Morning Briefing: Does baseball need a concussion protocol?

Morning Briefing: Does baseball need a concussion protocol?


Pirates general manager Neal Huntington (Jared Wickerham / Getty Images)

Concussions have become a major topic in sports over the last several years, mainly in football. But the Pittsburgh Pirates general manager would like to see concussions discussed more in baseball, particularly when it comes to catchers.

On Saturday, Pirates catcher Francisco Cervelli got his seventh concussion since the start of the 2015 season when he was hit in the head by a broken bat. He played for another half-inning after getting the concussion.

“The player has to feel pressure, as he’s standing there with 10,000 or 30,000 or 50,000 eyes on him, to make a decision, ‘Am I in or out of this game?’ ” Huntington told the Athletic on Sunday. “He knows if he takes himself out and he’s the catcher, there’s only one other catcher, and the game becomes a fiasco if that other catcher gets hurt.”

Huntington would like for a player to be able to come out of the game if there is a fear he has a concussion and, if that player passes a concussion test by the training staff in the clubhouse, be allowed to return. Current baseball rules do not allow a player who is removed from the game to return for any reason.

“It used to be, you’d get your bell rung and you’d stay in,” Huntington said. “We shouldn’t do that anymore. We should understand what that actually means. Our players’ safety should be first and foremost.”

Huntington knows some will argue against a new rule, like some argue against a 10-day injured list, which some teams have abused to give their pitchers extra rest.

“We’re going to abuse it — not necessarily [the Pirates], but as an industry, teams will abuse it. And it changes tradition. I probably should’ve had some behind-the-scenes conversations before having a public one today, but now it’s out there so, hopefully, there will be a dialogue.”

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Experimental PET scan detects abnormal tau protein in brains of living former NFL players

Experimental PET scan detects abnormal tau protein in brains of living former NFL players

(Boston) — Using an experimental positron emission tomography (PET) scan, researchers have found elevated amounts of abnormal tau protein in brain regions affected by chronic traumatic encephalopathy (CTE) in a small group of living former National Football League (NFL) players with cognitive, mood and behavior symptoms. The study was published online in the New England Journal of Medicine.

The researchers also found the more years of tackle football played (across all levels of play), the higher the tau protein levels detected by the PET scan. However, there was no relationship between the tau PET levels and cognitive test performance or severity of mood and behavior symptoms.

“The results of this study provide initial support for the flortaucipir PET scan to detect abnormal tau from CTE during life. However, we’re not there yet,” cautioned corresponding author Robert Stern, PhD, professor of neurology, neurosurgery and anatomy and neurobiology at Boston University School of Medicine (BUSM). “These results do not mean that we can now diagnose CTE during life or that this experimental test is ready for use in the clinic.”

CTE is a neurodegenerative disease that has been associated with a history of repetitive head impacts, including those that may or may not be associated with concussion symptoms in American football players. At this time, CTE can only be diagnosed after death by a neuropathological examination, with the hallmark findings of the build-up of an abnormal form of tau protein in a specific pattern in the brain. Like Alzheimer’s disease (AD), CTE has been suggested to be associated with a progressive loss of brain cells. In contrast to AD, the diagnosis of CTE is based in part on the pattern of tau deposition and a relative lack of amyloid plaques.

The study was conducted in Boston and Arizona by a multidisciplinary group of researchers from BUSM, Banner Alzheimer’s Institute, Mayo Clinic Arizona, Brigham and Women’s Hospital and Avid Radiopharmaceuticals. Experimental flortaucipir PET scans were used to assess tau deposition and FDA-approved florbetapir PET scans were used to assess amyloid plaque deposition in the brains of 26 living former NFL players with cognitive, mood, and behavior symptoms (ages 40-69) and a control group of 31 same-age men without symptoms or history of traumatic brain injury. Results showed that the tau PET levels were significantly higher in the former NFL group than in the controls, and the tau was seen in the areas of the brain which have been shown to be affected in post-mortem cases of neuropathologically diagnosed CTE.

Interestingly, the former player and control groups did not differ in their amyloid PET measurements. Indeed, only one former player had amyloid PET measurements comparable to those seen in Alzheimer’s disease.

“Our findings suggest that mild cognitive, emotional, and behavioral symptoms observed in athletes with a history of repetitive impacts are not attributable to AD, and they provide a foundation for additional research studies to advance the scientific understanding, diagnosis, treatment, and prevention of CTE in living persons, said co-author, Eric Reiman, MD, Executive Director of Banner Alzheimer’s Institute in Phoenix, Arizona. “More research is needed to draw firm conclusions, and contact sports athletes, their families, and other stakeholders are waiting.

With support from NIH, the authors are working with additional researchers to conduct a longitudinal study called the DIAGNOSE CTE Research Project in former NFL players, former college football players, and persons without a history of contact sports play to help address these and other important questions. Initial results of that study are expected in early 2020.

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Materials provided by Boston University School of MedicineNote: Content may be edited for style and length.

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Focus on Traumatic Brain Injury Research

Focus on Traumatic Brain Injury Research

NINDS Program Description

Traumatic brain injury (TBI) occurs when external physical forces cause damage to the brain, whether from impact, penetrating objects, blast waves or rapid movement of the brain within the skull.  Currently, TBI has three severity classifications (mild, moderate, severe) that are based primarily on the Glasgow Coma Scale.  The classification of mild TBI also includesconcussion, commonly defined as a transient alteration of brain function due to exposure to external physical forces. While acute TBI can be life threatening, TBI also can have long-term sequelae including cognitive and physical disabilitypost-concussion syndrome (PCS), and may contribute to the development of chronic traumatic encephalopathy (CTE). PCS results when various symptoms of concussion last weeks, months or more than a year following concussion.  CTE is a delayed neurodegenerative disorder that results from repetitive mild injury to the brain and can only be diagnosed postmortem. Additional general information about TBI can be found at the NINDS TBI Hope Through Research website.

Estimates of Funding for Various Research, Condition, and Disease Categories

Research/Disease Areas* FY 2016
FY 2017
FY 2018
FY 2019
Injury – Traumatic Brain Injury $105 $116 $122 $114

*Dollars in millions and rounded


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Quality of life in adolescents recovering from sports-related concussion or fracture

Quality of life in adolescents recovering from sports-related concussion or fracture

When we think of the recovery period in adolescents with a sports injury, we tend to focus on milestones marking relief from symptoms, restoration of strength, and perhaps return to play. But what about the effects of sports injury on other aspects of the young athlete’s life? How is the young athlete’s quality of life (QOL) affected following injury and throughout the recovery process?

In a new article in the Journal of Neurosurgery: Pediatrics by Kelly Russell, PhD, Erin Selci, BSc, Brian Black, MD, FRCSC, and Michael J. Ellis, MD, FRCSC, the authors define health-related QOL as “the ‘hidden morbidity’ or more subtle consequences of medical conditions or injuries on patient functioning that may not be captured by more traditional clinical outcome measures.” These researchers from Winnipeg conducted a prospective study of health-related QOL in young athletes who experienced a sports-related concussion or sports-related extremity fracture. The aim was twofold: 1) compare the effects of these sports-related concussions and extremity fractures on health-related QOL in adolescents during the recovery period and 2) identify what clinical variables are associated with worse QOL in adolescent patients with sports-related concussion.

In general, the study period extended from the date of the initial clinical assessment until physician-verified clinical recovery — a median of 26 days in the 135 patients with a concussion (60% male, mean age 14.7 years) and a median of 31 days in the 96 patients with a fractured extremity (59% male, mean age 14.1 years). Only three patients with a concussion did not attain verified clinical recovery during the study period.

At the time of the first clinical assessment, patients with a concussion were asked to rate their symptoms on a standard questionnaire (Post-Concussion Symptom Scale).

To evaluate all of the patients’ health-related QOL, the researchers relied on patient responses to self-assessment questionnaires covering cognitive functioning (Pediatric Quality of Life Inventory [PedsQL] Cognitive Functioning Scale) as well as physical, emotional, social, and school functioning, and also overall QOL (PedsQL Generic Core Scale). The questionnaires were completed at the time of the initial clinical assessment and again at each follow-up clinical appointment until physicians documented clinical recovery.

At the time of the initial clinical assessment (about 1 week postinjury), responses to the QOL questionnaires from the adolescents with a concussion demonstrated clinically meaningful impairments in physical, school, and overall health-related QOL when compared to healthy adolescent norms. The responses also demonstrated significantly worse cognitive QOL as well as greater impairments in school and overall health-related QOL when compared to responses from patients with a fractured extremity.

Patients with a concussion who attained clinical recovery within 28 days reported greater weekly improvements in QOL post-injury than those with delayed recovery times (median 51 days in this study). However, there was no evidence of persistent impairments in health-related QOL in the patients with a sports-related concussion or fracture who attained physician-documented clinical recovery during the study period.

In adolescent patients with a sports-related concussion, the authors found greater impairments in the initial health-related QOL in those patients with a history of previous concussion, higher initial symptom score, and/or length of clinical recovery.

To aid in the recovery process, the authors suggest that management of sports-related concussion in adolescents should be supplemented with early interventions to optimize cognitive, physical, and school QOL.

When asked about the study, Dr. Russell stated, “The results of this study indicate that adolescents who report lower health-related QOL after their concussion will likely take longer to recover. Even though adolescents can experience temporary impairments in health-related QOL after a sport-related concussion or fracture, these deficits generally do not persist past clinical recovery.”

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Materials provided by Journal of Neurosurgery Publishing GroupNote: Content may be edited for style and length.

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Current Concepts in Concussion: Initial Evaluation and Management

Current Concepts in Concussion: Initial Evaluation and Management

Am Fam Physician. 2019 Apr 1;99(7):426-434

Author disclosure: No relevant financial affiliations.

Mild traumatic brain injury, also known as concussion, is common in adults and youth and is a major health concern. Concussion is caused by direct or indirect external trauma to the head resulting in shear stress to brain tissue from rotational or angular forces. Concussion can affect a variety of clinical domains: physical, cognitive, and emotional or behavioral. Signs and symptoms are nonspecific; therefore, a temporal relationship between an appropriate mechanism of injury and symptom onset must be determined. Headache is the most common symptom. Initial evaluation involves eliminating concern for cervical spine injury and more serious traumatic brain injury before diagnosis is established.

Tools to aid diagnosis and monitor recovery include symptom checklists, neuropsychological tests, postural stability tests, and sideline assessment tools. If concussion is suspected in an athlete, the athlete should not return to play until medically cleared. Brief cognitive and physical rest are key components of initial management. Initial management also involves patient education and reassurance and symptom management. Individuals recover from concussion differently; therefore, rigid guidelines have been abandoned in favor of an individualized approach. As symptoms resolve, patients may gradually return to activity as tolerated. Those with risk factors, such as more severe symptoms immediately after injury, may require longer recovery periods. There is limited research in the younger population; however, given concern for potential consequences of injury to the developing brain, a more conservative approach to management is warranted.

Mild traumatic brain injury, also known as concussion, accounts for 80% to 90% of traumatic brain injuries and is recognized as a major national health concern.17 Whereas 2.8 million traumatic brain injuries were reported in 2013,8 estimates suggest up to 3.8 million occur annually.4,7,9. Concussion diagnosis and management can be challenging, complicated by the lack of a universal definition.2,6,10 No single objective measure or combination of measures for diagnosis and no definitive evidence-based treatments exist. Return-to-activity and return-to-play decisions are limited by a shortage of prospective data.6 Physicians must rely on expert guidelines and available assessment tools with clinical judgment for diagnosis and treatment.

therudedogshow@hotmail.comCurrent Concepts in Concussion: Initial Evaluation and Management
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