Concussion be gone

Andrew Cannon, MHS, PT, SCSDir., Sports Medicine, NRHN

Team PT, Lecturer, Merrimack CollegeNHIAA Sports Medicine Board

NH-SCAC

Is it Safe for Your Patient’s Brain to Play Sports?

Northeast Rehabilitation Hospital Acute Care Rehabilitation

– We have, on-site: Pain Clinic Pharmacy Outpatient Therapies Orthotics & Prosthetics

Clinic, Wheelchair Clinic,Low-Vision Clinic, DrivingAssessments

Programs consist mainly of: Stroke Neurological Brain Injury Spinal Cord Injury General Rehab Multi-trauma

23 Outpatient Clinics Home Care and more…

New Hampshire Sport ConcussionAdvisory Council

Mission: Improve concussion-related safety of NH athletes

Does academic performancerelate to physical activity?

7,961 school kids Age 7-15 Consistently across age

groups and genderacademic performancewas correlated withphysical activity andfitness measurements

Dwyer T, Relation of academic performance to physicalactivity and fitness in children.Ped ExSci 13:225-2372001

What is a ConcussionCDC

A type of brain injury that changes the way thebrain normally works.

Caused by a bump, blow, or jolt to the head thatcauses the head and brain to move rapidly backand forth.

Children and adolescents are among those atgreatest risk for concussion

Sport related concussion in US 1.6 - 3.8 million 6-10% of all sports related injuries Ages 5-18 the 5 leading sports/recreational

activities resulting in concussion are?

What % of concussions inchildren are sport related?

< 10 YO = 18.2% 10-14 YO = 53.4% 15-19 YO = 42.9% In contact sports 20% suffer concussion each

season Estimated concussions are under reported by

65%! 60 % high school students participate in sports The sheer volume makes sport related concussion

a public health issue!

Zurich Consensus Statement

Complex pathophysiological process affecting thebrain, induced by traumatic biomechanical forces.

Direct or indirect blow to the head or body with“impulsive” force to the head

Typically rapid onset of short-lived impairment ofneurological function that resolves spontaneously– 90% resolve 1-2 weeks– 10% suffer prolonged post-concussive symptoms

Zurich Consensus Statement

Concussionresultsinagradedsetofclinicalsymptomsthatmayormaynotinvolvelossofconsciousness.Resolutionoftheclinicalandcognitivesymptomstypicallyfollowsasequentialcoursehoweveritisimportanttonotethatinasmallpercentageofcaseshowever,postconcussivesymptomsmaybeprolonged.

Acute clinical sx’s largely represent a functionaldisturbance, not a structural one

No abnormality on standard structural neuroimagingstudies is seen in isolated concussion

SOFTWARE NOT HARDWARE

Chelsea Davis, 16 year old American diver,2005 world championships

broken nose, laceration, no concussion!

Evolving Knowledge LOC not required “Mild” traumatic brain injury (mTBI)

– With some disagreement? PCS Neurometabolic/neurochemical imbalance

– Neuronal depolarization, impaired axonal function– Energy crisis: cerebral blood flow; glucose demand– Problem with the software, not the hardware

discover magazine.com/2004/dec/lights-out/article

T h e M o l e c u l a rP a t h o p h y s i o l o g yo f C o n c u s s i v e B r a i nI n j u r yGarni Barkhoudarian, MD, David A. Hovda, PhDChristopher C. Giza, MD

Clin Sports Med 30 (2011) 33-48

Evolving Knowledge Second Impact Syndrome

– Further impact before resolution may be catastrophic– Diffuse cerebral edema– Does it exist?

Multiple Concussions– Subsequent concussions with less provocation– Prolonged recovery– PCS

Seminal Study (Barth et al., 1989)

Problem in MTBI: Adequate controls, controlling forpremorbid functioning, detecting change

Test-retest design – collegiate football players Baseline neuropsychological testing, serial post-

injury testing 10 universities – n=2350 players baseline tested Neurocognitive deficits at 24 hrs and 5 days post-

injury, with return to preseason baseline by Day 10 Sports arena recognized as a unique, relatively well-

controlled lab for assessing mTBI.

Recovery From Concussion:How Long Does it Take?

N=134 High School athletes

WEEK 1

WEEK 2

WEEK 3

WEEK 4

WEEK 5

Collins et al., 2006, Neurosurgery

Studies Reporting Individual Recovery Rates

NR

7 Days

7 Days

Total DaysSymptomResolution

40%recovered

w/in 7 days

50%recovered

w/in 7 days

91%recovered

w/in 7 days

IndividualRecovery

Rates

3-5 DaysPaper and PencilCollege94McCrea,Guskiewicz et

al.2003

10 daysComputerImPACT

High School30Iverson et al.2006

NRComputerImPACT

High School134CollinsLovell, et al.

2006

SampleSize

Authors Total DaysCognitiveResolution

Tests UtilizedPopulation

Concussion Epidemiology 7.5 million kids participate in HS sports, 3.1, 4.4 Published estimates

– CDC: 100,000 annual HS concussions– 9% of high school sports injuries– 19.3% high school football injuries!

Only MVAs cause more in 15-24 age group 1 in 20 HS football players per season Under-reported!!!

– Especially in football…don’t ask, don’t tell!

Concussion Epidemiology Injury rate per 100,000 player games in high school

athletes

– Football 47– Girls soccer 36– Boys soccer 22– Girls basketball 21– Wrestling 18– Boys basketball 7– Softball 7

Data from HS RIO, JAT, 2007

Concussion Epidemiology Head injury in younger players may impair

developing brain Females at higher risk for sustaining a

concussion than males in the same sport -especially at lower levels of competition

Explosion girls sports in NH since Title IX in 1971,now in NH, 1 in 3 girls participate

Girls sustain concussion 68% more often thanboys

Youth basketball rate is 3x higher for girls Lacrosse, soccer, hockey

Signs and Symptoms of Concussion

Signs Observed by Others– Appears dazed or stunned– Confused about events– Answers questions slowly– Repeats questions– Can’t recall events prior to injury– Can’t recall events after injury– Loss of consciousness– Shows behavior or personality changes– Forgets class schedule or assignments

4 Symptom Categories

Physical• Headache• Fatigue• Dizziness• Sensitivity to light and/or

noise• Nausea• Balance problems

Emotional• Irritability• Sadness• Feeling more emotional• Nervousness

Cognitive• Difficulty remembering• Difficulty concentrating• Feeling slowed down• Feeling mentally foggy

• Sleep• Drowsiness• Sleeping less than usual• Sleeping more than usual• Trouble falling asleep

ONE OR MORE SIGN ORSYMPTOMS IS A

CONCUSSION

What grade is it? Demonstratingtrueinternationalconsensusonthisissue,theZurichstatementmakesnomentionwhatsoeverofconcussiongradingscales.

Prague,2004putforthsimpleandcomplexasanoptiontoI,II,III

TheNHStateAdvisoryCouncilonSport‐RelatedConcussionagreeswiththeindividual‐athletemanagementanddecision‐makingapproachandsupportstheuseofcarefulmonitoringofclinicalsymptoms(somatic,cognitive,emotional),physicalsigns,behavior,balance,sleepandcognitionintheassessmentandmonitoringofconcussion.

Why worse in kids?Traditionally,youngageatthetimeofbraininjuryhasbeenthoughttohaveprotectivebenefits

However,growingliterature,stronglyindicatesthattheimmaturebrainismorevulnerable

Hypotheses

Skillsnotyetwellestablishedatthetimeofinsultcouldbemoresusceptibletodisruptionthanwell‐establishedones

Thebrainsystemsresponsibleforskillacquisitioncouldbeaffecteddirectlybydiffuseinjury

Functionalrecoverymayberestrictedbytheinjuredchild’ssmallerrepertoireofexistingskills

Injurytotheimmaturebraincouldinterfereneurobiologicallywiththeintricatesequenceofchemicalandanatomiceventsnecessaryfornormaldevelopment.

Effective Concussion Program

Education & Awareness (Pre-Injury) Baseline Neuropsychological & Balance Testing (preseason)

On Field Surveillance

Standardized Sideline Assessment

Post-Injury Neuropsychological & Balance Re-Testing

Management

– Physical Exertion

– Cognitive Exertion (Academics)

Gradual Return-To-Play Protocol

Acute Management Call 911:

– Extended (or late) loss ofconsciousness(15 seconds)

– Seizure/posturing– Vomiting (?repeated?)– Any worsening of symptoms (e.g.,

headache getting worse, increaseddisorientation, etc…)

– Frank amnesia– If you think you should!

On-Field or Sideline Evaluation

Medically evaluated using standardemergency management principles

After addressing first aid issues,assessment of the concussive injury using astandardized assessment tool (SCAT,BESS, SAC, etc)

Serial monitoring for deterioration over thethe initial hours following injury

ER/ Medical Evaluation

Medical assessment should include– Comprehensive history– Detailed neurological examination– Assessment of mental status and cognitive

functioning– Assessment of gait and balance

Treatment Current Cornerstones:

– Physical & cognitive rest until symptomsresolve and then

– Graded program of exertion prior tomedical clearance and return to play

Treatment

Physical Rest – NO activity:No gym classNo bike ridingNo weightliftingNo sports – games or practiceControversy – light activity? Leddy, et al, 2010 – CJSM

– Sub-symptom activity

Treatment

Cognitive Rest – NO/reduced activity:– School limitations

No school? Reduced schedule? No [standardized] tests Rest Reduced load – assignments, etc

– Home/social limitations TV, computer, videogames, IM/texting Reading

– ? Sub-symptom activity ?

Disturbance of brain function is related to:– neurometabolic dysfunction, rather than structural

injury– typically associated with normal structural

neuroimaging findings (i.e., CT scan, MRI). Concussion results in a constellation of

symptoms:– physical, cognitive, emotional and sleep-related

Concussion/ mTBIDefinition

Child and adolescent student-athlete– Strongly endorsed view no return to practice or play

until clinically completely symptom free– Cognitive rest highlighted– More conservative return to play approach;

appropriate to extend the amount of time ofasymptomatic rest and/or the length of the gradedexertion in children and adolescents.

– It is not appropriate for a child or adolescent student-athlete with concussion to RTP on the same day asthe injury regardless of the level of athleticperformance.

– Concussion modifiers apply even more than adultsand may mandate more cautious RTP advice.

Zurich CIS Consensus

Return to School Resume activities as tolerated

– No symptom exacerbation or recurrence– Increase task time/complexity as tolerated

Requires coordinated effort– Nurse– Guidance/Psychologist– Teachers– Administration

ACE (Acute Concussion Eval)CDC Tool kit

Return to Sport [Young] athletes:

NO same day return

Return to Sport Tolerating full school activities – student-athlete! Complete resolution of symptoms Return to baseline on neurocognitive tests Stepwise progression – gradual return Supervised by athletic trainer, team/ personnel

MD, neuropsychologist, sports PT, RN– Athletic trainer – licensed medical professional – not coach or

fitness!!

Return to Play Protocol

First few days after injury physical and cognitive rest is required Proceed to next level only if asymptomatic at the current Any post concussive symptoms occur, drop back to the previous

asymptomatic level, try again in 24 hours Age 5-18, slower recovery, worse injury, more conservative care

– 1. No activity, complete rest.– 2. Light exercise such as walking or stationary cycling.– 3. Sport specific activity (i.e. running, skating in hockey).– 4. "On surface" practice without body contact.– 5. "On surface" practice with body contact, once cleared to do so by a

physician. The time required to progress from full non-contactexercise to contact will vary with the severity of the concussion.

– 6. Game play.

Neurocognitive testing comparing the injuredathlete to their own baseline data is thecornerstone concussion management

Tools Standardized assessment of concussion(SAC) BESS SCAT II Computerized

– Impact– CogState– Etc.

Contribution of NeuropsychologicalTesting to Concussion Management

N=115 MANOVA p<.000000

ImPACT revealscognitive deficitsin asymptomaticathletes within 4 days post-injury

N=115 MANOVA p<.000000

ImPACT Reaction Time ImPACT Processing Speed

To evaluate concussion recovery,we cannot rely on athlete

symptom report alone!

(How many other injuries do weallow the athlete to decide when

they can return to play?)

Clinicians’ Return to Play Decisions100

80

60

40

20

00

ATC used GSC, SAC, BESS(testing w/ symptom report)

ATC used only GSC(player symptom report)

Marshall, Guskiewicz, & McCrea; In Review, 2006.

Preseason Baseline computerizedNeuropsychological Testing

25 minute computer-based test– Memory, Processing Speed, Reaction Time– Baseline symptoms

Conducted in group format (up to 15 per) Load on computers in lab Baseline data available for comparison post-

injury Ages 11-18 (currently) 11-14 15-18

Balance (Postural Stability) TestingBalance (Postural Stability) Testing

Concussions And Heading Exposure CauseCognitive Impairments In Soccer Players

Reductions in soccer players compared to the non contact sportathletes reflects subtitle deficits in the attention processes relatedto updating information in working memory. These results alsosuggest that heading exposure alone affects cognitive processingin soccer athletes.

AYSA over 10 to headDo Minor Head Impacts in Soccer Cause Concussive Injury? A Prospective Case-Control Study

Neurosurgery: April 2009 - Volume 64 - Issue 4 - p 719-725

Post-Concussion Syndrome

85-90% of concussed young athletes willrecover within 1 to 2 weeks

The remainder may have symptoms lastingfrom weeks to months interfering withschool and daily life

Subtle deficits may persist a lifetime

Post Concussion Syndrome

3 or more sx’s lasting greater than 3 or 6weeks with or without exertion

Often considered if just 1 sx lingers with orwithout exertion

Acute care rest, when is rest not enough Meds, NP for skill adjustment Sub Threshold Exercise?

University Buffalo Sports MedicinePCS Treatment

The athlete with PCS performs graded stationary cycleexercise under close observation, attempting to reach aheart rate target of 85% of age-predicted maximum. Bloodpressure and perceived state of effort are measured every2 minutes, and the athlete is instructed to stop the activitythe moment he or she feels any symptoms of concussion.Typical symptoms at the threshold are localized headache,feeling pressure in the head or the eyes, visualdisturbance, and foggy thinking. The symptom-free exer-cise duration and intensity become the threshold forsymptom regeneration, and we have the athlete return tothe laboratory to exercise at 15% below threshold for 2 or 3weeks.

Progression?

The opportunity to exercise is perceived as a verypositive activity (often leading to an immediatereduction in depressive symptoms). It is imperativethat the athlete not go beyond the new exerciselimit, which most athletes are keen to do. After the2 or 3 weeks of sub-threshold exercise, the athleteis reassessed to see if the threshold has changed.The exercise program is then realigned to be 15%less than the new threshold.

Integrate BESS as well We started this evening by agreeing that exercise

is a cornerstone!

Heads Up: Concussion in HighSchool Sports

Parent Fact Sheet Athlete Fact Sheet Guide for Coaches

www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm

NHSCAC

Organizational StructureNH State Advisory Sport Concussion Advisory Council

Advisory Council Chair Art Maelender, Ph.D.

Advisory Council Vice-Chair Laura Decoster, ATC

Coordinating Agency/Project Director Brain Injury Association of NH/Steven Wade

TheNewHampshireStateAdvisoryCouncilonSport‐RelatedConcussionwascreatedtoprovideguidanceforschoolandyouthleagueadministrators,coaches,parentsandathletesonthisveryimportanttopic.Thepurposeofthisconsensusstatementistoguidethecreationandimplementationofabest‐practicemodelforsport‐relatedconcussionmanagementincludingsafereturntosportsandreturntoschool.Thisstatementdoesnotincludespecificprotocolsbutservesasthebasisforsuchprotocols.Medicalscienceconcerningsport‐relatedconcussionisarapidlygrowingfield;themostrecentresearchwasusedinthepreparationofthisstatement.Statementsarebasedonevidencebutusersshouldbeawarethattherearestillmanyareasofcontroversyinthisrelativelyyoungresearchfield.Becauseofthisfact,thisdocumentwillbereviewedatleastyearlytotakeadvantageofadvancesinourknowledgeaboutconcussions.

ExecutiveSummary ｷ Aconcussionisaseriousinjury.Colloquialtermssuchas"ding"or"bellringer"minimizeandtrivializeaninjurythatmayhavelastingconsequences.Thosetermsshouldbeeliminatedfromtheconcussionvocabulary.Allinjuriestothebrain,regardlessofhowapparentlyminortheyseem,shouldbemanagedappropriately.

ｷ Neitherlossofconsciousnessnoramnesiaisarequiredelementforthediagnosisofaconcussion.Inthemajorityofconcussions,neitherispresent.

ｷ Ayoungathlete(throughhighschool)whoexperiencesconcussionsignsorsymptomsafteradirectorindirectblowtotheheadshouldnotreturntoactivityonthesameday.Somebraininjuriesevolveslowlyandthetrueseverityofaninjurymaynotbeapparentinitially.

ｷ Signsandsymptomsofconcussionmayfallintomultiplecategoriesinsomatic,cognitiveandemotionaldomains.Headache,fatigue,irritability,difficultyconcentratingandsleepdisturbanceareafewexamples.Coaches,athletes,parentsandschoolofficialsshouldbefamiliarwithcommonsignsandsymptomssoconcussionsand/ortheirsequelaedonotgounrecognized.

ｷ Eachconcussionisunique.Concussiongradingscalesfailtoaccountfortheindividualityofthisinjuryandmayresultinanathletebeingsentbacktoactivitytoosoonorheldouttoolong.Inplaceofconcussiongradingscales,healthcareprovidersareadvisedtomanageconcussionsonanindividualbasisincludingcarefulmonitoringofclinicalsymptoms,physicalsigns,behavior,balance,sleepandcognitionintheassessmentandmonitoringofconcussion.Onceallsignsandsymptomshaveresolved,amonitoredgradual,structuredreturntoactivityisrecommended.

ｷ Schoolpersonnel(nurse,guidance,teachers)shouldbeinformedoftheoccurrenceofaconcussionandstudent‐athleteswhohavesufferedaconcussionshouldbemonitoredatschoolforacademicperformancedifficultiesandbehaviorchanges.

ｷ Evidencesuggeststhatpediatricathletesmaybemorevulnerabletoconcussion,mayrequirealongerrecoveryperiodandmaysuffermorelong‐termsequelaethanadults.Theremayalsobeanincreasedriskofsecond‐impactsyndrome,anoften‐fatalbrainswelling,whichhasalmostexclusivelybeendocumentedinyoungathletes.

ｷ Neurocognitivebaselineassessmentofathleteswhoparticipateincollisionorcontactsportsisrecommendedwheneveritisfeasibleasitcanbeusedbyhealthcareprovidersasobjectiveevidenceofaninjuredathlete’sreturntocognitivenormalcy.However,neurocognitivetestingisonlyoneelementofwhatshouldbeamultiprongedapproachtoassessingandmanagingsportconcussion.Neurocognitivetestadministrationshouldbeappropriatelysupervisedandtestresultsshouldbeinterpretedbyneuropsychologists.

ｷ Athleticprograms,bothschoolandcommunity‐based,shouldadoptasportconcussionmanagementprotocol.TheNHCouncilhasdevelopedatemplateforsuchaprogramthatshouldbeadaptedaccordingtoeachprogram'sresourcesandinconsultationwithteamphysicians.

ｷ Coaches,athletesandinterestedparties(parents,administrators,etc.)shouldreceivecurrentbasiceducationonthetopicofsport‐relatedconcussion.

ｷ Physiciansmuststayabreastofcurrentpracticeguidelinesandtopicsregardingtheappropriatemanagementofathleteswhohavesufferedaconcussion,especiallyreturn‐to‐playdecision‐making.

A few take home’s

You need an office plan! Amnesia important for subacute recovery,

not predcitive of protracted On field dizziness best predictor of

protracted recovery! Sub acute it is “fogginess” LOC <30 sec not predictive

THANKS