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Understanding Concussion Assessment and Evaluation

Understanding Concussion Assessment and Evaluation. Philip Schatz, PhD Saint Joseph’s University, Philadelphia PA pschatz@sju.edu. Cerebral Concussion. Mild traumatic brain injury Alteration in consciousness due to a blow to the head or acceleration/deceleration/rotational force

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Understanding Concussion Assessment and Evaluation

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  1. Understanding Concussion Assessment and Evaluation Philip Schatz, PhD Saint Joseph’s University, Philadelphia PApschatz@sju.edu

  2. Cerebral Concussion • Mild traumatic brain injury • Alteration in consciousness due to a blow to the head or acceleration/deceleration/rotational force • Does NOT imply or require loss of consciousness. • Usually temporary changes in mental status • Temporary changes in somatic functioning • May produce a wide range of symptoms • Normal structural neuroimagingCISG, Vienna (2001); Prague (2004)

  3. Post Concussion Symptoms “Oh man… I was licking the dreamsicle” -- Professional wrestler, reflecting on a concussion Head Games Chris Nowinski

  4. “Physical”: Pressure in head Headache Balance troubles Visual Disturbance Numbness Tingling Feeling slow Sensitivity to light/noise “Psychological”: Feeling like in a “fog” Difficulty concentrating Difficulty remembering Irritability Sadness Nervousness Post Concussion Symptoms

  5. Headache (71%) Feeling slowed down (58%) Difficulty concentrating (57%) Dizziness (55%) “Fogginess” (53%) Fatigue (50%) Visual Blurring or double vision (49%) Light sensitivity (47%) Memory dysfunction (43%) Balance problems (43%) COMMONLY REPORTED SYMPTOMSHigh School/University Athletes within 3 days of injury

  6. Physiological Changes • Shearing or strain injury of axons • Diffuse microscopic changes to axons • Microscopic tearing of small blood vessels • Metabolic cascade resulting in imbalance between glucose demands and regional CBF supply (vulnerable to SIS)Giza & Hovda, JAT, 36(3), 228-35

  7. Neurometabolic Changes

  8. Incidence of Mild TBI • 75 to 85 % of all head injuries • 1.0 to 1.5 million cases per year in US • 300,000 from sports (an underestimate?) • Most cases go unreported

  9. Incidence of Mild TBI • Question: What sport has the highest incidence of concussion (if you know, don’t say it)

  10. Previous Findings: Epidemiology • By Sport: SPORT % RANGE Equestrian 3 - 91 Boxing 1 - 70 Rugby 2 - 25 Soccer 4 - 22 Football 2 - 20 Bicycling 0 - 13.8 Martial Arts 0 - 11 Auto Racing 0 - 10.5 Ice Hockey 3 - 7.5 Ruchinskas, et al., 1997, Applied Neuropsych

  11. Epidemiology: Issues (Macciocchi) • Recognition one occurred may be easier then measuring concussion severity • Diagnosis for epidemiological purposes may be more difficult than it seems • Discrepancy between # of players reporting and the # who believed they sustained one • Post-season, players reported symptoms but didn’t connect them to concussive injuries • 70% of football and 63% of soccer players reported post-concussion symptoms

  12. Epidemiology: Methods (Macciocchi) • Quasi-experimental comparison- athletes examined pre-season, followed for a period of time • Look at # of concussions sustained over that period • Generalize from cohort to population • Use date from “surveillance systems” • Monitor concussive injuries on a broader scale • Sometimes are organization-based, such as NCAA

  13. Epidemiology: Terminology (Macciocchi) • Athletic Exposure (AE) • Period of time when an athlete could have sustained an injury, such as practice or game • Confounded by time (a 5-minutes shift is the same as an entire game) • Injury Rate (IR) • Number of injuries incurred relative to the total number of exposures • Often stated as “per 1000 AE’s”

  14. Epidemiology: High School • 20% or 250,000 per year in football (Gerberich, et al. 1985) • 25,520 per season (Powell, 1995) • NATA High School Study • 57,716 occurrences of mTBI per year • 5.3% of football injuries • 4.4% of wrestling injuries • 3.4% of boys soccer • 2.6% girls soccer • 2.3% girls basketball

  15. Epidemiology: NCAA • College: NCAA Injury Surveillance System • 1.6 to 6.4% of all injuries • Ice Hockey - 4.5% of all injuries (.56 per 1,000 AE) • Football .43 per 1,000 AE • Wrestling .49 per 1,000 AE • Soccer (Men = .35/Women=.58) • Lacrosse (Men= .33/Women=.62) • Basketball (Men=.16.Women=.29)

  16. Concussion Base Rates • History of Previous Concussion: 10-80% • Recent Trend Upwards: (% with 1+ Previous Concussion) • Collins, et al (1999) 53% • Kaushik (2005) 75% • Moser, Schatz, Jordan (2005) 63% • Different “breed” of youth athletes in 2000’s vs. 1980’s?

  17. What about Gender?Hillary, Mann, Schatz, ACN, 2002 Study Sport (% of All Injuries) Males Females Powell, Barber-Foss Soccer 3.9% 4.3% Powell, Barber-Foss Basketball 2.6% 3.6% Powell, Barber-Foss Baseball/Softball 1.7% 2.7% NCAA Soccer 4.7% 4.4% Total % of all injuries 3.23% 3.75% Study Sport (Injuries per 1000 AE) Males Females Dick Soccer 0.348 0.578 Dick Lacrosse 0.334 0.618 Boden, et al. Soccer 0.6 0.4 NCAA Soccer 0.44 0.46 Powell, Barber-Foss Soccer 0.18 0.23 Powell, Barber-Foss Basketball 0.11 0.16 Powell, Barber-Foss Baseball/Softball 0.05 0.1 J. Kelly, J. Rosenberg Soccer 0.25 0.24 Total Ave per 1000 AE 0.289 0.348 Soccer Ave per 1000 AE 0.364 0.382 Other Ave per 1000 AE 0.165 0.293

  18. Epidemiology: GenderCovassin, Swanik, Sachs, JAT, 2003) • NCAA Injury Surveillance System: 3-year study • Of 14,591 reported injuries, 5.9% were classified as concussions • Concussions during practices: • Female athletes: 167 (3.6%) Male athletes 148 (5.2%) • Concussions during games: • Female athletes: 304 (9.5%) • Male athletes: 254 (6.4%)

  19. Epidemiology: GenderCovassin, Swanik, Sachs, JAT, 2003) • Barnes, et al, 1998, Am J Sports Med: • Female athletes could be at more risk due to their smaller size or greater ball-to-head size ratio. • Female athletes may have weaker neck muscles than male athletes. • Boden et al, 1998, Am J Sports Med: • Male athletes may be more skilled at protecting their heads from injury, but there are no data to support this hypothesis.

  20. Gender Differences at Baseline • 1209 NCAA Division 1 Athletes - 5 Northeastern Universities • Completed ImPACT at baseline • Female athletes performed significantly better than male athletes on baseline verbal memory scores (p = 0.001) • Male athletes performed significantly better than female athletes on baseline visual memory scores (p = 0.001). • Covassin, Swanik, Sachs, Kendrick, Schatz, Zillmer, Kaminaris, (BJSM, 2007)

  21. Gender Differences at Baseline • Female athletes endorsed a significant number of mild baseline symptoms as compared to male athletes: • Headache, nausea, fatigue, need more sleep, drowsiness, sensitive to noise, sadness, nervousness, more emotional, difficulty concentrating, visual problems. • Effect sizes ranged from .13 (Sleep) to .40 (Emotional)Covassin, Swanik, Sachs, Kendrick, Schatz, Zillmer, Kaminaris, (BJSM, 2007)

  22. Recommended schedule for measuring post-concussion status Sideline Testing NP Testing RETURN TO PLAY? BASELINE NP TESTING INJURY 1-2 DAYS AFTER INJURY PRE-SEASON

  23. Historical Aspects: UVA Football Study - Barth, et al., 1989 Trail Making B: Pre-Season and Post-Injury Performances

  24. Historical Aspects: Neuropsych Measures-Trails B

  25. Historical Aspects: Neuropsych Measures-Digit Symbol

  26. Historical Aspects: Neuropsych Measures - PASAT

  27. Historical Aspects: Neuropsych Measures - COWAT Tell me as many words that you can think of that start with the letter… F…A…S.

  28. Historical Aspects: Neuropsych Measures - STROOP

  29. Historical Aspects: Neuropsych Measures - STROOP

  30. Historical Aspects: Neuropsych Measures - STROOP

  31. Historical Aspects: Neuropsych Measures - STROOP

  32. Historical Aspects: UVA Football Study - Barth, et al., 1989 PASAT-4: Pre-Season and Post-Injury Performances

  33. Historical Aspects: Echemendia PSU: Hockey: COWAT

  34. Historical Aspects: • Egocentric view: • The Virginia Football Study • Echemendia’s PSU Program • Saint Joseph’s University • Division I, No Football, 400+ varsity athletes • Where can I find a place? • Computers circa 1998

  35. What We Knew: 2000 • Effects of Cerebral Concussions last up to 7-10 days • Primarily attention and concentrationAlves, Rimel, Nelson, 1987, Clinical Sports Medicine, 6(1), 211-8Barth, et al., 1989, in H. Levin’s Mild Head Injury: Oxford Press • Effects of cerebral concussions last up to 30 days and beyond (Echemendia, et al., 1999) • Extends to other cognitive processesEchemendia & Julian, 2001, NP Review 11(2), 69-88

  36. What We Knew: 2000 • LOC is not a predictor of concussion, and incidence of LOC does not effect cognitive performance (Lovell, et al, J. Clin Sports Med, 1999) • Individuals with history of Concussion and/or Learning Disability show lowered baseline performance on testing.(Collins, et al., JAMA, 1999)

  37. Current Research: How do I develop a Concussion Program at SJU? (Hopefully) based on Professional and Collegiate Concussion Management Programs • NFL - Majority • NHL - Mandatory • Baseline, Serial Post-concussion Evals. • Wide Network of Neuropsychologists • Colleges test teams pre-season

  38. SJU Concussion Pilot Study: Trails B

  39. SJU Concussion Pilot : Digit-Symbol

  40. SJU Concussion Pilot Study: d2

  41. There already was a trend towards computer-based assessment • CRI (HeadMinder.com)…………. 1999 • Web based • CogSport (CogState.com)………..1999 • Windows/Mac • ImPACT (ImPACTtest.com)……. 2000 • Windows based

  42. Why should we opt for computer-based assessment? • Sensitive to RT, Processing Speed • Randomized Trials: Improved reliability • Ability to test entire team at once (benefit?) • Better/Objective date for Athletic Trainers, Team Physicians • Assistance with Return to play decisions(Schatz & Zillmer, 2003, Applied Neuropsych; Schatz & Browndyke, 2003, JHTR)

  43. Why should we not opt for computer-based assessment? • Perhaps timing is not millisecond-accurate • Limited validation with np “standards” • Little qualitative or “verbal” data • Can be used by Athletic Trainers, Team Physicians in absence of Neuropsych • May determine return to play decisions(Schatz & Zillmer, 2003, Applied Neuropsych)

  44. There’s a whole lot of post-concussion tests and schedules Comparison of Post-concussion Assessment Schedules and Measures. (From McKeever & Schatz, Applied Neuropsychology, 10, 2003) Schedule of Serial Post-Concussion Assessments Hours Days Study 1-2 24-48 3 5 7 10 30 Measures Used NCAA- Multiple sports 2 24 7 30 cPC, dHVLT, fSDMT, gStroop, hTrails, jVIGIL/W, (Echmendia, et al., 2001) kDig. Span, lPSU,mCOWAT NCAA-Football 1 3 5 7 dHVLT, hTrails, kDig. Span, fSDMT, mCOWAT, (Collins, et al., 1999) nPegboard NCAA-Football 24 5 10 eSDMT, hTrails, oPASAT (Barth, et al., 1989) Prof. Hockey Players 24 5b 7bcPC, dHVLT, fSDMT, iTrails, lPSU, mCOWAT, (Echemendia, 2001) pBVMT-R Prof. Football Players 24 5 dHVLT, fSDMT, hTrails, kDig. Span, mCOWAT, (Lovell & Collins, 1998) nPegboard Prof. Rugby Players 1 5 eSDMT, rChoice RT., rMemory, rOrientation (McCrory, et al., 1997) Prof. Rugby Players 3a 7a 35 aeSDMT, qDigit Symbol, rSpeed of Comprehension (Hinton-Bayre, et al., 1999) aAthletes tested 1 to 3 days, 1-2weeks, 3-5 weeks post-concussion; bAthletes tested 5 to 7 days post-concussion

  45. Power In Numbers:Philadelphia Sports Concussion Program • Mandatory for Participation in Athletics • Drexel, Temple, SJU… Delaware, Rutgers • Baseline, 24-48 hr, 3, 5, 7, 10, weekly if Sx • ImPACT @ 4 schools, CRI @ Temple • Dissertations (McKeever, Covassin, Schneider), Master’s Theses • Validate multiple measures(ImPACT, CRI, CogSport, Trails, Digit Symbol, d2) • Gender, Sport, History, Club Sports, Cheerleaders, School Norms

  46. Cross-Validation of Computer-Based Measures - Rationale(Schatz & Putz, Applied Neuropsych 2006) • Limited “shared validation” of existing computer-based measures with standards • SDMT correlates with: • ImPACT Processing Speed (r=.70) and Reaction Time (r=-.60) • CRI Processing Speed (r=.60, r=.67) • Trails correlates with: • CRI Response Speed (A: r=.73; B: r=.74) • CRI Processing Speed (B: r=.37) • CogSport Complex RT (B: r=.34) • CogSport Simple RT (B: r=.44)

  47. Cross-Validation of Computer-Based Measures - Methodology • 30 Normal Volunteers • Computer-based: ImPACT, CRI, CogSport, d2, Trails A&B, Digit Symbol • Paper-based: Trails A&B, Digit Symbol • Administration: MWF, Individually • Grouping A: ImPACT, d2 Test of Attention (computerized) • Grouping B: CRI, Trails A and B. and Digit Symbol (pencil and paper). • Grouping C: CogSport, Trails A and B, and Digit Symbol (computerized). • ABC, ACB, BAC BCA, CAB, CBA.

  48. Cross-Validation Example: ImPACT CRT

  49. Cross-Validation Example: CogSport CRT

  50. Cross-Validation Example: CRI CRT Cued Reaction Time: Press the spacebar as quickly as possible only when a white circle immediately follows the presentation of a black square.

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