Understanding Sport-Related Concussion: Implications for Today

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Understanding Sport-Related Concussion
Implications for Todays Youth Athlete

• Safe Kids Delaware
• Tuesday June 18, 2013
• Modern Maturity Center Dover, DE

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Thomas W. Kaminski, PhD, ATC, FACSM Editor -
Athletic Training Sports Health Care Director
of Athletic Training Education Professor Universit
y of Delaware Department of Health, Nutrition
Exercise Sciences Biomechanics and Movement
Science Program - BIOMS Human Performance
Laboratory - Room 159 541 South College
Avenue Newark, DE 19716 302-831-6402
(office) 302-465-2335 (cell) 302-831-3693
(fax) http//www.udel.edu/HNES/AT/Site/index.html
kaminski_at_udel.edu
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Some Videos
American Football - http//www.youtube.com/watch?v
j9RfJwSkMU8
Other Sports - http//www.youtube.com/watch?vrapo
hLQ0UJw
NCAA Video - http//www.youtube.com/watch?vT3FLRD
xbLXgfeaturerelated
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Concussion

• Definition - a clinical syndrome characterized by
  immediate and transient post-traumatic impairment
  of neural functions, such as alteration of
  consciousness, disturbance of vision,
  equilibrium, etc... due to brain stem(connects
  cerebral hemispheres with the spinal cord)
  involvement
• It effects Function, not Structure, like other
  types of head injuries. That is why you dont
  see concussions on tests like CAT scans
• Four areas of function involved are how an
  athlete Feels, Thinks, Sleeps, and their Emotions

Analogous to ice cubes in a glass of water!
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Concussion Definition Revised (Vienna 2001)

• Sports concussion is defined as a complex
  pathophysiological process affecting the brain,
  induced by traumatic biomechanical forces.
• Clinical, pathological and biomechanical
  constructs
• May be caused by a direct blow to the head
• Usually results in the rapid onset of short-lived
  impairment of neuro function that resolves
  spontaneously
• May result in neuropathological changes, but the
  acute clinical symptoms largely reflect a
  functional disturbance rather than a structural
  injury
• Results in a graded set of clinical syndromes
  that may or may not involve LOC. Resolution of
  the clinical and cognitive symptoms typically
  follows a sequential course
• Typically associated with grossly normal
  neuroimaging studies

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What is a Concussion?

• Repeated mild TBIs can cause a condition known
  as chronic traumatic encephalopathy (CTE). This
  condition is marked, among other things, as
  causing severe memory problems.
• Repeated TBIs can also cause a life threatening
  disorder known as second impact syndrome.
• Evolving knowledge
• dings and bell ringers are serious brain
  injuries
• Do not have to have loss of consciousness ( lt10
  have LOC)
• Young athletes are at increased risk for serious
  problems

These two brains do not heal the same way!
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Coaches and even Medical Personnel have
historically mis-assessed concussions

• There is much variation in the knowledge of
  health care providers managing concussed
  athletes. Need to make sure the person clearing
  for return to sport is current with knowledge!
• Physicians (MD/DO)
• Physician assistants
• Nurse practitioners
• Chiropractors
• Athletic trainers
• School nurses
• New and emerging research and technologies will
  lead to a continuing evolution of care

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Problems for Athletes-Post-Concussion Syndrome

• 85-90 of concussed young athletes will recover
  within 1 to 2 weeks
• The remainder may have symptoms lasting from
  weeks to months interfering with school and daily
  life
• Subtle deficits may persist a lifetime

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Extent of the Problem

• Professional athletes get a great deal of
  attention- but just tip of iceberg!
• 1600 NFL players
• Much more common in US high school than any other
  level- due to large number of participants
• HS Sports Participants
• Football- 1.14 million
• Boys Soccer- 384,000
• Girls Soccer- 345,000
• Boys Basketball - 545,000
• Girls Basketball - 444,000

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Extent of the Problem

• 19.3 of all FB injuries in 2009!!!
• Over 100,000 concussions nationally in HS
  athletes yearly based on CDC estimates
• Over 1,000 concussions in HS athletes in
  Delaware each year

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Not Just a Football Problem

• 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

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What has happened to make this such a big deal?

• Increasing awareness and incidence
• Number of high profile athletes over the past 10
  years
• Bigger and faster kids, increased opportunities
• Increased litigation from misdiagnosis,
  treatment, and removal from sport

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What has happened to make this such a big deal?

• High profile cases
• Second Impact Syndrome
• Death or devastating brain damage when having a
  second injury when not healed from the first
• Long-term effects
• Possible long-term effects- dementia, depression

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Diagnosis / Recognition

• Sometimes easy, but not always
• Hallmarks confusion amnesia - Kelly Rosenberg
  (1997)
• Differential dx
• Trauma-induced headache
• Head injury w/ resultant HA
• Intracranial bleed

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Symptoms

• Headache most common
• (70)
• may be delayed
• Dizziness is also a key symptom!
• Variability in symptom
• presentation may
• depend on site of injury

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Zurich 2012

1. Current mgmt. consists of monitoring physical and
   cognitive rest as the concussed patient recovers
   it would be ideal if there were some way that
   clinicians could expedite healing!
2. Remains work to be done with implementation of
   Consensus in Sport (CIS) guidelines (Zurich,
   2008)
3. Need to develop strategies to transform consensus
   into custom must address the gap in care
   worldwide!
4. Realization that the most important people
   involved in initial concussion intervention are
   those closest to the player --- coaches,
   referees, parents!
5. SCAT2 is the clinical gold standard but has
   limitations!

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Highlights of the AMSSM Position Statement
Recommendations for Sideline Evaluation and
Management
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Concussion Symptom Checklist
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NFHS Learning Center
Concussion in Sports What You Need to Know
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Computerized Neuropsychological Testing

• ANAM Automated Neuropsychological Assessment
  Metrics
• IMPACT - Immediate Post-Concussion Assessment and
  Cognitive Testing
• Demonstrate both tests!

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Neuropsychological/Neurocognitive Testing

• Sensitive in assessment of brain injury
• Unique contribution to management
• RTP of concussed athletes
• Not new in realm of brain injury, but
• only recently applied to sport
• Protocols for using NP as part of
• concussion plan evolving
• One tool in the toolbox

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Rationale for Neurocognitive Testing

• Cognitive abilities
• Memory
• Attention
• Language
• Visuospatial skills
• Psychological function
• Personality
• Psychiatric symptoms

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Utilization of Neurocognitive Tests

• Cognitive impairments are most severe and easily
  detected in the acute/subacute post-injury phase
• Types of cognitive impairments include
• Memory
• Cognitive processing speed
• Executive functions (verbal fluency response
  inhibition)

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Recommendations for the Use of Neurocognitive
Testing with Sport-Related Concussion
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Administering Neurocognitive Tests in the
Athletic Population

• Sideline assessment post injury.
• Purposes
• Quantify severity
• Determine return-to-play status
• SAC has been widely studied and validated

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Administering Neurocognitive Tests in the
Athletic Population

• Clinical NP evaluations
• Best if have a baseline available for comparison
• Testing environment is different from a sideline
  examination
• Typically require 20-40 minutes to complete

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Types of Neurocognitive TestsPaper-and-Pencil

• Hopkins Verbal Learning Test
• WAIS-III Digit Span Test
• Symbol Digit Modalities Test
• Trail Making Test
• Controlled Oral Word Association Test
• Stroop Color Word Test

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Types of Neurocognitive TestComputerized Test
Batteries

• ANAM
• CogSport
• HeadMinder
• ImPACT

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Computer Demonstration
Immediate Post-Concussion Assessment and
Cognitive Testing
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ImPACT Measurements So What Does All This Mean?

• Post-concussion tests involve four different
  forms that are randomized to prevent learning
  effects
• Use of composite scores
• Large database of normative values is available
  for comparison

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ImPACT Test Modules
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Where can I find Normative Values?
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ImPACT Normative Scores - Boys
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ImPACT Normative Scores College-Aged Males
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ImPACT Normative Scores - Females
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King-Devick Test

• Tools to objectively measure oculomotor function

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Balance Error Scoring System (BESS)

• Method of assessing static postural stability due
  to the effects of head injuries
• Portable, cost-effective, and objective
• Used in the SAC (which is a portion of the SCAT3)

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DIAA Concussion Protocol
DIAA Concussion Regulations DIAA Regulation
1008/1009 3.1.5    Prior to resuming
participation, a player who is otherwise properly
certified to participate in interscholastic
athletics must present to the administrative head
of school or designee, a statement from a
qualified physician that the player is physically
able to participate if one of the following
conditions has occurred 3.1.5.1  The player is
physically unable to compete due to illness or
injury for five(5) consecutive days on which a
practice scrimmage or contest is held 3.1.5.2 
The player was apparently unconscious 3.1.5.3 
The player suffered a concussion.
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DIAA Concussion Protocol
1. If an athlete exhibits signs and symptoms
consistent with a concussion, they shall be
removed from play immediately.  Be aware of the
sport specific rule covering possible
concussions A qualified health care
professional must then determine whether or not
an apparent concussion has occurred. If one of
the aforementioned qualified healthcare
professionals is not present, the injury must be
treated as a concussion and the student not be
allowed to return to practice/game until
determined otherwise from a qualified healthcare
professional.  If a potential concussion, loss of
consciousness or apparent loss of consciousness
has occurred, according to DIAA regulation 3.1.5,
the athlete may only return to practice/game
after the administrative head of school or
designee receives "written clearance" from a
qualified physician. No athlete shall return to
practice or play (RTP) on the same day of a
concussion. Any athlete with a concussion should
be evaluated by their primary care provider or
qualified healthcare professional that day.  2.
A qualified healthcare professional shall be
defined as a MD or DO, or school nurse, nurse
practitioner, physician assistant, or athletic
trainer,  with collaboration and/or supervision
by a MD or DO as required by their professional
state laws and regulations.  The qualified
healthcare professional must be licensed and in
good standing with the State of Delaware and must
be approved or appointed by the administrative
head of school or designee, or the DIAA executive
director/assistant executive director.
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DIAA Concussion Protocol
3. "Written Clearance from a qualified physician
for return to play after a potential concussion
shall be a MD/DO only. The preferred method
would be to use the form that is attached. ACE
Care Plan. After medical clearance, return to
play should follow a step-wise protocol with
provisions for delayed return to play based upon
the return of any signs or symptoms. 4. Failure
to comply with medical requirements found in DIAA
regulation section 3.0 shall result in that
individual or school being considered
"ineligible" and shall be penalized according to
DIAA regulation 2.9- The school has used an
ineligible player and thus must forfeit the
contest
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You can view todays presentation at the
following web link http//www.udel.edu/HNES/AT/Si
te/lectures.html
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Thank You