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 RotationalLinear Impact deceleration Chemical/Vascular 1 st 7-10 days ↑K / ↑Ca / ↑glc / ↑glut ↓CBF “Period of vulnerability”

6. CONCUSSION CLASSIFICATION 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. GENERAL MANAGEMENT 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. CONCUSSION RECOGNITION 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 AttentionMemory 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. FEATURES OF COGNITIVE TESTING 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

17. CAROLINA SPORTS CONCUSSION 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. IMMEDIATE POST- CONCUSSION ASSESSMENT and COGNITIVE TESTING (ImPACT) 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

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

23. CONCUSSION MODIFIERS 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 ADOLESCENT ATHLETES 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-ELITE ATHLETES 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 CONCUSSION GUIDELINES 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. CTE TAU 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. DISQUALIFICATION LONG 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. Gender effects on injury, severity and outcome. Pediatric injury and management paradigms. Pediatric injury and management paradigms. Validation of SCAT2 as a sideline assessment tool. Validation of SCAT2 as a sideline assessment tool. Concussion surveillance using consistent definitions and outcome measures. Concussion surveillance using consistent definitions and outcome measures. Long-term outcomes. Long-term outcomes. Formal review of “concussion in sport” guidelines and update prior to December 1, 2012 by panel of international experts. 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