CONCUSSION MANAGEMENT: ImPACT

1. CONCUSSION MANAGEMENT:ImPACT David R. Wiercisiewski, MD Director, Carolina Sports Concussion Program at CNSA

2. STATISTICS • Incidence in HS football = 6%-8% per year. • Boy’s + Girl’s soccer = football. • Girl’s basketball 250% greater risk than Boy’s • Sports and recreational injuries with LOC = 300,000 per year. • Sports and recreational injuries with and without LOC = 1.6 million per year.

3. DEFINITION Complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces.

4. COMMON FEATURES • Caused by a direct or indirect blow to the head, face or neck. • Results in rapid onset of short-lived impairment of neurological function. • A concussion may or may not involve LOC. • The clinical symptoms reflect a functional rather than a structural disturbance.

5. PATHOPHYSIOLOGY • Mechanism of Injury • Rotational • Linear • Impact deceleration • Chemical/Vascular • 1st 7-10 days • ↑K / ↑Ca / ↑glc / ↑glut • ↓CBF • “Period of vulnerability”

6. CONCUSSIONCLASSIFICATION Recommendation to abandon the “simple” versus “complex” nomenclature with no endorsement of any other specific classification system.

7. PRIMARY AREAS OF FOCUS • Rule out more serious intracranial pathology • Prevent Second Impact Syndrome • Prevent repeat injury during post-concussion period of “vulnerability”. • Prevent against cumulative effects of injury • Neurobehavioral deficits • Lowered threshold to injury

8. GENERALMANAGEMENT • Majority of injuries will recover spontaneously. • Physical and cognitive rest are required while symptomatic. • When symptom free and improved “functionally” graduated return to play protocol should be utilized. • Same day return to play—NEVER!!!

9. CONCUSSION EVALUATION

10. PLAN—PLAN—PLAN • Agree on an approach to the management of concussions with other health care providers on the team. • Baseline cognitive testing if available. • Use a standardized PCS symptom scale (i.e. SCAT2) • Perform serial assessments • Identify your referral patterns ahead of time

11. CONCUSSIONRECOGNITION • Symptoms—somatic (headache), cognitive (feeling like in a fog) and emotional (lability). • Physical signs—LOC and amnesia. • Behavioral changes—irritability. • Cognitive impairment—slowed reaction times. • Sleep disturbance—drowsiness.

12. EVALUATION • Neurological assessment • Motor • Pupillary response • Coordination/postural control • Mental status testing • Attention • Memory • Processing speed

13. MENTAL STATUS TESTING • Be familiar with the different screening tools and their requirements. • Use tools that have been validated and published in peer-reviewed literature. • Results should be interpreted and integrated into the other relevant clinical information.

14. NEUROCOGNITIVE COMPUTERIZED TESTING • ImPACT (UPMC) • CogSport (Australia) • CRI (Headminder) • ANAM (NRH)

15. COMPUTERIZED TESTING • Format allows portability and efficiency. • Each vendor has their unique menu of cognitive domains that their product measures. • 20 – 30 minutes to administer. • Used as a “tool” to measure recovery and not to make a diagnosis or solely direct management.

16. Must assess pertinent domains. Baseline testing improves evaluation. Limitations: “Normal” range Sensitivity Specificity Learning effects Early return to baseline while still symptomatic Without baseline testing it can be more difficult to interpret FEATURES OFCOGNITIVE TESTING

17. CAROLINA SPORTSCONCUSSION PROGRAM • First sports concussion program in the greater Charlotte area. • Began in February 2007. • First year provided post-injury care only. • Subsequent years we have provided free baseline tests to middle and high school athletes participating in “high risk” sports through monies donated by SunTrust Bank. • Baseline testing program currently offered in 5 counties. • Utilize the ImPACT neurocognitive testing tool.

18. 8 separate tests Word memory Design memory X’s and O’s Symbol Match Color Match Three Letters Interference tests 6 composite scores Verbal memory Visual memory Visual motor speed Reaction time Impulsivity Total symptom score IMMEDIATE POST-CONCUSSION ASSESSMENT and COGNITIVE TESTING (ImPACT)

19. CONCUSSION SYMPTOM SCALE • Standardized survey with 0-6 scale rating • Developed by Lovell and Collins in 1998 • Sensitive tool to measure recovery • Symptoms generally classified into 3 main categories: Physical, Cognitive, and Emotional/Behavioral

20. OVERVIEW OF ImPACT • Proven in measures of reliability and validity • Provides useful concussion screening and management information • Validated with multiple peer-reviewed studies • Does not substitute for medical evaluation and treatment • Does not substitute for comprehensive neuropsychological testing

21. PREDICTING RECOVERY TIMELINES ALL ATHLETES ARE NOT CREATED EQUALLY

22. CONCUSSIONMODIFIERS • Symptoms—Number, duration (>10 days) and severity. • Signs—Prolonged LOC (>1 min.), amnesia. • Sequelae—Concussive convulsions. • Temporal—Frequency (number of concussions), Timing/”recency”

23. CONCUSSIONMODIFIERS • Threshold—Repeated concussions occurring with less force or slower recovery. • Age—Child and adolescent < 18 years old. • Co-morbidities—Migraine, depression or other mental health disorders, ADHD, learning disabilities and sleep disorders. • Medication—Psychoactive drugs and anticoagulants. • Behavior—Style of play. • Sport—Contact or collision sport, high-risk.

24. SPECIAL POPULATIONS

25. CHILD AND ADOLESCENTATHLETES • Clinical evaluation should include academic performance and behavior in school. • Neurocognitive testing may be performed earlier to aid in academic accommodations during recovery. • Return to exertion or game play should be slower when compared to the adult athlete. Also there should be particular focus on “cognitive rest”. • Never return to play on same day!

26. ELITE vs. NON-ELITEATHLETES • Both groups should follow the same treatment and return to play paradigm • Neurocognitive testing is preferred but providing for non-elite athletes may be restricted by financial resources

27. CASE STUDIES

28. RETURN TO PLAY PROTOCOL • No activity while symptomatic. • Light aerobic exercise. • Sport-specific exercise—no head impact drills. • Non-contact training drills. • Full contact practice. • Return to game play.

29. NFL CONCUSSIONGUIDELINES • Established in 2009. • No same day return to practice or game play. • Players encouraged to be honest and report symptoms. • Independent neurology opinion for each injury.

30. CHRONIC TRAUMATIC ENCEPHALOPATHY

31. CHRONIC TRAUMATIC ENCEPHALOPTHY • NFL Survey— • > 50 = 5x risk • 30-49 = 19x risk • Comparative data from the Framingham heart study. • Concept of subconcussive trauma. • Sports Legacy Institute.

32. CTETAU PROTEIN • Protein that invades cortical nerve cells and shuts them down effectively killing them. • Unlike Alzheimer’s disease and the neurofibrillary tangles associated with that disease, the build up of tau is related to trauma or injury.

33. DISQUALIFICATIONLONG TERM • 3 fold risk to have concussion if have 3 concussions in previous 7 years • 2 or more concussions have longer recovery times • 3 or more concussions: • 8 fold risk of LOC • 5.5 fold risk of PTA • 5.1 risk of confusion

34. INJURY PREVENTION • Protective Equipment—Mouthguards and helmets. • Rule changes. • Risk Compensation—use of protective equipment results in a behavioral change and may subsequently result in a paradoxical increase in injury rates. • Aggression versus violence in sports.

35. FUTURE DIRECTIONS • Gender effects on injury, severity and outcome. • Pediatric injury and management paradigms. • Validation of SCAT2 as a sideline assessment tool. • Concussion surveillance using consistent definitions and outcome measures. • Long-term outcomes. • Formal review of “concussion in sport” guidelines and update prior to December 1, 2012 by panel of international experts.

36. PROTECTING THE “3 LB. UNIVERSE”OBSERVATIONS FROM CLINIC • Moving the mountain. • Improved awareness and increase in concussion recognition. • Gap in club sports. • Dealing with the devil. • The sickness of our sports culture. • Creating a road map. • Defining expectations of recovery based on the individual’s unique medical history and mechanism of injury. • Kids are real people too! • Emotional response to the injury. • My “uneasy” chair. • How many is too many?

37. THANK YOU