On Tuesday 11^th July 2017, Queen Square Private Healthcare welcomed an audience of primary care professionals to the 4^th in our popular series of GP Seminars.   For this event, we were pleased to welcome Dr Richard Sylvester, who is a consultant neurologist at the National Hospital for Neurology and Neurosurgery here in Queen Square. He is also an advisor to the English Football association and consults with a number of professional sports people from several different sports at the nearby Institute of Sport Exercise and Health (ISEH). His subject for the evening’s seminar was Concussion in the context of sport, a subject that is covered in the press with several high-profile cases being reported in the last few years.

Dr Sylvester introduced the evening by saying that concussion was not a purely sports related problem, although it would be the main focus for the evening. He showed us footage of the 1953 FA Cup final, where one of the goal keepers appeared to lose consciousness but was encouraged to continue playing. This demonstrated the attitude to head injury at this time. Dr Sylvester then raised the question “Has anything really changed?”

Dr Sylvester then moved on to introduce acute management of head injury and raised the questions “Why is concussion an issue?” and “Does Second Impact Syndrome exist?”

A case of possible ‘Second Impact Syndrome’ was used as an example. Dr Sylvester explained that the patient in question had suffered an injury on an amateur rugby pitch but was not removed from play. He then suffered another injury and sadly died from the injuries to his brain. It was explained that after the first impact to the brain, patients may then be more susceptible to further damage even if the first impact seemed minor – this is thought to be due to increased confusion and ataxia following the first impact worsening the second. This example highlighted that acute management of traumatic brain injury (TBI) needs to be considered carefully at all levels even if the injury seems minor to begin with.

The delegates at the seminar found this point interesting and raised some questions during this, with regards to patients they had seen and how they could apply head injury protocols to individual cases.

After answering questions from delegates, Dr Sylvester commented that clinicians need to be aware of concussion as an issue.  In support of this point, an explanation of concussion as a clinical syndrome was shown to us and this would be discussed later in the evening.

Dr Sylvester then moved on to talking about the long-term effects that could be attributed to concussion. This included chronic symptoms and young onset Dementia and the involvement of TAU proteins.

Reduced Participation

Dr Sylvester, with interesting points raised by the audience, raised concerns about the press involvement in the wider discussion about concussion. He suggested that exaggerated stories in the press could lead to reduced participation in sport and this is detrimental to society as a whole. Delegates asked the question as to whether young children should be banned from playing certain sports or heading the ball. It was suggested that younger children should not be playing contact sports but instead of banning them, sports apparatus should be adapted and, for example, softer or lighter balls should be used. Dr Sylvester said that children should be encouraged to play sport and build up muscles which in fact act as natural protection to impact injury, rather than stopping them from participating.

What is Concussion? A Clinical Syndrome?

In order to demonstrate the varying mechanisms of injury that could cause concussion, we were next shown footage of the 2014 Football world cup final. This showed a player who had a been knocked unconscious but allowed to play on and not checked for TBI. He was subsequently shown to approach the referee and ask where he was and what match he was playing in.

A description of concussion was then offered which included any of the following:

• Symptoms -Groggy feelings
• Signs- Loss of consciousness
• Balance impairment -Vestibular symptoms
• Behaviour Changes
• Cognitive Impairment
• Sleep/Wake disturbance

Although this is not a definitive list, Dr Sylvester suggested that these signs and symptoms could also be attributed to other clinical diagnoses, for example depression.

This then lead to the question; What is concussion?

Again, with audience participation, it was discussed that we don’t really know what concussion is. It means different things to different people. A definition was attempted at the 5th International Consensus Conference on Concussion in Sport (Berlin 2016) but this has not been adopted as a useful tool. Concussion can manifest as many different symptoms with many different pathological mechanisms. Some people suffer persistent symptoms which can be attributed to concussion

A list of persistent symptoms was also provided:

• Peripheral vestibular damage
• Disequilibrium
• Gait disturbance
• Head Pressure
• Anxiety
• Vertigo
• Visual vertigo
• Tinnitus

Concussion and Mild Traumatic Brain Injury (mTBI) – What is the difference?

Dr Sylvester explained that there was essentially no difference between concussion and mild traumatic brain injury, with both terms commonly being used interchangeably.  There exists great uncertainty in classification of head injury since quite often, the mechanism of injury is not always clear and brain imaging is classed as normal.  Interestingly, it was suggested that the sports world were generally extremely resistant to the use of the term mTBI, since it carries more serious connotations. Therefore, the distinction is further blurred by social and financial implications.

What is going on in the Brain with concussion?

Dr Sylvester then gave us an explanation of what happens in the brain when a concussion occurs, although it is still not generally considered to be fully understood. An acute impact and rotational force are generally suffered when a concussion occurs. The most vulnerable part of the brain that suffers damage when an impact occurs is the axons. Emerging evidence suggests that this seems to create a ‘biochemical cascade’ and causes microscopic changes, especially with TAU proteins which are also implicated in dementia and Parkinsonism. This also seems to lead Hippocampal disconnection which was demonstrated to us on the presentation screen with two Coronal Hi- resolution MRI images.

Diagnosis

It is important to firstly take a good history from the patient, with Dr Sylvester emphasising that diagnosis is reliant on the presence of an injury and symptoms. Although loss of consciousness is often associated with concussion, this only happens in around 10% of cases.

A good history should include questioning and examination of the patient and this should include orientation, memory, balance and symptoms. Quick concussion recognition tools can be used on the pitch with professional sports people and the SCAT 5 standardised assessment for concussion and mTBI should be used.  Dr Sylvester explained that the adoption of ‘Hawk eye’ technology in rugby and NFL in particular, meant that incidents could now be visualised like never before, gaining new insight to the mechanism of injury.

Diagnostic imaging, especially MRI with SWI (susceptibility weighted Imaging) can be very helpful in the assessment of mTBI and more severe injuries.

The SCAT 5 standardised assessment for concussion and mTBI should be used.

Management of mTBI

In the case of mTBI the 4 Rs should be used:

Recognise

Remove from play

Rest

Return to play (may be phased return)

In general, it was suggested that a gradual return to normal life and sports activities is the best option after a concussion. A gradual return to sport after 3 1\2 weeks was suggested as the ideal recovery time although Dr Sylvester said that younger people, especially under the age of 19 years of age, should have a longer recovery time. After 1 week, 85% of people will return to normal and after 1 month, if symptoms persist, then this may indicate that the patient may experience more long-term issues.

Where next?

Again, while engaging in interesting discussion, Dr Sylvester suggested that a better understanding of the subject and better epidemiology would aid diagnosis and treatment of mild traumatic brain injury and concussion. Prevention was then suggested as the next phase.

Prevention – Should helmets be used?

Some of the delegates asked a question with regards to helmets and their use in the prevention of concussion in sport, specifically in rugby and boxing. Dr Sylvester replied that helmets did not offer any extra protection and then provided statistics to show that serious concussion reduced by 50% after participants had stopped wearing helmets. It was stated that not wearing a helmet made the sports people play with more care, with boxers punching in a different way when the helmets were not present.

Gum shields were suggested as a much better option and a collar/neck guard was also shown, although the efficacy of these pieces of preventative equipment has not yet been validated.

The Future

Dr Sylvester proceeded to discuss emerging theories regarding the relationship between concussion and early onset cognitive symptoms.  He explained that as early as the 1920’s, persistent cognitive symptoms had been identified in boxers (Dementia Pugilistica) and in the 1970’s tauopathy had been identified in neuropathology studies which had a very different pattern to other dementias.  Chronic Traumatic Encephalopathy (CTE) has since been identified in soccer players, boxers and NFL players, although the difficulty is that there is currently no diagnostic criteria in place and no clinical phenotype.  Dr Sylvester suggested that the use of CSF biomarkers and Tau imaging (such as PET MRI) could increase understanding of the potential link between mTBI and CTE in the future.

Dr Sylvester started to summarise the evening by talking about the future and where treatment and diagnosis of concussion may lead to. He said that the use of biomarkers is a key area for future research. A blood test looking for markers, similar to Troponin tests in cardiac assessment, could be a growth area in traumatic brain injury assessment. A multi-modal assessment and approach was also suggested as a good way to progress, including neurological assessment, bio-markers and imaging modalities, especially MRI. Personalised rehab is also seen as an important way to progress and aid patients’ recovery from long term persistent symptoms.  Dr Sylvester also emphasised that efforts much be focussed on creating new regional expertise and care pathways for non-professional sports injury also, with education playing a key role in prevention.  In the professional sphere, a change in attitude must also be adopted, so that financial interests would no longer supersede medical advice.

Summary

In this interesting, engaging and very entertaining evening, Dr Sylvester provided the delegates with information on the signs and symptoms of concussion and traumatic brain injury and how to deal with acute presentation as well as long term effects.

For further information on this topic, or to contact Dr Sylvester to discuss a referral to his clinics in Queen Square, please contact Charlotte Wade at cwade@qsprivatehealtcare.com, or 020 8712 9618.

The next Queen Square GP seminar will be on 5^th September 2017, when Mr Ahmed Toma will be discussing normal pressure hydrocephalus and CSF flow disturbance.