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Oregon Concussion Awareness and Management Program: Making an Impact. Michael C. Koester, MD, ATC, FAAP 6th Annual Pacific Northwest Conference on Brain Injury February 29th, 2008 Slocum Center for Orthopedics and Sports Medicine Director, Sports Concussion Program Eugene, Oregon.

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Oregon Concussion Awareness and Management Program: Making an Impact

Michael C. Koester, MD, ATC, FAAP

6th Annual Pacific Northwest Conference on Brain Injury

February 29th, 2008

Slocum Center for Orthopedics and Sports Medicine

Director, Sports Concussion Program

Eugene, Oregon


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The Problem

  • We now realize that concussions occur more often than previously thought

  • Young athletes are at risk for serious short-term and long-term problems


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The Problem

  • There is much variation in the knowledge of Health Care Providers managing concussed athletes

  • New and emerging technologies and research will lead to a continuing evolution of care


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The Opportunity

  • Bill Bowers, Executive Director of the OADA, met with me last fall and expressed interest in developing a statewide concussion program similar to a program implemented in New York state last year.

  • I have envisioned a “dream program” for the past several years, but needed “buy-in” from the involved parties.

  • We have willing participants, OSAA & OADA backing, and multiple media stories trumpeting the problem--- the time is now!!!!


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Extent of the Problem

  • Like all problems in sports- what is seen at the pro level is only a small part of the problem

  • Much more common in high school than any other level- due to large number of participants


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Extent of the Problem

  • Estimated 300,000 sports-related head injuries in high school athletes yearly

  • 9% of all sports injuries

  • 678 head-injuries in Oregon HS athletes in 2004-5 based on OSAA participation stats


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The Goal

  • State-wide concussion management program involving all high schools

    • Establish state-wide physician network

    • Uniform evaluation and management protocol

    • Consultation service for coaches, athletes, parents, and physicians

    • ImPACT neuropsychologic testing available for all contact and collision sport athletes


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How do we achieve our goals?

  • What happens when coaches and other members of the Sports Medicine Team work together to promote safety and injury prevention?


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Episodes of Permanent Paralysis in Football

1976 – implementation of NCAA/High School rule changes and using coaching techniques eliminating the head as a battering ram


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Episodes of Permanent Paralysis in Football

1987-1989 – gradual increase in permanent quadriplegia


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Episodes of Permanent Paralysis in Football

1991 – distribution of video “Prevent Paralysis: Don’t Hit with your Head” and release of educational poster “Play Heads-Up Football”


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Three Tiers of Education

Medical Professionals

Physicians

Nurse Practioners/Physician Assitants

Athletic Trainers

Chiropractors

Paramedics/EMT’s

Educators

Athletic Directors

Coaches

Principals/Administrators

Counselors

Community

Parents/Athletes

School Boards

The Plan


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The Plan

Identify Regional Leaders

  • Portland- Jim Chessnutt, MD

  • Eugene- M. Koester, MD, ATC

  • Bend- Mark Belza, MD

  • Each regional leader will “oversee” programs at the “satellite” sites

    • Phone/e-mail consultation

    • Office evaluation if desired


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Teams will carry out presentations throughout the state in late Spring and early Fall 2008

Portland

Hillsboro

Gresham

Wilsonville

Astoria

The Dalles

Eugene

Corvallis

Salem

Roseburg

Medford

Bend

Ontario

La Grande

John Day

Hermiston

Klamath Falls

Regional Presentations


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Multimedia Campaign

  • Presentations at each site

  • PowerPoint available to anyone who asks

  • Brochures

  • Webcasts of presentations

  • Podcasts available

  • Local and regional television, radio, and newspaper

  • Website- Link through OSAA or our own site


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Neuropsychologic Testing

  • Immediate Post-Concussion Assessment and Cognitive Testing

    • Computerized Neurocognitive Testing

    • Available on-line- yearly cost of $350-450 per school on average

  • Used extensively in professional, collegiate, and high school athletes

    • Vast majority of NFL and NHL teams

    • Has received significant media attention

  • Athletes receive “baseline” testing prior to the start of the sports season

    • Should be done at least every other year


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What can we accomplish?

  • The opportunity presents itself for us to establish a program which can:

    • Maximize the health and safety of our athletes

    • Minimize worry and liability for our coaches and administrators

    • Provide a model for other western states to emulate


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What is a Concussion?

  • A concussion is a mild traumatic brain injury that interferes with normal function of the brain

  • Evolving knowledge- “dings” and “bell ringers” are brain injuries


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What happens to the brain?

  • A complex physiological process induced by traumatic biomechanical forces:

    • sudden chemical changes- neurotransmitters and glucose utilization disrupted

    • stretching and tearing of brain cells

  • Structural brain imaging (CT or MRI) is almost always normal

  • Still many unanswered questions . . .


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Increasing Exposure of the Problem

  • High profile athletes with severe or career ending injuries

    • Steve Young

    • Troy Aikman

    • Merrill Hodge

    • Trent Green

  • ESPN and Sports Illustrated frequently cover the issue-not always very well

    • Highlights of hits

    • Features in print and television


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Not Just a Football Problem

Injury rate per 100,000 player games in high school athletes

  • Football47

  • Girls soccer36

  • Boys soccer22

  • Girls basketball21

  • Boys basketball7

    • JAT


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Potential Complications

  • 15% of all head-injured athletes suffer long-term complications

  • Increased risk for future and more serious concussions

  • Learning Disorders unmasked

  • Second Impact Syndrome?


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Concussion and “same-day” RTP

  • Long held that RTP after 15 minutes if “symptom free” is acceptable standard (Grade 1 concussion)

  • 43 HS athletes with Grade 1 concussion

    • 32 with symptoms at 36 hours

    • 36 with abnormal ImPACT at 36 hours

      • AJSM, 2004


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Risk for further concussion

  • Everyone asks….

  • Prospective cohort of 2905 FB players at 25 colleges

  • 184 with concussion, 12 with repeat in same season

  • Hx of 3 or more concussions: 3X more likely to have concussion


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Risk for further concussion

  • These had slower recovery:

    • 30% with hx had symptoms > 1 week

    • 14.6% without hx had symptoms > 1 week

  • 11/12 of the repeat concussions occurred within 10 days of first

    • JAMA, 2003


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Neuropsychological Testing

  • ImPACT, Cogsport, Headminder

  • Traditional “pen and paper” battery

  • Great deal of controversy due to aggressive marketing and no “gold standard”


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Neuropsychological Testing

  • Assesses 6 domains of brain function:

    • Attention span     

    • Working memory     

    • Sustained and selective attention time

    • Response variability     

    • Non-verbal Problem Solving     

    • Reaction time

  • Not a perfect tool and not to be used in the absence of an experienced and knowledgeable physician.


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Neuropsychological Testing

  • Computerized tests

    • Can be administered to a group or at home

    • Can be repeated multiple times

  • Ideally, baseline testing is done before the season starts

    • Test is repeated after concussion and results are compared to baseline

    • Can compare to “population norms” if no baseline


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ImPACT

for Sports Concussion Management


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Concussion

The Diagnostic and Return to

Play

Dilemma


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What ImPACT Is and Isn’t:

  • IS a useful concussion screening and management program

  • IS validated with multiple published studies

  • IS NOT a substitute for medical evaluation and treatment

  • IS NOT a substitute for comprehensive neuropsychological testing when needed


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ImPACT:Post-Concussion Evaluation

  • Demographics

  • Concussion History Questionnaire

  • Concussion Symptom Scale

  • Neurocognitive Measures

    • Memory, Working Memory, Attention,

    • Reaction Time, Mental Speed

  • Detailed Clinical Report

    • Automatically Computer Scored


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    Clinical Protocol: Neurocognitive Testing

    24-72 Hours

    Day 5-10

    Beyond if

    necessary

    Baseline TestingNot necessary for decision making

    Concussion


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    Unique Contribution of Neurocognitive Testing to Concussion Management

    Testing reveals

    cognitive deficits

    in asymptomatic

    athletes within 4

    days post-concussion

    N=215(Lovell et al., 2004)


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    ImPACT ‘Bell-Ringer’ StudyBrief versus Prolonged On-field Mental Status Changes

    P<.04

    P<.004

    P<.02

    N = 64

    High School

    Athletes

    ImPACT Memory-Percent Correct

    Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003

    Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32;47-54,2004


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    Recovery From Concussion:How Long Does it Take on ImPACT?

    WEEK 5

    WEEK 4

    WEEK 1

    WEEK 3

    WEEK 2

    N=134 High School athletes

    Collins et al., 2006, Neurosurgery


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    Neuropsych testing and RTP decisions

    • Do I have to use this?

    • Not yet standard of care

    • Recommended to be used by current guidelines-Prague, 2004

    • Provides extra data

      • Think of it like any lab test, MRI, etc


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    ImPACT and RTP decisions

    • How well does ImPACT identify concussed athletes?

    • Sensitivity

      • Identified 80% within 24 hours

      • 68% identified by self-report of symptoms

        • J Neurosurg, 2007


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    ImPACT and RTP decisions

    • “Value-added” effect in 122 concussed HS and college athletes

      • 83% abnormal ImPACT

      • 64% with symptoms

      • 93% with combo of both

      • No one in control group had abnormal ImPACT and symptoms

        • AJSM, 2006


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    ImPACT and RTP decisions

    • When to use ImPACT?

    • Recommended to be used 24-72 hours post-injury, 5-10 days post injury and beyond if needed.

    • No need to test if athlete is still symptomatic

      • May need to use to show coaches, parents, etc- BE CAREFULL!!


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    Prague Guidelines, 2004

    • What’s a Grade 1 concussion?

    • Notion of grading systems has been abandoned

      • Over 20 classifications

      • Can only be applied retrospectively

    • Simple versus Complex

      • Complex-persistent symptoms, specific sequelae, prolonged LOC, multiple concussions

    • Graded Return to Activity


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    Prague Guidelines, 2004

    • Simple concussion

      • LOC < 1 minute

      • resolves in 7-10 days

      • first concussion

    • Complex concussion

      • LOC > 1 minute

      • symptoms last longer than 7 – 10 days

      • history of multiple concussions

      • increasing “concussability”

    No athlete returns in the current game or practice (same day)


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    Return to Activity Protocol

    7 Steps to a Safe Return

    Step 1.Complete cognitive rest. This may include staying home from school or limited school hours for several days. Activities requiring concentration and attention may worsen symptoms and delay recovery.

    • Step 2.Return to school full-time.


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    Return to Activity Protocol

    7 Steps to a Safe Return(cont)

    • Step 3. Light exercise. This step cannot begin until you are cleared by your physician for further activity.

    • Step 4. Running in the gym or on the field. No helmet or other equipment.

    • Step 5. Non-contact training drills in full equipment. Weight-training can begin.


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    Return to Activity Protocol

    7 Steps to a Safe Return(cont)

    • Step 6. Full contact practice or training.

    • Step 7. Game play. Must be cleared by your physician before returning to play.

    • Cannot advance to next level if symptomatic

    • Progression usually takes about 1 week


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    Return to Activity

    • Recommend written and standardized Return to Activity Plan for all concussed athletes

    • Sets standard and is understood by all coaches, parents and athletes

    • Cannot advance to next level if symptomatic


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    Education

    • No such thing as “just a concussion”

    • Coaches, athletes, AD’s, and parents must be educated on signs and symptoms, as well as need for proper management

    • CDC Tool Kit on Concussion for High School Coaches

      • http://www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm


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    Prevention

    • “Concussion prevention” has become the “holy grail” for sports equipment marketers

    • “Special” helmets, soccer head pads, mouth guards- NO PROVEN PROTECTION FROM CONCUSSION!!

    • Multiple flaws in recent study looking at “newer helmet technology.”

      • Neurosurgery, 2006


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    Conclusions

    • Concussion management continues to evolve. Health care providers must be knowledgeable of the most up to date management recommendations.

    • Neuropsychological testing plays an important role in concussion management- but cannot stand alone.

    • Schools should have evaluation and RTP policies and procedures in place to ensure excellent and consistent care.


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    THANK YOU!!!!!!

    • Thad Stanford, MD, JD- Salem

    • Bill Bowers- Executive Director, OADA

    • Tom Welter- Executive Director, OSAA

    • Mark Belza, MD- Bend

    • Mickey Collins, PhD- Pittsburgh

    • Ron Savage, EdD- New Jersey

    • Brian Rieger, PhD- New York

    • Ann Glang, PhD- Eugene


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