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

2. Plan Concussion Basics Concussion Basics A Peak at the Zurich Consensus Statement A Peak at the Zurich Consensus Statement Effective System of Concussion Management Effective System of Concussion Management  Collaboration between ATC and Neuropsychologist Concussion Evaluation Concussion Evaluation  Role of Neuropsychological Testing Concussion Treatment 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 Problem in MTBI: Adequate controls, controlling for premorbid functioning, detecting change Test-retest design – collegiate football players Test-retest design – collegiate football players Baseline neuropsychological testing, serial post- injury testing (P&P) Baseline neuropsychological testing, serial post- injury testing (P&P) 10 universities – n=2350 players baseline tested 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 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. Sports arena recognized as a unique, relatively well- controlled lab for assessing mTBI.

4. 1-3 Days y Day 5-10 Pre-Concussion Baseline Testing Sports as a Laboratory Assessment Model (SLAM*) y Day 12-16 *Barth et al., 2002 Concussion

5. 1-3 Days Pre-Concussion Baseline Testing Sports as a Laboratory Assessment Model (SLAM*) *Barth et al., 2002 Concussion

6. Zurich CIS Consensus Abandon the simple vs. complex terminology 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. 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 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. 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.

7. Zurich CIS Consensus CONCUSSION INVESTIGATIONS: additional exams utilized to assist diagnosis and/or exclusion of injury Neuroimaging: still limited Neuroimaging: still limited Objective Balance Assessment (eg BESS, force plate) Objective Balance Assessment (eg BESS, force plate) Neuropsychological Assessment: Use of neuropsychologists in the interpretation 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. 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.

8. Zurich CIS Consensus Concussion Management 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

9. 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. 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. May be additional management considerations beyond simple RTP advice. More important role for formal NP testing, balance assessment, and neuroimaging.  Concussion history, LOC > 1 minute, comorbidities/premorbidities Zurich CIS Consensus

10. Child and adolescent student-athlete 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. Zurich CIS Consensus

11. Child and adolescent student-athlete 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. Zurich CIS Consensus

12. Goals of the Effective Sports Concussion Program Student-Athlete Student-Athlete  Safeguard Health #1  Facilitate Speedy Return to Play/ Life Activities Athletic System Athletic System  Reduce Risk/ Liability for Student-athlete safety  Achieve Greater Success

13. Effective Sports Concussion Program Pre-Injury Pre-Injury Concussion- Education Parent, athlete Coach, ATC Emergency Dept Primary Care Physician Other Medical Specialist School Personnel (School RN, Psycholologist) Knowledge and Preparation of All is the Foundation On-field evaluation ATC/MD Athlete Concussion Suspected Preseason BL Testing No Injury Monitoring Early Identification Return To Play (RTP) Evidence of concussion? Decision

14. Evidence of concussion? Decision Parent contacted PCP contacted ED evaluation? Post-Injury Clinical Evaluation (24 hours) Yes Post-Injury Communication/ Coordination Removal from Play Effective Sports Concussion Program Post-Injury Neuropsychological & Balance Testing Symptoms Comparison to “BL”

15. Post-Injury Clinical Evaluation (24-72 hours) Neuropsychological & Balance Testing Symptoms Comparison to “BL” Management/ Treatment Medical Sports Academic Home No Gradual Exertional RTP Protocol (ATC) Yes Stage 1 Recovery? (at rest) Initiate RTP? No Yes Stage 1 Recovery 7 ? Initiate RTP? Stage 2 Recovery? (w/ exertion) RTP? Yes Return To Play (RTP) No Effective Sports Concussion Program Post-Injury

16. Concussion: “Facts & Figures” Annually, millions of children sustain a TBI Annually, millions of children sustain a TBI 80-90% “ mild” 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) New CDC estimates of sports/ recreation TBI alone (adults and children): 1.6 – 3.8 million per year (revised from previous estimate of 300K)

17. A concussion (or mild traumatic brain injury) is defined as a 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. Concussion/ mTBI Definition CDC Heads Up: Brain Injury in Your Practice (2007)

18. Disturbance of brain function is related to: 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). Concussion may or may not involve a loss of consciousness (LOC). Concussion/ mTBI Definition CDC Heads Up: Brain Injury in Your Practice (2007)

19. Concussion results in a constellation of symptoms: 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. 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. Concussion/ mTBI Definition CDC Heads Up: Brain Injury in Your Practice (2007)

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

21. Anatomical Timeline of a Concussion Defining the Key Factors LOC <10% Antero- grade Amnesia 25-40% CONCUSSION Pre-Injury Risks Retro- grade Amnesia 20-35% Neurocog dysfx & Post-Concuss Sx’s Sec-HrsHours - Days - Weeks+ Sec-Min Sec-Hrs A. Injury Characteristics B. Symptom Assessment C. Risk Factors

22. Sports Concussion A Few Facts Some Injuries are worse than others. Some Injuries are worse than others. Some athletes are more vulnerable Some athletes are more vulnerable Pre-injury risk factors combine with injury Pre-injury risk factors combine with injury  # previous concussions, headache, ADHD, LD, mood Other possible factors that influence recovery 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

23. Symptoms can take significantly longer to recover. Symptoms can take significantly longer to recover. Player is more likely to be re-injured. Player is more likely to be re-injured. Second/ third... injuries: 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 Increased Risks if not properly identified and managed

24. Exertional Effects Increase or re-emergence of post- concussion symptoms following significant exertional activity Increase or re-emergence of post- concussion symptoms following significant exertional activity  Physical activity  Cognitive activity

25. Effects of Concussive Forces on the Brain Typically, the “software” of the brain is affected Typically, the “software” of the brain is affected  Neurometabolic/ neurochemical processes  Physiological Not the “hardware” Not the “hardware”  Structure

26. 4 Symptom Categories Physical Physical Headache Headache Fatigue Fatigue Dizziness Dizziness Sensitivity to light and/or noise Sensitivity to light and/or noise Nausea Nausea Balance problems 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

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

28. Neuropsychological Effects of Concussion Attention, concentration Attention, concentration “Working memory” (holding info in mind during activity) “Working memory” (holding info in mind during activity) New learning & memory storage/ retrieval New learning & memory storage/ retrieval Speed of processing information Speed of processing information Reaction time Reaction time

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

30. Studies Reporting Individual Recovery Rates Authors Sample Size Population Tests Utilized Total Days Cognitive Resolution Total Days Symptom Resolution IndividualRecoveryRates McCrea, Guskiewicz et al. 200394College Paper and Pencil 3-5 Days 7 Days 91% recovered w/in 7 days Iverson et al. 200630 High School ComputerImPACT 10 days 7 Days 50% recovered w/in 7 days Collins Lovell, et al. 2006134 High School ComputerImPACTNRNR 40% recovered w/in 7 days

31. 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

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

33. “What’s 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. 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 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 Death usually follows rapidly (2-5 minutes) due to brainstem herniation Disordered cerebral autoregulation of cerebral blood flow  vascular engorgement  increased ICP  Brainstem herniation Disordered cerebral autoregulation of cerebral blood flow  vascular engorgement  increased ICP  Brainstem herniation Mortality  50-100% Mortality  50-100%

36. Effective System of Sports Concussion Management

37. Effective Concussion Program Education & Awareness (Pre-Injury) Education & Awareness (Pre-Injury) Baseline Neuropsychological & Balance Testing (preseason) Baseline Neuropsychological & Balance Testing (preseason) On Field Surveillance On Field Surveillance Standardized Sideline Assessment Standardized Sideline Assessment Post-Injury Neuropsychological & Balance Re-Testing Post-Injury Neuropsychological & Balance Re-Testing Management Management  Physical Exertion  Cognitive Exertion (Academics) Gradual Return-To-Play Protocol Gradual Return-To-Play Protocol

38. Heads Up: Concussion in High School Sports Parent Fact Sheet Parent Fact Sheet Athlete Fact Sheet Athlete Fact Sheet Guide for Coaches Guide for Coaches www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm

39. Effective Concussion Program Education & Awareness (Pre-Injury) Education & Awareness (Pre-Injury) Baseline Neuropsychological & Balance Testing (preseason) Baseline Neuropsychological & Balance Testing (preseason) On Field Surveillance On Field Surveillance Standardized Sideline Assessment Standardized Sideline Assessment Post-Injury Neuropsychological & Balance Re-Testing Post-Injury Neuropsychological & Balance Re-Testing Management Management  Physical Exertion  Cognitive Exertion (Academics) Gradual Return-To-Play Protocol Gradual Return-To-Play Protocol

40. Relying on Athlete Symptom Report Do Athletes Underreport Symptoms? Lovell MR, Collins MW, Maroon et al. Medicine and Science in Sports Exercise, 34:5;2002

41. UNIQUE CONTRIBUTION OF Neuropsychological Testing TO CONCUSSION MANAGEMENT N=115 MANOVA p<.000000 ImPACT reveals cognitive deficits in asymptomatic athletes within 4 days post-injury

42. N=115 MANOVA p<.000000 ImPACT Reaction Time ImPACT Processing Speed UNIQUE CONTRIBUTION OF Neuropsychological Testing TO CONCUSSION MANAGEMENT

43. 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 25 minute computer-based test  Memory, Processing Speed, Reaction Time  Baseline symptoms Conducted in group format (up to 15 per) Conducted in group format (up to 15 per) Load on computers in lab Load on computers in lab Baseline data available for comparison post- injury Baseline data available for comparison post- injury Ages 11-18 (currently) Ages 11-18 (currently)

45. Balance (Postural Stability) Testing

46. Effective Concussion Program Education & Awareness (Pre-Injury) Education & Awareness (Pre-Injury) Baseline Neuropsychological & Balance Testing (preseason) Baseline Neuropsychological & Balance Testing (preseason) On Field Surveillance On Field Surveillance Standardized Sideline Assessment Standardized Sideline Assessment Post-Injury Neuropsychological & Balance Re-Testing Post-Injury Neuropsychological & Balance Re-Testing Management Management  Physical Exertion  Cognitive Exertion (Academics) Gradual Return-To-Play Protocol Gradual Return-To-Play Protocol

47. 1-3 Days y Day 5-10 Pre-Concussion Baseline Testing y Day 12-16 *Barth et al., 2002 Concussion Clinical Protocol Neurocognitive Testing

48. 1-3 Days Pre-Concussion Baseline Testing *Barth et al., 2002 Concussion Clinical Protocol Neurocognitive Testing

49. Effective Concussion Program Education & Awareness (Pre-Injury) Education & Awareness (Pre-Injury) Baseline Neuropsychological & Balance Testing (preseason) Baseline Neuropsychological & Balance Testing (preseason) On Field Surveillance, Standardized Sideline Assessment On Field Surveillance, Standardized Sideline Assessment Post-Injury Neuropsychological & Balance Re-Testing Post-Injury Neuropsychological & Balance Re-Testing Management Management  Physical Exertion  Cognitive Exertion (Academics) Gradual Return-To-Play Protocol Gradual Return-To-Play Protocol

50. Management Rest, Rest, Rest  Essential for brain’s recovery  Sleep  Low activity, not increasing heartrate significantly

51. Concerns are broader than Sports Concerns are broader than Sports  Sport  Academic  Daily activity Treatment / Management

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

53. Physical Rest? No sports No sports No exercise No exercise No weightlifting No weightlifting Exertion with Activities of Daily Living? Exertion with Activities of Daily Living? REST = ABSOLUTE REST!

54. Mental/ Cognitive Rest? No prolonged concentration No prolonged concentration No prolonged homework No prolonged homework No prolonged classes (block scheduling) No prolonged classes (block scheduling) No prolonged days No prolonged days REST = ABSOLUTE REST!

55. 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 Current Symptoms & Red Flags Daily Activities Daily Activities Return to School Return to School Return to Work Return to Work Return to Sports Return to Sports

58. Effective Concussion Program Education & Awareness (Pre-Injury) Education & Awareness (Pre-Injury) Baseline Neuropsychological & Balance Testing (preseason) Baseline Neuropsychological & Balance Testing (preseason) On Field Surveillance, Standardized Sideline Assessment On Field Surveillance, Standardized Sideline Assessment Post-Injury Neuropsychological & Balance Re-Testing Post-Injury Neuropsychological & Balance Re-Testing Management Management  Physical Exertion  Cognitive Exertion (Academics) Gradual Return-To-Play Protocol 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)

60. When Return to Play? Criteria for RTP No longer have symptoms No longer have symptoms  No longer need medicine to control symptoms. Cognitive/ thinking skills & balance back to “normal.” Cognitive/ thinking skills & balance back to “normal.” After rest and gradual activity (exertion) After rest and gradual activity (exertion) Cleared by medical professional. Cleared by medical professional. Zurich: Recognition that the child/ adolescent student- athlete may take longer, and we should proceed more cautiously

61. MANAGEMENT STRATEGIES CIS 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  Rest  Aerobic exercise  Sport Specific training  Non-contact drills  Full-contact training

62. Coach/ Player/ Parent Concern: Isn’t this Concussion program going to hold my players out longer?

63. Clinicians’ Return to Play Decisions 100 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.

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

65. Relying on symptom assessment alone is relying on limited and possibly faulty information 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 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. Student-athlete should not return to play until symptom free & post-injury test results are normal at rest and after exertion. Summary

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

67. What Must Youth & High Schools Sports Programs Do? Begin the Process of Implementing an Effective Sports Concussion Program 1. Outfit All High School Athletics Programs with Certified Athletic Trainers 2. 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 Injury - elbowed in forehead during basketball game Initially, no symptoms but within 10 minutes, became “foggy” with poor concentration, memory, dizziness 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 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 10th grade honors student Seen in the SCORE Concussion Clinic at Day 7 & 14 Seen in the SCORE Concussion Clinic at Day 7 & 14 Neuropsychological Concussion Evaluation initially demonstrated: Neuropsychological Concussion Evaluation initially demonstrated:  Poor attention  Poor “working memory”  Slowed processing speed  Reduced reaction time By 14 days, excellent recovery & return to “baseline” By 14 days, excellent recovery & return to “baseline”

71. 16 year old male Able to educate and guide the family and patient Able to educate and guide the family and patient Consulted with the ATC and pediatrician Consulted with the ATC and pediatrician Made recommendations for accommodations in school Made recommendations for accommodations in school Kept him safe by managing his gradual return to sports Kept him safe by managing his gradual return to sports