Concussion Assessment: A Standardized Approach

1. Concussion Assessment: A Standardized Approach

3. Although the athlete depicted here suffered a severe laceration to the face and gums, he did not sustain a concussion Although concussions obviously cannot be graded or judged simply by the viciousness of the hit, they can be judged and graded using a few simple tools Your athletes� lives just may depend upon it� Introduction

4. Is there a time efficient, easy, and economical means through which we can determine when an athlete has sustained a traumatic brain injury? Introduction

5. Rationale for using a standardized approach: Startling facts about concussions Anatomy of concussions Signs and symptoms of concussions Common concussion sequelae Overview: Concussion Assessment: A Standardized Approach

6. Administration of the Standardized Assessment for Concussion (SAC) Administration of the Balance Error Scoring System (BESS) Considerations for implementation Overview: Concussion Assessment: A Standardized Approach

7. Definitions �A violent shaking or jarring action that can result in immediate or transient impairment of neurological function� (Anderson & Hall, 1995). �A traumatically induced alteration in brain function resulting from a direct blow to the head or a whipping force, which can jar the brain against the skull� (Sugarman & Roche, 2000). Concussion

8. Facts About Concussion Centers for Disease Control and Prevention (CDC) estimates 300,000 sports-related concussions occur per year 100,000 in football alone Over 63% of certified athletic trainers report not using any objective criteria in their concussion protocol (Ferrara, et al., 2001)

9. Concussions occur most often in males and are most prevalent among adolescents and young adults Risk of concussion in football is 4-6 times higher in players with a previous concussion Facts About Concussion

10. Significant relationship noted between diagnosed learning disabilities and incidence of concussion Facts About Concussion

11. Concussions per every 100,000 games and/or practices at the collegiate level Football: 27 Ice Hockey: 25 Men�s soccer: 25 Women�s soccer: 24 Wrestling: 20 Women�s basketball: 15 Men�s basketball: 12 (Head and Neck Injury in Sports, R.W. Dick) Facts About Concussion

12. Skull bony casing around brain Brain approximately 1/4� space between skull and brain in sub-arachnoid space Anatomy

13. Anatomy The brain is a jello-like substance vulnerable to outside trauma.  The skull protects the brain against trauma, but does not absorb impact forces.

14. Anatomy Cervical spine allows the head to rotate to avoid blunt trauma, however, rotational forces can be the most damaging during concussion

15. Two Primary Mechanisms of Concussion Linear Example: A quarterback falls to the ground and hits the back of his head. The falling motion propels the brain in a straight line downward. Rotational Example: As a football player is tackled, his head strikes an opponent�s knee; This contact to the head can cause arotational motion.

16. Impaired attention -- vacant stare, delayed responses, inability to focus Slurred or incoherent speech Gross incoordination Immediate Signs of Concussion(Occurring Within Seconds to Minutes)

17. Disorientation Emotional reactions out of proportion Memory deficits Any loss of consciousness Immediate Signs of Concussion(Occurring Within Seconds to Minutes)

18. Persistent headache Dizziness/vertigo Poor attention and concentration Memory dysfunction Nausea or vomiting Later Signs of Concussion(Occurring Within Hours to Days)

19. Fatigue easily Irritability Intolerance of bright lights (photophobia) Intolerance of loud noises Anxiety and/or depression Sleep disturbances Later Signs of Concussion(Occurring Within Hours to Days)

20. Post Concussion Syndrome Lingering symptoms and continuing cognitive deficit following a concussion injury May occur weeks or months after injury Associated with concussion grades II & III Common Concussion Sequelae

21. Subdural Hematoma Epidural Hematoma Generalized brain swelling and diminished blood flow to sensitive brain tissues Common Concussion Sequelae

22. Second Impact Syndrome Second concussion occurs while still symptomatic & healing from previousinjury days or weeks earlier Athlete may or may not lose consciousness Second impact more likely to cause brain swelling and other widespread damage Loss of cerebral blood flow autoregulation results in massive vasodilation and 100% mortality (Snoek, et al., 1984) Common Concussion Sequelae

23. Primary survey to rule out immediate threats to life Trending vital signs Secondary survey to identify potential threats to life or limb C-spine Neuro exam How Are Concussions Assessed?

24. Neurological exam should include: Cranial nerve check Myotome testing Dermatome testing Reflexes Cognition How Are Concussions Assessed?

25. At least 14 concussion grading systems now exist, with three being pre-eminent Cantu guidelines (1988) Colorado Medical Society (CMS) guidelines (1991) American Academy of Neurology guidelines (1997) How Are Concussions Assessed?

26. Problems with Cantu, CMS, and AAN guidelines include: Inconsistency of criteria to determine severity Controversy regarding the importance of loss of consciousness, post-traumatic amnesia, and post-concussive symptoms How Are Concussions Assessed?

27. No scientific basis for return to play guidelines No consensus within sports medicine for any of the established guidelines Most do not use objective, repeatable measures How Are Concussions Assessed?

28. Neuropsychological baseline testing considered the �gold standard� but not frequently used Too costly ($500-2000 per athlete) Too time consuming (4-8 hours per athlete) Standardized Assessment for Concussion (SAC) developed as a time-efficient and cost-effective alternative How Are Concussions Assessed?

29. Standardized Assessment for Concussion (SAC) (McCrea, Kelly, Randolph, et al.) Relatively quick and easy Norms being established, but key is comparison to athlete�s own pre-participation baseline How Are Concussions Assessed?

30. NeuroCom Smart Balance Master considered �gold standard� Again, not cost efficient and cannot be used on the sideline Balance Error Scoring System (BESS) (Guskiewicz, McCrae, et al.) Whereas SAC assesses cognitive function, BESS assesses balance and equilibrium function Relatively quick and easy How Are Concussions Assessed?

31. Orientation (5 points) Ask athlete a series of questions regarding time, day, date, etc Aimed at establishing athlete�s awareness Five questions scored (1 point for correct answer, 0 points for incorrect answer) Administration of the SAC

32. Immediate recall/learning (15 points) Recite list of words and ask athlete to repeat Recite list additional times to see if recall improves Do NOT inform athlete of delayed recall of same list later during the administration of the test Administration of the SAC

33. Concentration (5 points) Recite increasingly long series of numbers and ask athlete to recite list in reverse order Ask athlete to recite months of the year in reverse order Administration of the SAC

34. Delayed recall (5 points) Ask athlete to recite word list from immediate memory portion of SAC Administration of the SAC

35. Scoring system compare subject�s test score(s) to his/her baseline, not to other subjects� scores Norms not yet established, but differences of 2-3 points considered significant Administration of the SAC

36. Total of six stances with eyes closed and hands on iliac crests Firm surface two-feet, non-dominant one foot, and tandem (heel to toe) Soft surface (AirEx Balance Pad) two-feet, non-dominant one foot, and tandem (heel to toe) Administration of the BESS

37. Stance held for 20 seconds and errors counted Errors consist of any of the following: Lifting hand(s) from iliac crest(s) Step, stumble, or fall Lifting forefoot or heel Moving hip more than 30 degrees from starting position Staying out of testing area > 5 seconds Administration of the BESS

38. Maximum number of errors per position is 10 Errors for each position added together for final BESS score out of 60 Test valid and reliable (Riemann, et al., 1999) Considerations for implementation include distraction, taping/bracing, pads, fatigue, and inter-rater reliability Administration of the BESS

39. Objective measure of cognitive function Identifies signs and symptoms that may be too subtle to otherwise detect Difficult to cheat Athletes who should not return easily identified What SAC/BESS testing CAN Tell You

40. No way to determine grade of concussion from SAC/BESS data alone�must use other criteria Return to play guidelines utilize SAC/BESS data as a portion of the overall picture to be considered What SAC/BESS testing CANNOT Tell You

41. Baselines should be completed BEFORE contact begins Maintain list of baselines and keep them handy Sometimes helpful to keep with insurance documentation Considerations for Implementation

42. Mimic the surroundings of a competition/sideline while administering baseline test to ensure validity Keep a small, laminated version of the SAC and BESS in your fanny pack or kit for ease of use during game situations Considerations for Implementation

43. Objectives of RTP guidelines Prevent �missed� concussions and the complications that may potentially arise Improve awareness and identification of concussions among medical and coaching staff Reduce subjectivity Discontinue arbitrary decision making for RTP duration Return to Play Guidelines

44. Utah State University (USU) Model (Finnoff & Mildenberger) Utilizes SAC, BESS, and functional testing data to determine RTP Athlete may not return to play until 5 days AFTER SAC & BESS normalization and asymptomatic functional testing Return to Play Guidelines

46. Return to Play Guidelines: USU Model

47. By using the SAC and the BESS, you can be better prepared to objectively evaluate athletes with concussion-like symptoms quickly, easily, and consistently Along with a functional progression, such information can help determine without question when an athlete may safely return to play