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Management of Sports Concussion and The ImPACT Program. Jon French, PsyD University of Pittsburgh Medical Center Department of Orthopaedic Surgery Clinical Fellow and Neuropsychologist UPMC Sports Concussion Program. Mark Lovell PhD, FACPN, D.Sci Chairman and CEO Software Developer

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slide1

Management of Sports Concussion and The ImPACT Program

Jon French, PsyD

University of Pittsburgh Medical Center

Department of OrthopaedicSurgery

Clinical Fellow and Neuropsychologist

UPMC Sports Concussion Program

Mark Lovell PhD, FACPN, D.Sci

Chairman and CEO

Software Developer

ImPACT Applications, Inc.

Micky Collins, PhD

University of Pittsburgh Medical Center

Department of Orthopaedic Surgery

Department of Neurological Surgery

Program Director

UPMC Sports Concussion Program

Co-Founder, ImPACT Applications

workshop goals
Workshop Goals

To Provide Background Information Regarding Concussion Management

To Present Data Pertaining to Outcomes and Risk Factors Associated with Sports Concussion

To Discuss Academic Needs for Recovering Student Athlete with Concussion

To Review the Utility of Computerized Neurocognitivie Testing and ImPACT as a Tool for Effective Concussion Management

To Review Clinical Case Material

slide3

Concussion 101: Biomechanics, Pathophysiology, Definition

  • Micky Collins, PhD
  • Associate Professor and Director
  • UPMC Sports Medicine Concussion Program
neurometabolic cascade following cerebral concussion mtbi
Neurometabolic Cascade Following Cerebral Concussion/MTBI

500

Calcium

400

K+

300

Glucose

% of normal

200

Glutamate

100

50

2

6

12

20

30

6

24

3

6

10

Cerebral Blood Flow

0

hours

days

minutes

(Giza & Hovda, 2001)

UCLA Brain Injury Research Center

slide18

Concussion Management: Areas of Focus

  • Acute Management
    • Rule out more serious intracranial pathology
    • CT, MRI, neurologic examination primary diagnostic tests
  • Post Injury Management
    • Prevent against Second Impact Syndrome
    • Prevent against cumulative effects of injury
    • Less biomechanical force causing extension of injury
    • Prevent presence of Post-Concussion Syndrome
    • Determination of asymptomatic status essential for reducing repetitive and chronic morbidity of injury
slide19

Most Commonly Reported Symptoms

Athletes with Concussion – 1-7 days following concussion

Kontos, Elbin, French Collins, Data Under Review; N = 1,438

slide20

Post-Concussion

Symptom

Groups

(Pardini, Lovell, Collins, et al. 2004)

N=327, High School and University

Athletes Within

7 Days of Concussion

slide21

The Evolving Definition of Concussion

CDC Physicians Toolkit 2007

Regarding Cerebral Concussion……

A concussion (or mild traumatic brain injury) is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. Disturbance of brain function is related to neurometabolic dysfunction, rather than structural brain injury, and is typically associated with normal structural imaging findings (CT Scan, MRI). Concussion may or may not involve a loss of consciousness. Concussion results in a constellation of physical, cognitive, emotional, and sleep-related symptoms. Recovery is a sequential process and symptoms may last from several minutes to days, weeks, months, or even longer in some cases.”

CDC Physicians Toolkit; Collins, Gioia et al 2006

slide22

Management of MTBI: Topics of Concern

  • Grading systems ineffective/not data based.
  • CT and MRI insensitive to subtleties of injury.
  • Self-report predicates management directives.
  • Variability in clinician recommendations.
  • Lack of education and awareness of injury.
  • Inadequate/Improper recommendations from ED/Trauma Departments.
slide23

“When it comes to concussion,

don’t believe me when I tell you that I’m OK ”

NFL Athlete, 2010

23

slide24

Return to Play Following mTBI:

Can we safely rely on symptoms alone?

  • In some cases (not all), athletes will minimize difficulties
  • Athletes are naïve to the subtleties of the injury
  • Young athletes lack insight into self-assessment of MTBI symptoms
  • Studies suggest that up to 50% of athletes experience concussion symptoms per year but only 10 % report having an injury
  • Need for comprehensive understanding of athletes recovery status
slide25

Computer-Based Neurocognitive Testing

CURRENTLY AVAILABLE PROGRAMS:

Cogsport (Axon)

Headminders (CRI)

ANAM

CNS Vital Signs

ImPACT

Extensive research since 2001

immediate post concussion assessment and cognitive testing computerized neurocognitive testing
Immediate Post-Concussion Assessmentand Cognitive TestingComputerized Neurocognitive Testing

Mark Lovell, PhD, FACPN, Dsci, Software Developer, ImPACT

Micky Collins, PhD - UPMC Dept. of Orthopaedic Surgery

Joseph Maroon, MD - UPMC Dept. of Neurological Surgery

ImPACT

impact post concussion evaluation
Demographic / Concussion History Questionnaire

Concussion Symptom Scale

21 Item Likert Scale (e.g. headache, dizziness, nausea, etc)

8 Neurocognitive Measures

Verbal Memory, Visual Memory, Reaction Time, Processing Speed Summary Scores

Detailed Clinical Report

Outlines Demographic, Symptom, Neurocognitive Data

Automatically Computer Scored

Internal baseline validity checks built into program

Desktop and On-Line Versions Available

Extensive normative data available from ages 11-60

Over 100 peer-reviewed research articles/books/chapters, published since 2000

Extensive data published on reliability, validity, sensitivity/specificity of test

ImPACT: Post-Concussion Evaluation
slide29

Concussion Evaluation Timeline

Pre-season

1-3 Days

Return to Play

Remove From Play

Evaluation

Supervised at School

Or clinic

slide32

Three-year prospective study in Western PA.

      • 17 high school football teams (2,141 total sample)
  • 134 athletes with diagnosed concussion (6.2%)
  • All athletes referred for evaluation at UPMC
  • Recovery determined by “Back to Baseline” on computer
  • neurocognitive test scores & symptom inventory
  • Determined by Reliable Change Index Scores-RCI’s)

Collins, Lovell, Iverson, Ide, Maroon et al, Neurosurgery, 2006:58;275-283

individual recovery from sports mtbi how long does it take
Individual Recovery From Sports MTBI: How Long Does it Take?

WEEK 1

WEEK 2

WEEK 3

WEEK 4

WEEK 5

80%

RECOVERED

60%

RECOVERED

N=134 High School Male Football Athletes

40%

RECOVERED

Collins et al., 2006, Neurosurgery

slide34

Functional MRI and Sports Concussion

Lovell, Collins, Eddy, Becker, Pardini, Maroon, Field, Marion, and Boada (2001-2006) RO1 HD 42386-05

slide35

Brain Metabolism is Related to Recovery

  • Over 200 High School Athletes Studied using fMRI
      • Tested w/in 7 days of concussion and at point of clinical recovery
  • Hyperactivation predicts CLINICAL recovery time
  • Resolution of hyperactivation correlates with recovery on ImPACT

Lovell et al., Neurosurgery, 2007

recovery fmri subsample upmc program lovell pardini collins et al neurosurgery 2007
Recovery: fMRI Subsample (UPMC Program)(Lovell, Pardini, Collins et al; Neurosurgery 2007)

Mean Age: 16.2 yrs

Gender: 78% male

N = 208

slide37

Prognosticating Concussion Outcomes:

An Evidence-Based Analysis

Micky Collins, Ph.D.

University of Pittsburgh Medical Center

Associate Professor

Department of Orthopaedic Surgery

Department of Neurological Surgery

Director

UPMC Sports Concussion Program

slide38

Researching/Determining Prognosis for Sports Concussion: Why is it Important?

  • Helps to set up clear communication to player, coaches, and medical personnel regarding recovery expectations
      • May help to alleviate some pressure on RTP issue
  • May help to immediately provide individualized clinical management recommendations (e.g. need for academic accommodations/physical rest, etc.)
  • Begins to create a risk profile for sports concussion and may set stage to effectively research treatment and rehabilitation strategies.
  • Because it is the next stage in our scientific understanding of this injury….
slide39

Lau B, Kontos A, Lovell MR, Collins MW, AJSM: 2011

Which On-Field Symptoms

Predict Protracted Recovery

(i.e. Post-Concussion Syndrome)?

slide40

Which On-Field Symptoms Increase Risk of

Post Concussion Syndrome in High School Football Players?

  • 176 Male HS Football Players (Mean Age = 16.2 years)
  • Athletes had baseline ImPACT testing and were revaluated within 3 days of injury.
  • All followed until clinical recovery (Mean = 4.1 evaluations)
    • Within RCI of baseline on ImPACT for neurocognitive/symptom scores
  • 32% of sample required < 7 days until recovery (N =56) “Rapid Recovery” (Mean = 4.9 days)
  • 39% of sample required 7-14 days until recovery (N = 68)
  • 17% of sample required > 21 days until recovery (N = 31) “Protracted Recovery”
  • (Mean = 33.2 days)
  • 12% lost to follow up (e.g. did not RTP or no follow-up in clinic) (N = 21)
  • MANOVA used to determine differences between rapid/> 3 week recovery
  • ATC’s documented on-field markers (e.g. LOC, Amnesia) and on-field Symptoms (e.g. headache, dizziness, etc)

Lau B, Kontos A, Lovell MR, Collins MW, AJSM 2011

slide41

Which On-Field Markers/Symptoms Predict 3 or More WeekRecovery from MTBI In High School Football Players

**p<.01

The total sample was 107. Due to the normal difficulties with collecting on-field markers, there were varying degrees of missing data. The number of subjects who had each coded ranged from 92-98. The N column represents the number of subjects for whom data were available for each category. Markers of injury are not mutually exclusive.

Lau, Kontos, Collins, Lovell , AJSM 2011

slide42

On-Field Symptom Summary

  • Brief LOC (<30 sec) not predictive of subacute or protracted outcomes following sports-concussion
  • Amnesia important for sub-acute presentation, but may not be as predictive of protracted recovery
  • On-Field dizziness best predictor of protracted recovery and
  • “post concussion syndrome”
  • Etiology of dizziness?
  • Migraine variant?
  • Central Vestibular Dysfunction?
  • Peripheral Vestibular Dysfunction?
  • Cervico-genic?
  • Psychiatric?
slide43

Lau B, Lovell MR, Collins MW; Pardini J;

CJSM 2009 (3):216-21

Which SubacuteSymptoms

Predict Protracted Recovery?

slide44

108 concussed high school football players

    • Athletes had baseline ImPACT testing and were revaluated within 3 days of injury (Mean = 2.2 days)
    • All followed until clinical recovery
      • - Within Reliable Change Score of baseline for neurocognitive/symptom scores
    • 43.5% of sample recovered < 10 days = “Quick”
      • - Mean = 5.9 Days
    • 56.5% of sample required >10 days until recovery = “Protracted”
      • - Mean = 29.2 Days
    • MANOVA conducted on which individual symptoms and neurocognitive domains predicted “quick” versus “protracted” recovery

Lau B, Lovell MR, Collins MW; Pardini J; CJSM 2009 (3):216-21

slide45

Post-Concussion

Symptom Scale

slide46

Top 11 Symptom Predictors of Protracted Recovery

Expressed as Effect Sizes (Cohen’s D). Only includes symptoms with large (greater than .80) effect sizes. Sample is composed of 108 male HS football athletes.

Lau, Lovell, Collins et al. 2009, CJSM

slide47
“Fogginess” Athlete Descriptions
  • “It is like going from a high definition TV world
    • to standard TV world”
  • “Feeling one step removed from my surroundings”
  • “It is like my vision is impaired, but it isn’t”
  • “Feeling like I am underwater”

Iverson, Lovell, Collins. JINS (2004),10, 94-906.

slide48

Factor Analysis,

Post-Concussion

Symptom Scale

(Pardini, Lovell, Collins et al. 2004)

N=327, High School and University

Athletes Within

7 Days of Concussion

rank order of most predictive symptoms of outcome
Rank Order of Most Predictive Symptoms of Outcome

Lau, Lovell, Collins et al. CJSM, 2009

*Symptoms with the largest contributions to differences between “quick” and “protracted” recovery in each symptom factor.

slide50

The Role of Sub-Acute Migraine-Symptoms in Determining Outcomes Following Concussion

Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; data in preparation for publication

slide51

Post-traumatic Migraine (PTM) Defined

  • Post-traumatic Migraine
    • Headache, nausea, AND sensitivity to light OR noise (International Headache Society Guidelines)
  • Determined by utilizing PCSS at 1-7 days post-concussion

Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; In preparation..

slide52

Study Overview

  • 174 high school athletes with a concussion
    • No prior hx of LD, moderate TBI, psychiatric disorder
  • Athletes followed until recovery
    • Neurocognitive scores returned to baseline (w/in RCI)
    • Symptom free and rest and exertion
  • 97 athletes met Rapid or Protracted Criteria for Recovery:
    • Rapid (≤7 days)= 61
    • Protracted (≥21 days)= 36
  • Recovery studied for three groups
    • No headache group
    • Headache only group
    • Post-traumatic migraine group (headache with nausea and/or light and noise sensitivity)
  • Data Analysis
    • Chi-square analysis with Odds Ratios for Recovery Time Groups
    • Repeated measures ANOVAs for ImPACT scores across 3 time periods

Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; In preparation..

slide53

How does PTM compare to No Headache and Headache groups in predicting Protracted (>21 days) Recovery from Sports Concussion? (N= 97)

Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; In preparation..

slide55

PTM =

Post Traumatic

Migraine

ImPACT

Visual Memory

Raw Score

N = 97 HS Athletes with concussion

Comparison of ImPACT Visual Memory scores for PTM, Headache, and No PTM or Headache groups (λ= .88, F= 4.24, p= .002, η2 = .06)*

*PTM significantly different than both groups at 1-7 and 8-14 days

PTM defined as headache with nausea and sensitivity to light or noise (IHS Classification)

slide56

PTM =

Post-Traumatic Migraine

ImPACT

Reaction Time

Raw Score

Comparison of Reaction Time scores for PTM, Headache, and No PTM or Headache groups (λ= .87, F= 4.96, p= .001, η2= .07)

*PTM significantly different than both groups at 1-7 and 8-14 days

PTM defined as headache with nausea and sensitivity to light or noise (IHS Classification)

slide57

Conclusion

“It’s more than just a headache”:

  • Athletes with migraine-type symptoms (headache with nausea and/or light-noise sensitivity) exhibit more protracted recovery than with athletes with headache only
  • 81% of post-traumatic migraine group also reported dizziness (post-traumatic vestibular migraine??)
  • Important to assess for quality and type of headache in athletes with concussion
slide59

Sensitivity and Specificity of ImPACT in Classifying

Athletes with Concussion

  • Schatz P, Pardini J, Lovell MR, Collins MW. Archives of Clinical Neuropsychology 2005:21;91-99.
  • Discriminate Function Analysis
  • Statistical classification of Concussed (physician dx)/Control subjects
  • No Clinician Input
  • Testing completed within 3 days post injury
  • Positive Predictive Value (90%)

(Probability that that a concussion is present when test is positive)

  • Negative Predictive Value (82%)
  • (Probability that a concussion is not present when test is negative)

N = 138 controls/

concussed athletes

slide60

Lau B, Collins MW, Lovell MR

Neurosurgery2012;Feb 70(2):371-79.

Determination of Neurocognitive Cutoff Scores that Predict Protracted Recovery

(at 2 days post injury)

slide61

108 concussed HS and Collegiate Athletes

    • Athletes had baseline computerized NP testing and were revaluated within 3 days of injury (Mean = 2.2 days)
    • All followed until clinical recovery
      • Within Reliable Change Score of baseline for neurocognitive/symptom scores
    • 43.5% of sample recovered < 14 days = “Quick”
      • Mean = 5.9 Days
    • 56.5% of sample required >14 days until recovery = “Protracted”
      • Mean = 33.0 Days
    • ImPACT composite cutoff scores statistically calculated at 75%, 80%, and 85% sensitivity to predict protracted recovery (i.e. 1 month or longer for clinical recovery)

Lau B, Collins MW, Lovell MR. Neurosurgery In Press

slide62

Cutoff Values of ImPACT Neurocognitive Scores at 2 Days Post Injury That Predict Protracted Recovery

Sensitivity is defined as the ability of the cutoff to accurately identify protracted recovery (>14 days; Mean = 1 month) in an athlete.

Lau B, Collins MW, Lovell MR. Neurosurgery2012.

slide63

Iverson G. CJSM; 2008

Predicting Quick versus Protracted Recovery from

Sports mTBI

  • - At three days post-injury, if athlete exhibit three or more RCI changes on ImPACT composite scores (relative to baseline), there is a 94% chance that recovery will require >10 days.
  • - Exhibiting a high symptom score did not improve classification accuracy over neurocognitive test scores in isolation.
  • - Athletes with prior history of concussion were not statistically more likely to have “protracted” recovery from concussion.
slide64

Other Recent Peer Reviewed Research Examining Neurocognitive Testing

When computerized neurocognitive testing is utilized, athletes are less likely toreturn to play within a week compared to those in whom it was not utilized-13.6% vs 32.9%

(Meehan et al, AJSM, 2010).

slide65

Use of Computerized Neurocognitive Testing

In High School Athletes (Meehan et al, 2011)

  • 41.2% of US High Schools that employ at least 1 ATC utilized computerized neurocognitive testing during 2009-2010 academic year (25.7% in 2008-2009 year)
      • 93% use ImPACT
  • 100% of schools utilizing testing reported that scores were utilized in making RTP decisions
  • 86% of these schools performed baseline testing
  • Athletes who underwent computerized NP tesing were less likely to be returned to play within 10 days of injury (38.5% vs 55.7%, p < .01) and were more likely to be returned to play by a physician (60.9% vs 45.6%, p <.01)
slide67

Summary

  • Outcomes are highly variable
  • Vestibular-related symptoms following injury predict more protracted recoveries
  • Migraine-type symptoms (and potentially preexisting history of migraine)may place individuals at increased risk of injury and longer recovery
  • Neurocognitive testing is valuable in determining prognosis and recovery in sports-related mTBI
  • Clinical management key to preventing poor outcomes
  • The “mild” injuries may become severe and the “severe” injuries may become mild
slide68

Sports Concussion

Scientific Evolution and Building Consensus: Where are we Headed?

cdc physician toolkit collins gioia et al 2007
CDC Physician Toolkit (Collins, Gioia, et al. 2007)
  • Post-Injury Management
    • Removalfrom contest if concussion suspected-no RTP in same game
    • No return to play while symptomatic or if symptomatic with exertion
    • Carefully monitored and graded increase in exertion over time
    • Need to be mindful of cognitive exertion on role of recovery
  • Need for conservative management in children/adolescents
  • Neurocognitive testing recommended for athletes sustaining concussion
  • Criteria for Return to Play
    • Symptom-Free at Rest
    • Symptom-Free with Cognitive/Physical Exertion
    • Normal Neurocognitive Data/Objective Evaluation

Recommended Sports Concussion Management