Concussion Management in the Athletic Population

1. Concussion Management in the Athletic Population Jim Turner, D.O. Medical Director, Richard G. Lugar Center for Rural Health Medical Director, Emergency Medical Services, Union Hospital

2. Overview • Pre-Test • Definition • Quick Facts • Concussion Recognition • Initial Management of Concussion • Ongoing Management of Concussion • Neurocognitive Testing • Return to Play Decisions • Short and Long Term Sequelae of Concussion • Future Recommendations

3. Question #1 • The 17 yo patient had a helmet to helmet collision, walked off the field, complained of fogginess and dizziness, but had no loss of consciousness • True or False—This patient suffered a concussion

4. Question #2 • The patient went to the Emergency Room and had a normal head CT scan and was given a note to return to football • True or False—The diagnosis of concussion was incorrect • True or False—The school should allow him to return to football

5. Question #3 • The patient’s symptoms resolve but he still has computerized neurocognitive testing scores well below his baseline • True or False—The patient has a history of ADHD and his parents want his scores invalidated. Do you agree?

6. Question #4 • The patient had previously suffered a concussion at age 5, age 14, and age 16 • True or False—He is at no increased risk of long term sequelae

7. Question #5 • The patient’s symptoms have resolved and his scores have returned to baseline. He and his family understand and acknowledge an increased risk of long term sequelae • True or False—He will be allowed to play in the very next game/practice

8. Consensus Definition • Concussion is a complex pathophysiological process affecting the brain, induced by biomechanical forces and associated with 5 common features: • 1. Concussion may be caused by a direct blow to the head, face, neck, or elsewhere on the body with an “impulsive” force transmitted to the head. • 2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. • 3. Concussion may result in neuropathologic changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury. • 4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course; however, it is important to note that in a small percentage of cases, postconcussive symptoms may be prolonged. • 5. No abnormality on standard structural neuroimaging studies is seen in concussion.

9. What is a Concussion? • A concussion is a disturbance in brain function that occurs either following a blow to the head or as a result of a violent shaking of the head • It is a form of mild traumatic brain injury • Altered brain metabolism due to changes in intracellular/extracellular levels of glutamate, K+, and Ca2+

10. Concussion: Quick Facts • Between 1.6 and 3.8 million sports and recreation related concussions occur each year (Langlois JA et al. J Head Trauma Rehabil. 2006;21:375-78.) • Many mild concussions go unreported so it is difficult to estimate concussion rate per sport • Felt to include at least 300,000 concussions in organized high school football per year • 10-20% of high school football players suffer a concussion per year • 34% of college football players have had at least 1 concussion • 5-fold more likely to sustain a second concussion • Effects of concussion are cumulative in individuals who return to play prior to complete recovery • Females are more likely to have prolonged symptoms

11. Organized Sports: Football Men’s Ice Hockey Women’s Soccer Wrestling Men’s Soccer Lacrosse/Field Hockey Basketball ** Cheerleading Recreational Activities: Football Bicycling Basketball Playground Soccer ** Skateboarding ** All-Terrain Vehicles Concussion: Epidemiology

12. Concussion Recognition

13. On-Field Signs: Appears dazed/stunned “Vacant Stare” Confused/Forgets plays Unsure of game/score/team Moves clumsily Answers slowly Loses consciousness Behavior change Forgets events prior to hit (retrograde amnesia) Forgets events after hit (anterograde amnesia) On-Field Symptoms: Headache Nausea/Vomiting Balance problems/Dizziness Double or fuzzy vision Sensitivity to light or noise Feeling sluggish Feeling “foggy” Change in sleep pattern Concentration or memory problems Emotional lability Concussion Recognition

14. Concussion Grading • Grades? Where we’re going…there are no grades. • Prior to 2004---Alphabet Soup • Prague Conference 2004 • Simple Concussion • Majority of concussions progressively resolves without complication over 7-10 days • Vs. Complex Concussion • Zurich Conference 2008 • Each concussion must be managed independently • Decision Making may be affected by modifying factors

15. Concussion Modifying Factors • Duration of Symptoms (>10d) • Prolonged LOC • Post-Traumatic Amnesia • Convulsive concussions • “Recency” • Repeated concussions occurring with less force • Child or Adolescent • Migraines • Depression • ADHD • Learning disabilities • Psychoactive Meds • High-Risk sport or dangerous style of play

16. Sideline Concussion Management • Requires players, parents, coaches, officials and medical personnel to identify injured individuals • Make the Diagnosis • Standard emergency management principles • Allow off-field assessment without affecting flow of game • Symptom Evaluation • Maddocks questions (What venue? What is score? Who playing?) • Cognitive Assessment (orientation, immediate memory, concentration) • Balance and Coordination Exam (single leg stance, tandem stance, finger-nose-finger testing) • Delayed Recall

17. Sideline Concussion Management • Every concussion is different and should be managed individually • A player with a concussion should NOT continue to practice or return to a game • IHSAA rules for 2010 allow an official to remove a player from play if a concussion is suspected • Identify patients at risk for intracranial bleeding • Talk with parents/roommates about significance of concussion, continued observation, and framework of further evaluation • No NSAIDs for first 72 hours

18. Sideline Concussion Management • Athletes at higher risk for intracranial bleeding necessitate further imaging: • Prolonged loss of consciousness • Emesis--“Two Puke Rule” • Persistent mental status changes • Increasing agitation or confusion • Focal neurological or visual deficits • Gestalt perception

23. Initial Concussion Management • Day 2: Re-evaluated by certified athletic trainer or team physician • Reassessment of symptoms and avoidance of provocative activities • Metabolic imbalance after concussion means that increased cerebral blood flow will worsen symptoms and may impede the recovery process • Sports, conditioning, weight lifting, reading, watching TV, playing video games, texting, taking hot tubs, arguing • School attendance and activities may need to be modified • Safety considerations: Operating a vehicle • Neurocognitive testing ideally within 48 hours

24. Ongoing Concussion Management • Avoidance of physical activities until symptoms completely resolve • Support in academic environment • Consider further imaging if symptoms persist • Management of co-existing conditions (e.g. headaches, acute illness, heat illness) • Use of neurocognitive testing to aid in decision making

25. Neurocognitive Testing • Helpful due to the wide variety of concussion signs/symptoms that may be subtle to the athlete, coach, or medical personnel • Athletes may not understand potential serious consequences of concussion and may minimize or deny symptoms • Formal neuropsychological cognitive testing may take 4-8 hours • Several computerized versions of neurocognitive testing available (ImPACT, HeadMinder, Cogsport)

26. Neurocognitive Testing ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing)—software available for five local high schools with interpretation through Union Sports Medicine • Computerized test developed by clinical researchers at the University of Pittsburgh • Developed to allow for a more objective assessment of concussion and recovery • Accounts for individual differences in cognitive ability and symptom reporting through the use of baseline testing • Provides a common metric which allows for effective collaboration between athletic trainers, coaches, physicians, and neuropsychologists in concussion management • Utilized throughout professional and amateur sports across the country and internationally

27. Neurocognitive Testing WHAT DOES ImPACT MEASURE? • Demographic/Concussion History Questionnaire • Concussion Symptom Scale • 21 Item Likert scale (e.g. headache, dizziness, nausea, etc) • Eight Neurocognitive Measures • Measures domains of Memory, Working Memory, Attention, Reaction Time, Mental Speed, Verbal Memory, Visual Memory, and Processing Speed • Detailed Clinical Report • Automatically computes composite and percentile score for visual memory, verbal memory, visual motor speed, and reaction time • Shows statistically significant falls from baseline • Outlines demographic, symptom, and neurocognitive data

28. Clinical Studies 24-72 Hours Day 5-10 Concussion Baseline Testing (Normative data available for decision making when baseline data not available) Beyond (if necessary)

29. Neurocognitive Testing Interpreting Data: • Very strong test-retest reliability • Athletes suffering concussion are much more likely to have decreased scores in 2 or more of the 4 categories (63% vs. 3%, p<0.00001, Odds Ratio 46.8) • An increase in symptom score and statistically significant drop in 1 category is valid as witnessed concussion • Patients diagnosed with concussion that return to sport with even 1 category still statistically significantly lower than baseline are more likely to suffer a recurrent concussion

30. Neurocognitive Testing • Beneficial in determining subtle changes in cognitive performance • Is most often used in a manner that appropriately delays return to play • Drawbacks: • Not all athletes get baseline exams • Testing environment is important • It is a commercial product • It should be used as a tool to aid in the overall diagnosis and management plan

31. Neurocognitive Testing ImPACT currently used by: • All NFL teams (since 2007) • 29 MLB teams (including Cardinals, Cubs, and Reds) and all MLB umpires • IRL, Formula 1, and Champ Racing • USA Hockey, Boxing, and Soccer • 8 NBA teams (including Pacers) • All NHL and MLS teams • US Army, US Navy, WWE Wrestling, Cirque de Soleil • 330 colleges (including ISU, RHIT, all Big Ten except Illinois, Harvard, Princeton…)

32. …but not Yale

33. Return to Play Decisions • An adolescent athlete should not return to the same game or practice • Complete rest from physical activity until all symptoms are resolved • Return to baseline on neurocognitive testing • Compare to normative data if baseline not available • Graduated return to activity with cessation of activity is symptoms recur

34. Return to Play Decisions Graduated Return to Activity: • Step 1: No activity, complete rest until asymptomatic • Step 2: Light aerobic exercise such as walking or stationary biking • Step 3: Sport-specific exercise (e.g. skating in hockey, running in soccer) • Step 4: Non-contact training drills • Step 5: Full contact training after medical clearance • Step 6: Game play • Progress activity on a daily basis as tolerated. If symptoms recur, the athlete should drop back down to the previous asymptomatic level

35. Return to Play Decisions Union Sports Medicine Policy • Covers Terre Haute North, West Vigo, Marshall, South Vermillion, Riverton Parke and Rockville • Any athlete diagnosed with concussion must be removed from practice/play • Recommend all athletes see physician • All concussion symptoms and neuropsychological scores are discussed with a team physician • If scores are below baseline they may not be cleared to return • Athletes must be symptom free and complete a graded RTP progression before game play

36. Concussion Sequelae • Second Impact Syndrome • Post-concussion syndrome • Multiple concussions • Overwhelming evidence of the increased risk after a concussion for a second concussion during the same season or in subsequent seasons • Chronic traumatic encephalopathy (CTE) • CTE is the chronic neurodegeneration following a single episode of severe traumatic brain injury or repeated episodes of mild TBI • Dementia pugilistica

37. Second Impact Syndrome • First described in 1973 • Now over 100 cases reported in literature • Second injury causes a catastrophic increase in intracranial pressure in individuals under age 21 who have had recent concussion • May not have reported initial injury • Occurs in individuals who have not completely recovered from initial injury • Often occurs with very innocuous force • May be related to vasomotor paralysis with subsequent cerebral edema, herniation and resultant coma, permanent brain injury, or death • Others have reported it is diffuse cerebral edema that is seen in other types of traumatic brain injury • 100% morbidity and 50% mortality

38. Post-Concussion Syndrome (PCS) • Persistent cognitive symptoms following a mild traumatic brain injury or concussion • Increased risk with repeated concussions • Headache, sleeping difficulties, trouble concentrating, impaired academic performance, emotional changes • Females are at increased risk than males for PCS • Varying definitions on the duration of symptoms to qualify as PCS • Currently considering it at one month after injury • DSM-IV recommends three months • If symptoms have not resolved by one year they are likely to be permanent • Recommend MRI after 2-3 weeks of persistent symptoms

39. Multiple Concussions over Lifetime • Athletes as young as 18 have been reported to have findings of CTE • Athletes with a history of 3 or more concussions are more likely to suffer LOC, post-event amnesia, and confusion • High school students with a history of 2 or more concussions are more likely to have a statistically significant lower GPA compared to those never concussed (Moser RS. Neurosurgery. 2005;57(2):300-306) • No evidence-based guidelines on when to retire an athlete from sport • Proposed that any individual with 3 concussions in a season or post-concussion symptoms greater than 3 months should take a prolonged period of time away from sport

40. Multiple Concussions over Lifetime • Guskiewicz et al (2005) reported that those retired NFL players suffering 3 or more concussions increased the risk of mild cognitive impairment and a trend to develop Alzheimer’s disease at an earlier age • In 2007, Guskiewicz similarly reported an association with clinical depression in same population • Several case reports of CTE on autopsy in the brains of retired NFL players with premorbid clinical evidence of neurodegenerative disease • Brain showed neurofibrillary tangles and neuritic threads found in Alzheimer’s • Did not show the typical amyloid plaques • Ongoing recruitment of “sample tissue” at Boston University

41. Future Recommendations Prevention Strategies: • 1. Education (of medical personnel, coaches, athletes and families) • 2. Rule Changes • Ejection for helmet-to-helmet collisions • Upper limb to head contact in soccer heading increases risk of concussions (Andersen T et al. Br J Sports Med. 2004;38(6):690-696) • 3. Helmet Technology • Revolution helmet has shown a 2.3% absolute risk reduction in concussions (Collins MW et al. Neurosurgery. 2006 Feb;58(2):275-286.) • NNT of 43 athletes • Other helmets may reduce “low-impact” concussions (e.g. Xenith) • 4. Recognition of Undiagnosed Brain Injury • Repetitive hits by linemen during practice may cause injury to the frontal cortex and visual memory without ever having symptoms of concussion • http://sportsillustrated.cnn.com/vault/article/magazine/MAG1176377/1/index.htm • 5. Funding for neurocognitive testing at all schools

42. Future Recommendations Areas of Further Research: • Refine validity and adjustment of neurocognitive testing and possible use in the asymptomatic • Identify cause of persistent symptoms in female athletes • Use of functional MRI to make return to play criteria • Effects of repeated sports concussions and late-life cognitive impairment • Significance of apolipoprotein E4 (ApoE4), ApoE4 promoter gene, and tau polymerase • Has been postulated that gene variant may predispose individual to encephalopathy (Jordan BD et al. 1997. JAMA. 278(2):136-140)

43. Summary • Sports-related concussions are common in youth, high school, and collegiate athletes • Concussion has many signs and symptoms that may overlap with over medical conditions • LOC is uncommon • Neuroimaging is normal with a concussion • ImPACT testing can be helpful in providing objective data to athletes after a concussion • Athletes with concussion should not return to the same game and should rest both physically and cognitively (including modified school workloads) • The long-term effects of concussion are still relatively unknown • Retirement from contact or collision sports may be necessary for the athlete with a history of multiple concussions

44. “Captain, how soon can you land this plane?” “I can’t tell.” “You can tell me. I’m a doctor.”

45. Thank You