Concussion Management on the Field & Return to Play Decisions: A New Approach

1. Concussion Management on the Field & Return to Play Decisions: A New Approach

2. Plan • Concussion Basics • A Peak at the Zurich Consensus Statement • Effective System of Concussion Management • Collaboration between ATC and Neuropsychologist • Concussion Evaluation • Role of Neuropsychological Testing • Concussion Treatment • Managing Cognitive Exertion in the School

3. Seminal Study (Barth et al., 1989) • Problem in MTBI: Adequate controls, controlling for premorbid functioning, detecting change • Test-retest design – collegiate football players • Baseline neuropsychological testing, serial post-injury testing (P&P) • 10 universities – n=2350 players baseline tested • Neurocognitive deficits at 24 hrs and 5 days post-injury, with return to preseason baseline by Day 10 • Sports arena recognized as a unique, relatively well-controlled lab for assessing mTBI.

4. Sports as a Laboratory Assessment Model (SLAM*) Pre-Concussion Baseline Testing 1-3 Days Day 5-10 Day 12-16 Concussion *Barth et al., 2002

5. Sports as a Laboratory Assessment Model (SLAM*) Pre-Concussion Baseline Testing 1-3 Days Concussion *Barth et al., 2002

6. Zurich CIS Consensus • Abandon the simple vs. complex terminology • Majority (80-90%) of concussions resolve in a short (7-10 day) period, although the recovery time frame may be longer in children and adolescents. • SCAT2 form – incorporates SAC & BESS • Sideline: A player with diagnosed concussion should not be allowed to return to play on the day of injury. Occasionally in adult athletes, there may be return to play on the same day as the injury.

7. Zurich CIS Consensus CONCUSSION INVESTIGATIONS: additional exams utilized to assist diagnosis and/or exclusion of injury • Neuroimaging: still limited • Objective Balance Assessment (eg BESS, force plate) • Neuropsychological Assessment: Use of neuropsychologists in the interpretation • There may be situations (e.g. child and adolescent student-athletes) where testing may be performed early whilst the patient is still symptomatic to assist in determining management.

8. Zurich CIS Consensus • Concussion Management • Physical AND Cognitive Rest • Graduated RTP: when asymptomatic at rest • stepwise progression, proceed to next level if asymptomatic at current. • Each step take 24 hours; would take approximately one week to proceed through the full rehabilitation protocol • Same Day RTP: not appropriate in child or adolescent student-athlete (possible in adult ONLY if within well established system) • Recognized delayed onset of symptoms

9. Zurich CIS Consensus MODIFYING FACTORS IN CONCUSSION MANAGEMENT • A range of ‘modifying’ factors may influence the investigation and management of concussion and in some cases, may predict the potential for prolonged or persistent symptoms. • May be additional management considerations beyond simple RTP advice. More important role for formal NP testing, balance assessment, and neuroimaging. • Concussion history, LOC > 1 minute, comorbidities/premorbidities

10. Zurich CIS Consensus • Child and adolescent student-athlete • Clinical evaluation include patient and parent, and school when appropriate • Evaluation generally similar to adults; timing of testing differs to assist treatment planning in school and home • Age-appropriate baseline necessary • More important to use neuropsychologists to interpret assessment data, particularly with LD and ADHD.

11. Zurich CIS Consensus • Child and adolescent student-athlete • Strongly endorsed view no return to practice or play until clinically completely symptom free • Cognitive rest highlighted • More conservative return to play approach; appropriate to extend the amount of time of asymptomatic rest and/or the length of the graded exertion in children and adolescents. • It is not appropriate for a child or adolescent student-athlete with concussion to RTP on the same day as the injury regardless of the level of athletic performance. • Concussion modifiers apply even more than adults and may mandate more cautious RTP advice.

12. Goals of the Effective Sports Concussion Program • Student-Athlete • Safeguard Health #1 • Facilitate Speedy Return to Play/ Life Activities • Athletic System • Reduce Risk/ Liability for Student-athlete safety • Achieve Greater Success

13. Effective Sports Concussion ProgramPre-Injury Knowledge and Preparation of All is the Foundation Injury Monitoring Early Identification Decision Pre-Injury Concussion-Education Parent, athlete Coach, ATC Emergency Dept Primary Care Physician Other Medical Specialist School Personnel (School RN, Psycholologist) Athlete Concussion Suspected Preseason BL Testing On-field evaluation ATC/MD Evidence of concussion? No Return To Play (RTP)

14. Effective Sports Concussion ProgramPost-Injury Post-Injury Clinical Evaluation (24 hours) Post-Injury Communication/ Coordination Decision Parent contacted Neuropsychological & Balance Testing Symptoms Comparison to “BL” PCP contacted Evidence of concussion? Removal from Play Yes ED evaluation?

15. Effective Sports Concussion ProgramPost-Injury Management/ Treatment Medical Sports Academic Home Post-Injury Clinical Evaluation (24-72 hours) No Neuropsychological & Balance Testing Symptoms Comparison to “BL” Stage 1 Recovery? (at rest) Initiate RTP? Stage 1 Recovery7? Initiate RTP? No Yes Yes Gradual Exertional RTP Protocol (ATC) Stage 2 Recovery? (w/ exertion) RTP? Return To Play (RTP) No Yes

16. Concussion:“Facts & Figures” • Annually, millions of children sustain a TBI • 80-90% “ mild” • New CDC estimates of sports/ recreation TBI alone (adults and children): 1.6 – 3.8 million per year (revised from previous estimate of 300K)

17. Concussion/ mTBIDefinition • A concussion (or mild traumatic brain injury)is defined as a • complex pathophysiologic process affecting the brain, • induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. CDC Heads Up: Brain Injury in Your Practice (2007)

18. Concussion/ mTBIDefinition • Disturbance of brain function is related to: • neurometabolic dysfunction, rather than structural injury • typically associated with normal structural neuroimaging findings (i.e., CT scan, MRI). • Concussion may or may not involve a loss of consciousness (LOC). CDC Heads Up: Brain Injury in Your Practice (2007)

19. Concussion/ mTBIDefinition • Concussion results in a constellation of symptoms: • physical, cognitive, emotional and sleep-related. • Duration of symptoms are variable may last for as short as several minutes and last as long as several days, weeks, months or even longer in some cases. CDC Heads Up: Brain Injury in Your Practice (2007)

20. Concussion/ mTBIAdditional Criteria • Glasgow Coma Scale > 13 (3-15 scale) • Loss of Consciousness no longer than 10 minutes (typically no longer than 30-60 sec.) • No evidence of complicated TBI/ structural abnormality (skull fracture, intracranial bleed, known lesion)

21. Anatomical Timeline of a ConcussionDefining the Key Factors C. Risk Factors A. Injury Characteristics B. Symptom Assessment Retro- grade Amnesia 20-35% Antero- grade Amnesia 25-40% CONCUSSION LOC <10% Neurocog dysfx & Post-Concuss Sx’s Pre-Injury Risks Sec-Hrs Sec-Hrs Hours - Days - Weeks+ Sec-Min

22. Sports ConcussionA Few Facts • Some Injuries are worse than others. • Some athletes are more vulnerable • Pre-injury risk factors combine with injury • # previous concussions, headache, ADHD, LD, mood • Other possible factors that influence recovery • Magnitude of force that is received • Location that force is received • Defensive position/ prep of individual receiving force • Size, speed factors

23. Increased Risks if not properly identified and managed • Symptoms can take significantly longer to recover. • Player is more likely to be re-injured. • Second/ third... injuries: • Are more likely to be more severe • Could cause permanent brain damage • Can take longer to recover from • Increase risk of retirement from sport

24. Exertional Effects • Increase or re-emergence of post-concussion symptoms following significant exertional activity • Physical activity • Cognitive activity

25. Effects of Concussive Forces on the Brain • Typically, the “software” of the brain is affected • Neurometabolic/ neurochemical processes • Physiological • Not the “hardware” • Structure

26. Physical Headache Fatigue Dizziness Sensitivity to light and/or noise Nausea Balance problems Emotional Irritability Sadness Feeling more emotional Nervousness 4 Symptom Categories • Sleep • Drowsiness • Sleeping less than usual • Sleeping more than usual • Trouble falling asleep • Cognitive • Difficulty remembering • Difficulty concentrating • Feeling slowed down • Feeling mentally foggy

27. Everyday Functional Effects • Home • Difficulty completing tasks at home • Reduced play/ activity • Irritability with challenges • School • Concentration • Remembering directions • Disorganized • Completing assignments • Fatigue • Fall behind, fail tests, reduced grades

28. Neuropsychological Effects of Concussion • Attention, concentration • “Working memory” (holding info in mind during activity) • New learning & memory storage/ retrieval • Speed of processing information • Reaction time

29. How Long Does It Take The Athlete To Recover from Concussion?

30. Studies Reporting Individual Recovery Rates

31. Recovery From Concussion:How Long Does it Take? WEEK 5 WEEK 4 WEEK 1 WEEK 3 WEEK 2 N=134 High School athletes Collins et al., 2006, Neurosurgery

32. However! • Every individual injury is different • Many will recover within 1-2 weeks • Some take longer, some shorter • We MUST evaluate EVERY concussion individually Just like every other injury – • If not recognized and managed early, much greater chance of more severe injury and longer recovery

33. “What’s the worst thing that can happen to my son?”[Father of football player with multiple concussions in one season, 2003]

34. Second Impact Syndrome • Diffuse cerebral swelling with delayed catastrophic deterioration, a known complication of brain trauma postulated to occur after repeated concussive brain injury in sports.

35. Second Impact Syndrome • Athlete who has sustained an initial mild brain injury sustains a second mild brain injury before symptoms associated with the first have fully cleared • Death usually follows rapidly (2-5 minutes) due to brainstem herniation • Disordered cerebral autoregulation of cerebral blood flow vascular engorgementincreased ICPBrainstem herniation • Mortality 50-100%

36. Effective System of Sports Concussion Management

37. Effective Concussion Program • Education & Awareness (Pre-Injury) • Baseline Neuropsychological & Balance Testing (preseason) • On Field Surveillance • Standardized Sideline Assessment • Post-Injury Neuropsychological & Balance Re-Testing • Management • Physical Exertion • Cognitive Exertion (Academics) • Gradual Return-To-Play Protocol

38. Heads Up: Concussion in High School Sports • Parent Fact Sheet • Athlete Fact Sheet • Guide for Coaches www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm

39. Effective Concussion Program • Education & Awareness (Pre-Injury) • Baseline Neuropsychological & Balance Testing (preseason) • On Field Surveillance • Standardized Sideline Assessment • Post-Injury Neuropsychological & Balance Re-Testing • Management • Physical Exertion • Cognitive Exertion (Academics) • Gradual Return-To-Play Protocol

40. Relying on Athlete Symptom Report Do Athletes Underreport Symptoms? Lovell MR, Collins MW, Maroon et al. Medicine and Science in Sports Exercise, 34:5;2002

41. UNIQUE CONTRIBUTION OF Neuropsychological TestingTO CONCUSSION MANAGEMENT ImPACT reveals cognitive deficits in asymptomatic athletes within 4 days post-injury N=115 MANOVA p<.000000

42. UNIQUE CONTRIBUTION OF Neuropsychological TestingTO CONCUSSION MANAGEMENT ImPACT Processing Speed ImPACT Reaction Time N=115 MANOVA p<.000000

43. To evaluate concussion recovery, we cannot rely on athlete symptom report alone! (How many other injuries do we allow the athlete to decide when they can return to play?)

44. Preseason Baseline Neuropsychological Testing • 25 minute computer-based test • Memory, Processing Speed, Reaction Time • Baseline symptoms • Conducted in group format (up to 15 per) • Load on computers in lab • Baseline data available for comparison post-injury • Ages 11-18 (currently)

45. Balance (Postural Stability) Testing

46. Effective Concussion Program • Education & Awareness (Pre-Injury) • Baseline Neuropsychological & Balance Testing (preseason) • On Field Surveillance • Standardized Sideline Assessment • Post-Injury Neuropsychological & Balance Re-Testing • Management • Physical Exertion • Cognitive Exertion (Academics) • Gradual Return-To-Play Protocol

47. Clinical ProtocolNeurocognitive Testing Pre-Concussion Baseline Testing 1-3 Days Day 5-10 Day 12-16 Concussion *Barth et al., 2002

48. Clinical ProtocolNeurocognitive Testing Pre-Concussion Baseline Testing 1-3 Days Concussion *Barth et al., 2002

49. Effective Concussion Program • Education & Awareness (Pre-Injury) • Baseline Neuropsychological & Balance Testing (preseason) • On Field Surveillance, Standardized Sideline Assessment • Post-Injury Neuropsychological & Balance Re-Testing • Management • Physical Exertion • Cognitive Exertion (Academics) • Gradual Return-To-Play Protocol

50. Management Rest, Rest, Rest • Essential for brain’s recovery • Sleep • Low activity, not increasing heartrate significantly