Player Safety: Concussion & Baseline Impact Testing David Bernhardt, M.D. University of Wisconsin Sports Medicine

Concussion Mild traumatic brain injury Vienna Consensus Statement 2001

Symptoms Dazed appearance Confusion Memory Loss Headache Dizziness Balance problems Irritable Personality change Slowed response Poor focus/attention +/- LOC

Memory

What if the athlete suffers brief LOC? Should this athlete be DQ’d for the remainder of the game? Does LOC predict long term prognosis?

What if the athlete suffers brief LOC? 383 MTBI patients (GCS 14-15) Confusion, agitation, retrograde amnesia, LOC Poorer performance for all groups on neuropsychological tests sensitive to MTBI No differences between groups based on LOC, uncertain LOC and no LOC Lovell MR, et al. Clin J Sports Med 1999

Simple Concussion Resolves without complication in 7-10 days Rest until all symptoms have resolved Graded return to play

Complex Concussion Persistent symptoms Specific sequelae (seizures) Prolonged LOC (> 1 minute) Prolonged cognitive impairment Repeated concussions with less force Consider neuropsychological testing Multidisciplinary approach

Sideline evaluation Orientation Concentration Month: ___________________ 0 1 Digits backward (If correct, go to Date: _____________________ 0 1 next string length. If incorrect, read Day of week: ______________ 0 1 trial 2. Stop if both incorrect. Year: ____________________ ______0 1 Time (within 1 hour): _______ _____ ______0 1 Orientation Total Score _________ / _____0 1 Months in reverse order: (entire sequence correct for 1 pt) Dec  Jan 0 1 Concentration Total Score ____ / 5

Sideline evaluation Immediate Memory: (all 3 trials are complete regardless of score on trial 1 & 2; total score equals sum across all 3 trials) ListTrial 1Trial 2Trial 3 Word Exertional maneuvers Word Coordination Word Strength Word Sensation Word Recall of injury Total Immediate Memory Total Score _____ / 15 Delayed recall Word Word Word Word Word Delayed Recall Total Score _____/5McCrea M et al. Summary of Total Scores _____ / 30Neurology 1997

Serial 7’s 522 high school athletes, PPPE Serial 7, serial 3, months in reverse Seven consecutive or 11 with one mistake 51% serial 7’s, 79% serial 3’s 89% months in reverse Young CC, Jacobs BA et al. Clinical Journal of Sports Medicine 1997

DO NOT ALLOW RETURN TO PLAY UNTIL COMPLETELY ASYMPTOMATIC

If You Do Not Know Athlete’s Baseline Neuropsychological Status, It Is Difficult To Judge Normal

High school athletes often require a significantly longer period of time to become asymptomatic and for their cognitive function to return to normal than both collegiate and professional athletes

Catastrophic complications Epidural Subdural Second impact syndrome

Not fully recovered from previous head injury when sustain a second head injury Loss of vascular autoregulation Cerebral vascular congestion Malignant brain edema, brainstem herniation, death

POST CONCUSSIVE SYNDROME Recurrent headachesDizziness Memory impairmentDepression Loss of libidoTinnitus AtaxiaAnxiety Alcohol intolerance Photophobia HyperacousisConcentration

Post concussive syndrome Not necessarily related to severity of concussion Attention and learning difficulty may be subtle Cumulative effects of multiple concussions

Neuropsychological testing Nature and degree of deficit acutely Relationship to standard sideline evaluation Recovery curves

Computerized Neurocognitive Testing IMPACT Headminders Cogsport