Concussion Management on the Field

1
Concussion Management on the Field Return to
Play Decisions A New Approach

• Gerard A. Gioia, Ph.D.
• Pediatric Neuropsychologist
• Chief, Division of Pediatric Neuropsychology
• Director, Safe Concussion Outcome, Recovery
  Education (SCORE) Program
• Childrens National Medical Center
• Washington, DC

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Plan

• Concussion Basics
• A Peak at the Zurich Consensus Statement
• Effective System of Concussion Management
• Collaboration between ATC and Neuropsychologist
• Concussion Evaluation
• Role of Neuropsychological Testing
• Concussion Treatment
• Managing Cognitive Exertion in the School

3
Seminal Study (Barth et al., 1989)

• Problem in MTBI Adequate controls, controlling
  for premorbid functioning, detecting change
• Test-retest design collegiate football players
• Baseline neuropsychological testing, serial
  post-injury testing (PP)
• 10 universities n2350 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.

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Sports as a Laboratory Assessment Model (SLAM)
Pre-Concussion Baseline Testing
1-3 Days
Day 5-10
Day 12-16
Concussion
Barth et al., 2002
5
Sports as a Laboratory Assessment Model (SLAM)
Pre-Concussion Baseline Testing
1-3 Days
Concussion
Barth et al., 2002
6
Zurich CIS Consensus

• Abandon the simple vs. complex terminology
• Majority (80-90) of concussions resolve in a
  short (7-10 day) period, although the recovery
  time frame may be longer in children and
  adolescents.
• SCAT2 form incorporates SAC BESS
• Sideline A player with diagnosed concussion
  should not be allowed to return to play on the
  day of injury. Occasionally in adult athletes,
  there may be return to play on the same day as
  the injury.

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Zurich CIS Consensus

• CONCUSSION INVESTIGATIONS additional exams
  utilized to assist diagnosis and/or exclusion of
  injury
• Neuroimaging still limited
• Objective Balance Assessment (eg BESS, force
  plate)
• Neuropsychological Assessment Use of
  neuropsychologists in the interpretation
• There may be situations (e.g. child and
  adolescent student-athletes) where testing may be
  performed early whilst the patient is still
  symptomatic to assist in determining management.

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Zurich CIS Consensus

• Concussion Management
• Physical AND Cognitive Rest
• Graduated RTP when asymptomatic at rest
• stepwise progression, proceed to next level if
  asymptomatic at current.
• Each step take 24 hours would take approximately
  one week to proceed through the full
  rehabilitation protocol
• Same Day RTP not appropriate in child or
  adolescent student-athlete (possible in adult
  ONLY if within well established system)
• Recognized delayed onset of symptoms

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Zurich CIS Consensus

• MODIFYING FACTORS IN CONCUSSION MANAGEMENT
• A range of modifying factors may influence the
  investigation and management of concussion and in
  some cases, may predict the potential for
  prolonged or persistent symptoms.
• May be additional management considerations
  beyond simple RTP advice. More important role for
  formal NP testing, balance assessment, and
  neuroimaging.
• Concussion history, LOC gt 1 minute,
  comorbidities/premorbidities

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Zurich CIS Consensus

• Child and adolescent student-athlete
• Clinical evaluation include patient and parent,
  and school when appropriate
• Evaluation generally similar to adults timing of
  testing differs to assist treatment planning in
  school and home
• Age-appropriate baseline necessary
• More important to use neuropsychologists to
  interpret assessment data, particularly with LD
  and ADHD.

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Zurich CIS Consensus

• 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 of
  asymptomatic rest and/or the length of the graded
  exertion in children and adolescents.
• It is not appropriate for a child or adolescent
  student-athlete with concussion to RTP on the
  same day as the injury regardless of the level of
  athletic performance.
• Concussion modifiers apply even more than adults
  and may mandate more cautious RTP advice.

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Goals of the Effective Sports Concussion Program

• Student-Athlete
• Safeguard Health 1
• Facilitate Speedy Return to Play/ Life Activities
  
• Athletic System
• Reduce Risk/ Liability for Student-athlete safety
• Achieve Greater Success

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Effective Sports Concussion ProgramPre-Injury
Knowledge and Preparation of All is the Foundation
Injury Monitoring
Early Identification
Decision
Pre-Injury Concussion-Education Parent,
athlete Coach, ATC Emergency Dept Primary Care
Physician Other Medical Specialist School
Personnel (School RN, Psycholologist)
Athlete Concussion Suspected
On-field evaluation ATC/MD
Preseason BL Testing
Evidence of concussion?
No
Return To Play (RTP)
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Effective Sports Concussion ProgramPost-Injury
Post-Injury Clinical Evaluation (24 hours)
Post-Injury Communication/ Coordination
Decision
Parent contacted
Neuropsychological Balance Testing Symptoms Com
parison to BL
PCP contacted
Evidence of concussion?
Removal from Play
Yes
ED evaluation?
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Effective Sports Concussion ProgramPost-Injury
Management/ Treatment Medical Sports Academic Home
Post-Injury Clinical Evaluation (24-72 hours)
No
Neuropsychological Balance Testing Symptoms Com
parison to BL
Stage 1 Recovery? (at rest) Initiate RTP?
Stage 1 Recovery7? Initiate RTP?
No
Yes
Yes
Gradual Exertional RTP Protocol (ATC)
Stage 2 Recovery? (w/ exertion) RTP?
Return To Play (RTP)
No
Yes
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Concussion Facts Figures

• Annually, millions of children sustain a TBI
• 80-90 mild
• New CDC estimates of sports/ recreation TBI alone
  (adults and children) 1.6 3.8 million per year
  (revised from previous estimate of 300K)

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Concussion/ mTBIDefinition

• A concussion (or mild traumatic brain injury) is
  defined as a
• complex pathophysiologic process affecting the
  brain,
• induced by traumatic biomechanical forces
  secondary to direct or indirect forces to the
  head.

CDC Heads Up Brain Injury in Your Practice (2007)
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Concussion/ mTBIDefinition

• 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 may or may not involve a loss of
  consciousness (LOC).

CDC Heads Up Brain Injury in Your Practice (2007)
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Concussion/ mTBIDefinition

• Concussion results in a constellation of
  symptoms
• physical, cognitive, emotional and sleep-related.
  
• Duration of symptoms are variable may last for as
  short as several minutes and last as long as
  several days, weeks, months or even longer in
  some cases.

CDC Heads Up Brain Injury in Your Practice (2007)
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Concussion/ mTBIAdditional Criteria

• Glasgow Coma Scale gt 13 (3-15 scale)
• Loss of Consciousness no longer than 10 minutes
  (typically no longer than 30-60 sec.)
• No evidence of complicated TBI/ structural
  abnormality (skull fracture, intracranial bleed,
  known lesion)

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Anatomical Timeline of a ConcussionDefining the
Key Factors
C. Risk Factors
A. Injury Characteristics
B. Symptom Assessment
Retro- grade Amnesia 20-35
Antero- grade Amnesia 25-40
CONCUSSION
LOC lt10
Neurocog dysfx Post-Concuss Sxs
Pre-Injury Risks
Sec-Hrs
Hours - Days - Weeks
Sec-Hrs
Sec-Min
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Sports ConcussionA Few Facts

• Some Injuries are worse than others.
• Some athletes are more vulnerable
• Pre-injury risk factors combine with injury
• previous concussions, headache, ADHD, LD, mood
• Other possible factors that influence recovery
• Magnitude of force that is received
• Location that force is received
• Defensive position/ prep of individual receiving
  force
• Size, speed factors

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Increased Risks if not properly identified and
managed

• Symptoms can take significantly longer to
  recover.
• Player is more likely to be re-injured.
• Second/ third... injuries
• Are more likely to be more severe
• Could cause permanent brain damage
• Can take longer to recover from
• Increase risk of retirement from sport

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Exertional Effects

• Increase or re-emergence of post-concussion
  symptoms following significant exertional
  activity
• Physical activity
• Cognitive activity

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Effects of Concussive Forces on the Brain

• Typically, the software of the brain is
  affected
• Neurometabolic/ neurochemical processes
• Physiological
• Not the hardware
• Structure

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4 Symptom Categories

• Physical
• Headache
• Fatigue
• Dizziness
• Sensitivity to light and/or noise
• Nausea
• Balance problems

• Emotional
• Irritability
• Sadness
• Feeling more emotional
• Nervousness

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

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

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Everyday Functional Effects

• Home
• Difficulty completing tasks at home
• Reduced play/ activity
• Irritability with challenges
• School
• Concentration
• Remembering directions
• Disorganized
• Completing assignments
• Fatigue
• Fall behind, fail tests, reduced grades

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Neuropsychological Effects of Concussion

• Attention, concentration
• Working memory (holding info in mind during
  activity)
• New learning memory storage/ retrieval
• Speed of processing information
• Reaction time

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• How Long Does It Take The Athlete To Recover
  from Concussion?

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Studies Reporting Individual Recovery Rates
31
Recovery From ConcussionHow Long Does it Take?
WEEK 5
WEEK 4
WEEK 1
WEEK 3
WEEK 2
N134 High School athletes
Collins et al., 2006, Neurosurgery
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However!

• Every individual injury is different
• Many will recover within 1-2 weeks
• Some take longer, some shorter
• We MUST evaluate EVERY concussion individually
• Just like every other injury
• If not recognized and managed early, much greater
  chance of more severe injury and longer recovery

33
Whats the worst thing that can happen to my
son?Father of football player with multiple
concussions in one season, 2003
34
Second Impact Syndrome

• Diffuse cerebral swelling with delayed
  catastrophic deterioration, a known complication
  of brain trauma postulated to occur after
  repeated concussive brain injury in sports.

35
Second Impact Syndrome

• Athlete who has sustained an initial mild brain
  injury sustains a second mild brain injury before
  symptoms associated with the first have fully
  cleared
• Death usually follows rapidly (2-5 minutes) due
  to brainstem herniation
• Disordered cerebral autoregulation of cerebral
  blood flow ?vascular engorgement?increased
  ICP?Brainstem herniation
• Mortality? 50-100

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Effective System of Sports Concussion Management
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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

38
Heads Up Concussion in High School Sports

• Parent Fact Sheet
• Athlete Fact Sheet
• Guide for Coaches
• www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm

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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

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• Relying on Athlete Symptom Report
• Do Athletes Underreport Symptoms?

Lovell MR, Collins MW, Maroon et al. Medicine and
Science in Sports Exercise, 3452002
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UNIQUE CONTRIBUTION OF Neuropsychological
TestingTO CONCUSSION MANAGEMENT
ImPACT reveals cognitive deficits in
asymptomatic athletes within 4 days post-injury
N115 MANOVA plt.000000
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UNIQUE CONTRIBUTION OF Neuropsychological
TestingTO CONCUSSION MANAGEMENT
ImPACT Processing Speed
ImPACT Reaction Time
N115 MANOVA plt.000000
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To evaluate concussion recovery, we cannot rely
on athlete symptom report alone!

• (How many other injuries do we allow the athlete
  to decide when they can return to play?)

44
Preseason Baseline Neuropsychological 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)

45
Balance (Postural Stability) Testing
46
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

47
Clinical ProtocolNeurocognitive Testing
Pre-Concussion Baseline Testing
1-3 Days
Day 5-10
Day 12-16
Concussion
Barth et al., 2002
48
Clinical ProtocolNeurocognitive Testing
Pre-Concussion Baseline Testing
1-3 Days
Concussion
Barth et al., 2002
49
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

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Management

• Rest, Rest, Rest
• Essential for brains recovery
• Sleep
• Low activity, not increasing heartrate
  significantly

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Treatment / Management

• Concerns are broader than Sports
• Sport
• Academic
• Daily activity

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Managing Exertion

• Managing physical and cognitive activity
• Risk for increase or re-emergence of
  post-concussion symptoms following significant
  exertional activity
• Managing school demands and physical activities

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Physical Rest?

• No sports
• No exercise
• No weightlifting
• Exertion with Activities of Daily Living?
• REST ABSOLUTE REST!

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Mental/ Cognitive Rest?

• No prolonged concentration
• No prolonged homework
• No prolonged classes (block scheduling)
• No prolonged days
• REST ABSOLUTE REST!

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ACE Care Plan

• Linking Diagnosis With Treatment

56
Purpose of Care Plan Guide recovery Educate Manage
exertional activity, safety
57
ACE Care Plan

• Current Symptoms Red Flags
• Daily Activities
• Return to School
• Return to Work
• Return to Sports

58
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

59
When Return to Play?

• It is not appropriate for a child or adolescent
  student-athlete with concussion to RTP on the
  same day as the injury.
• Zurich consensus statement on concussion in sport
  (2008)

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When Return to Play?Criteria for RTP

• No longer have symptoms
• No longer need medicine to control symptoms.
• Cognitive/ thinking skills balance back to
  normal.
• After rest and gradual activity (exertion)
• Cleared by medical professional.
• Zurich Recognition that the child/ adolescent
  student-athlete may take longer, and we should
  proceed more cautiously

61
MANAGEMENT STRATEGIESCIS Group, 2001, 2004, 2008

• Emphasis on careful on-field evaluation
• Restriction of play for symptomatic
  student-athletes
• Neuropsychological testing recommended
• Graduated return to play
• Rest
• Aerobic exercise
• Sport Specific training
• Non-contact drills
• Full-contact training

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Coach/ Player/ Parent Concern Isnt this
Concussion program going to hold my players out
longer?
63
Clinicians Return to Play Decisions
100
80
ATC used GSC, SAC, BESS (testing w/ symptom
report)
60
40
ATC used only GSC (player symptom report)
20
00
Marshall, Guskiewicz, McCrea In Review, 2006.
64
Summary

• We know a lot about injuries to the brain
• We have systems that can be put in place to
• Safeguard the student-athletes
• Facilitate speedy but safe return to play
• Reduce risk/ liability to the athletic system
• Improve overall athletic system performance

65
Summary

• Relying on symptom assessment alone is relying on
  limited and possibly faulty information
• Neuropsychological balance testing are
  sensitive and valid tools to help augment
  clinical evaluation and guide concussion
  management
• Student-athlete should not return to play until
  symptom free post-injury test results are
  normal at rest and after exertion.

66
Summary

• Careful individualized clinical assessment and
  tracking from time of injury is necessary
• Sideline assessment
• Sensitive computerized Neuropsychological testing
• Balance testing
• Symptom reporting

67
What Must Youth High Schools Sports Programs Do?

• Begin the Process of Implementing an Effective
  Sports Concussion Program
• Outfit All High School Athletics Programs with
  Certified Athletic Trainers
• Consultative Input to Youth Sports Programs
• Education Awareness (Pre-Injury)
• Preseason Baselining testing
• Organized Sideline assessment
• Post-Injury Neuropsychological balance testing,
  symptom assessment
• Support Management Recovery
• Cautious and gradual return to play based on
  individual assessment data of recovery

68
Typical Outcome
69
16 year old male

• Injury - elbowed in forehead during basketball
  game
• Initially, no symptoms but within 10 minutes,
  became foggy with poor concentration, memory,
  dizziness
• Subsequent loss of memory for event,
  irritability, headaches, reduced energy,
  sensitive to light and noise, sleeping more than
  usual, poor balance

70
16 year old male

• 10th grade honors student
• Seen in the SCORE Concussion Clinic at Day 7 14
• Neuropsychological Concussion Evaluation
  initially demonstrated
• Poor attention
• Poor working memory
• Slowed processing speed
• Reduced reaction time
• By 14 days, excellent recovery return to
  baseline

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16 year old male

• Able to educate and guide the family and patient
• Consulted with the ATC and pediatrician
• Made recommendations for accommodations in school
• Kept him safe by managing his gradual return to
  sports