore
previously, but there are a number of players that wear Schutt designs already, as they are available to any player to wear.”
Schutt AiR XP: “Tests Don’t Lie”---Schutt website
“In head-to-head testing at 105 degree by an independent research lab the TPU pcushioning inside the AiR XP dramatically out performed the bonnet system in the Xenith X1 and the foam cushioning in the Riddell Revolution.”
“The Xenith X1 helmet absorbed 23% less impact than the AiR XP.”“Th Ridd ll R l ti h l t b b d “The Riddell Revolution helmet absorbed 12% less impact then the XP.”
“The Riddell VSR-4 absorbed 28% less impact than the XP.”
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Spokesmen for the Packers turnedPackers turned down requests for further comments on Rodgers’ new helmet citing respect for “his privacy”
Schutt TPU (Thermoplastic Urethane Cushioning) “TPU remains the best performing
padding system in football today ”padding system in football today.”
“In game conditions, the AiR XP outperform all the other helmets on the field.”
“It’s proven superior to traditional foam padding in game-like conditions: better impact absorption, better heat management, and better hygenics”
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“TPU cushioning won’t take awon t take a compression set, won’t break down (even after thousands of impacts) and is resistant to moldresistant to mold, mildew, fungus, and bacteria”
Schutt website fine print warning
WARNING: Contact in football may result in Concussion/Brain injury which no helmetin Concussion/Brain injury which no helmet can prevent. Symptoms include: loss of consciousness or memory, dizziness, headache, nausea, or confusion. If you have symptoms, immediately stop and report them to your coach, trainer, and parents. NO HELMET SYSTEM CAN PROTECT YOU FROM SERIOUS BRAIN INJURIESBRAIN AND/OR NECK INJURIES INCLUDING
PARALYSIS OR DEATH. TO AVOID THESE RISKS, DO NOT ENGAGE IN THE SPORT OF FOOTBALL.
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NFL Player’s Association Report
“Dangers of the Game”Game Based on 2010
regular season
After week 15, NFL on pace for 269 concussions
21% increase from21% increase from 2009
34% increase from 2008
Alan Schwarz , October 2010“As Injuries Rise, Scant Oversight of Helmet Safety”
Reports the lone existing helmet t d d ittstandard was written
more than 30 years ago by a volunteer consortium that includes and is largely financed by the helmet makers themselves, that that this standard is aimed at preventing skull fractures, not concussions.
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“Helmets both new and used are not –and never have been – formally testedand never have been – formally tested against the forces believed to cause concussions”
“…the fact that helmets are held to no standard regarding concussions surprised almost every one of dozens of p ypeople interviewed for this article, from coaches and parents to doctors and league officials.”
January 2011Federal Trade Commission Investigation
Looking into marketingLooking into marketing claims for some helmets
Including the Schutt Air XP
Prompted by Jan 4 letter by US Rep Tom Udall of New Mexico
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FTC Probe
Investigating “the misleading safety claims and deceptive practices” in theclaims and deceptive practices” in the industry
Takes aim at Ridell claims that its popular Revolution models “decrease concussions by 31%”
Cushioned by traditional padding used by competitors: the head-sized fruit is squashed
Surrounded by the plastic-based padding touted by Schutt for its “impact absorption”: the fruit remains whole
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Schutt Air XP Youtube.com video advertisement
Robert Erb, CEO of Schutt Sports: “The video was meant as a parody and
Schutt never claims its products are concussion proof.”
Virginia Tech May 2011 Study releases new rating system of adult football helmets
Accepted for Accepted for publication in upcoming issue of Annals of Biomedical Engineering
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2011 VT Helmet Study
First time comparative test results on football helmets have been made publicfootball helmets have been made public
Assigned 1 to 5 star ratings providing a “prediction of associated concussion risk.”
Study based on “analysis of a million impacts we’ve collected” -- lead author and professor of biomedical engineering, Stefan Duma
2011 VT Helmet Study
Performed 120 impacts on each helmet model at multiple locations and impactmodel at multiple locations and impact energies.
A total of three new helmets were purchased for each model and tested
Utilized over one million measured head impacts to quantify the impact exposure and concussion risk
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2011 VT Helmet Study
Impacts performed replicating on-field football head impactsfootball head impacts
Each helmet is tested at four impact locations (front, back, side, and top) at five different impact drop heights ranging from 12 inches to 60 inches.
2011 VT Helmet Study
Cost of helmet showed little correlation to the relative protection offeredto the relative protection offered
NR (not recommended): Adams A2000 Pro Elite --- $199.95
1 star: Riddell VSR4 --- cost not available
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2011 VT Helmet Study
4 starS h tt ION 4D $259 95 Schutt ION 4D -- $259.95
Schutt DNA 4+ -- $169.95
Xenith X1 -- $299.99
Riddell Revolution -- $182.99
Riddell Revolution IQ -- $222.99
5 star Riddell Revolution Speed -- $243.99
2011 VT Helmet Study Criticism
Researchers simulated only head-to-ground impacts instead of helmet toground impacts, instead of helmet-to-helmet
Rotational forces not considered
Time duration of impact not considered
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“We disagree with the decision, and it was a clean hit.” – Vancouver captain Henrik Sedinc ea t a cou e capta e Sed
“It seems like four games is pretty excessive in the Stanley Cup finals” – Canucks Keith Ballard
“In my opinion, it’s not the right call. It was a bit late, but anybody that’s played the game y y p y gknows you have to make a decision in a fraction of a second. I don’t know how the league could come up with that decision really.” – Vancouver coach Alain Vigneault
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“I saw him coming, but there is nothing but t e e s ot gyou can do. Mine, they say it was late, it’s arbitrary….that is the decision they made and I have to respect that, but I d fi it l d ’tdefinitely don’t agree with it.” --Aaron Rome, Vancouver Canucks
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James Harrison 2008: $20,000 fine for criticizing a roughing the
passer penalty2009 $5 000 fi f l t hit Ci i ti B l 2009: $5,000 fine for late hit on Cincinnati Bengal Andrew Whitworth
2010: $5,000 fine for slamming Vince Young to the turf
2010: fined $75,000 for helmet-leading hits knocking Cleveland Browns receivers Josh Cribbs and Mohamed Massaquoi out of same game
2010: fined $20 000 for late hit on Drew Brees 2010: fined $20,000 for late hit on Drew Brees 2010: fined $20,000 for helmet-leading hit on Buffalo
QB Ryan Fitzpatrick
James Harrison on Cribbs being briefly knocked unconscious: “"I thought Cribbs was asleep. A hit like
that geeks you up especially when youthat geeks you up, especially when you find out the guy is not really hurt, he's just sleeping. He's knocked out but he's going to be OK."
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James HarrisonSuper Bowl Week
Suggested the league “lay a pillow down where I’m going to tackle them so theywhere I’m going to tackle them, so they don’t hit the ground too hard.”
Concussions (history)*high school death Oct. 25, 1921
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Traumatic Brain Injuries Remain in Headlines Weekly, if not Daily
Eastern Oregon University WR Dylan U e s ty y aSteigers dies from CHI on May 9, 2010
Boston Celtics Glenn “Big Baby” Davis (concussion) in 2010 Game 5 Eastern Conference Finals vs. Orlando Magic
Marc Savard Boston Bruins center
NHL All-Star 2008 & 2009009
March 7th, 2010 concussion vs. Pittsburgh
February 8th, 2011 suffers second concussion in 10concussion in 10 months
Does not play during Stanley Cup run
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Marc Savard
“I’m feeling better. I still have my days. The memory is the biggest thing for meThe memory is the biggest thing for me and the mornings are kind of tough. The memory stuff is really terrible and hopefully it gets better.”
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Fencing Response
Described by Lifshitzet al @ UK Spinalet al @ UK Spinal Cord & Brain Injury Research Center
2009 publication in Medicine and Science in Sports and Exercise
Jahvid Best Hold multiple Cal records 2008 Pac 10 leading rusher 2008 Pac 10 leading rusher 2008 Emerald Bowl rushing record 2010 NFL draft 30th pick by Detroit (via
Minnesota) Signed $9.8 million over 5 year deal on
July 30, 2010 CJ Spiller (Clemson) picked 9th by Buffalo CJ Spiller (Clemson) picked 9th by Buffalo
signed for $25 million over 5 years Ryan Matthews (Fresno State) picked 12th by
San Diego signed for $26 million over 5 years
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Concussions and Suicide Concussion and depression relationship
well-established Prevalence of depression in general population
5% Prevalence in head trauma patients approaches
40% in some studies fMRI with reduced activity in regions known
to be implicated in depression Dorsolateral prefrontal cortex and striatum Dorsolateral prefrontal cortex and striatum Medial frontal and temporal lobes Same pattern as that seen in non-concussed
patients with major depression
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Owen Thomas Suicide April 25th,
2010 21 yo U Penn DE No previous hx of
depression or concussion
Brain autopsy discovered early stages of CTE
t Youngest and 1st
amateur player to have documented CTE via brain autopsy
Kenny McKinley
Suicide September 20th, 20100 , 0 0
23 yo Denver Broncos WR
No documented concussions
Brain donated to Boston UniversityBoston University Center for the Study of Traumatic Encephalopathy
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Dave Duerson Suicide February 17th,
2011 50 yo former Chicago
Bears DB Note to family
included the request, “Please see that my brain is given to the NFL’s brain bank ”NFL s brain bank.
Neuropathology exam revealed indisputable evidence of CTE
Ricky Bell
Died February 17th, 20112011
Suicide suspected
36 yo former Chicago Bear and Canadian Football League DBg
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Ricky Bell Harold Nash – current strength & conditioning coach for
New England Patriots -- played with Bell in the Winnipeg secondary in 2002 and 2003secondary in 2002 and 2003.
Nash recalled a game against Toronto in which Bell took a head shot. The wobbly Bell wanted to go right back in.
"Ricky found his helmet," said Nash. “But he wouldn't do any of the (concussion) testing. Rick was just, 'No, I'm not doing the test.' He finds , ghis helmet, and he lines up in the box. He's supposed to be out there covering a receiver.”
Derek Boogaard
Found dead May 13th 201113 , 2011
“Accidental death due to mixed alcohol and oxycodonetoxicity”
28 yo New York yRanger left wing
Concussion suffered December 9th, 2010
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Derek Boogaard 3 documented concussions during playing career Suffered lingering effects consistent with post-
i dconcussive syndrome Told reporter from The Minneapolis Star-Tribune: “I
didn’t have people around me. That’s why when (Rangers’ forward Marian Gaborik) got his concussion, I’d call him everyday and say, ‘I want you to call me and we’ll go for lunch and we’ll do something for at least an hour just so you can get out of your apartment.’ I didn’t want him going through y p g g gthe same thing I did.”
Brain donated to BU reseach team
Dave UlinskiKentucky OLy
Daniel NobleOklahoma DT
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“…a quest for cures, treatments, and dead men’s brains.”
“I hadn’t buried my son yet, but I finally realized what was going on: There was a competition for his brain” --- Ken McKinley, Sr.
“Coming to a head”Peater Keating of espn.com, December 2010
“It’s a new reality of the NFL. Grieving families can expect two phone calls: onefamilies can expect two phone calls: one from Morgantown, the other from Boston. “There should be one process, something simple where maybe players check a box to donate their brains,” McKinley says “Then maybe othersMcKinley says. Then maybe others won’t have to go through was I went through”
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Chris Benoit Michael Benoit ---
“What are my thoughts? My thoughts are that the CTE doctors and advocates need theiradvocates need their behinds kicked. Everyone loves to be in front of the cameras talking about the latest case of CTE, but no one is talking about the people who are currently suffering. The research world is an old boys’ club. yHow many more brains do we need to prove that concussions can cause CTE?
WWE Statement: "It is natural that a father would try to come up with
a reason why his son would tragically murder his if d hild d th it i id B dwife and child, and then commit suicide. Based on
the study by the Sports Legacy Institute that claimed Chris Benoit had the brain of an 85-year-old with dementia, Mr. Benoit asserts that head trauma was the cause of his son's aberrant, criminal behavior. However, common sense would dictate that this is impossible. Someone with the brain of an 85-year-old with dementia would be unable to keep a traveling work schedule, drive himself to arenas, and perform intricate maneuvers in the ring much less commit a methodical murder-suicide over a 48 hour period."
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CTE mimicks ALS?
Journal of Neuropathology and eu opat o ogy a dExperimental Neurology, August 2010
12 brains with dx of CTE examined
Of these 12, three Of these 12, three also concurrently diagnosed with ALS (ante mortem)
Chronic Traumatic Encephalomyopathy (CTEM) Protein markers in these 3 patients NOT
consistent with ALSconsistent with ALS
TDP-43 found in brain and spinal tissue
TDP-43 NOT found in ALS
New term coined: CTEM
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Live game EEG data? Dr. Hashem Ashrafiuon Mechanical Engineering professor Mechanical Engineering professor,
Villanova University BCILab™ analyzes EEG waveforms
recorded by headset in order to predict abnormalities in brain activity
Software currently being developed by Brain Computer Interface (BCI), a Yardley, p ( ), y,PA firm
Publication of research findings expected this summer
Neurology, April 26, 2011
“The King-Devit test as a determinant of head trauma and concussion in boxershead trauma and concussion in boxers and MMA fighters” Measures speed of reading aloud a series of
single-digit numbers from left to right on 3 standardized test cards
Requires less than 2 minutes to complete Requires less than 2 minutes to complete
Delay on retesting after suspected concussion suggests true injury
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“The King-Devit test as a determinant of head trauma and concussion in boxers and MMA fighters”
Several limitations: Population selected (MMA participants and
boxers) likely had prestudy exposure to head trauma
Trials were performed ringside – no description given of level of activity around subjects or degree to which other j genvironmental factors were controlled
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