Mark Lovell PhD, FACPN, D.Sci Chairman and CEO Software Developer ImPACT Applications, Inc.

1. Management of Sports Concussion and The ImPACT Program Jon French, PsyD University of Pittsburgh Medical Center Department of OrthopaedicSurgery Clinical Fellow and Neuropsychologist UPMC Sports Concussion Program Mark Lovell PhD, FACPN, D.Sci Chairman and CEO Software Developer ImPACT Applications, Inc. Micky Collins, PhD University of Pittsburgh Medical Center Department of Orthopaedic Surgery Department of Neurological Surgery Program Director UPMC Sports Concussion Program Co-Founder, ImPACT Applications

2. Workshop Goals To Provide Background Information Regarding Concussion Management To Present Data Pertaining to Outcomes and Risk Factors Associated with Sports Concussion To Discuss Academic Needs for Recovering Student Athlete with Concussion To Review the Utility of Computerized Neurocognitivie Testing and ImPACT as a Tool for Effective Concussion Management To Review Clinical Case Material

3. Concussion 101: Biomechanics, Pathophysiology, Definition • Micky Collins, PhD • Associate Professor and Director • UPMC Sports Medicine Concussion Program

13. Neurometabolic Cascade Following Cerebral Concussion/MTBI 500 Calcium 400 K+ 300 Glucose % of normal 200 Glutamate 100 50 2 6 12 20 30 6 24 3 6 10 Cerebral Blood Flow 0 hours days minutes (Giza & Hovda, 2001) UCLA Brain Injury Research Center

18. Concussion Management: Areas of Focus • Acute Management • Rule out more serious intracranial pathology • CT, MRI, neurologic examination primary diagnostic tests • Post Injury Management • Prevent against Second Impact Syndrome • Prevent against cumulative effects of injury • Less biomechanical force causing extension of injury • Prevent presence of Post-Concussion Syndrome • Determination of asymptomatic status essential for reducing repetitive and chronic morbidity of injury

19. Most Commonly Reported Symptoms Athletes with Concussion – 1-7 days following concussion Kontos, Elbin, French Collins, Data Under Review; N = 1,438

20. Post-Concussion Symptom Groups (Pardini, Lovell, Collins, et al. 2004) N=327, High School and University Athletes Within 7 Days of Concussion

21. The Evolving Definition of Concussion CDC Physicians Toolkit 2007 Regarding Cerebral Concussion…… A concussion (or mild traumatic brain injury) is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. Disturbance of brain function is related to neurometabolic dysfunction, rather than structural brain injury, and is typically associated with normal structural imaging findings (CT Scan, MRI). Concussion may or may not involve a loss of consciousness. Concussion results in a constellation of physical, cognitive, emotional, and sleep-related symptoms. Recovery is a sequential process and symptoms may last from several minutes to days, weeks, months, or even longer in some cases.” CDC Physicians Toolkit; Collins, Gioia et al 2006

22. Management of MTBI: Topics of Concern • Grading systems ineffective/not data based. • CT and MRI insensitive to subtleties of injury. • Self-report predicates management directives. • Variability in clinician recommendations. • Lack of education and awareness of injury. • Inadequate/Improper recommendations from ED/Trauma Departments.

23. “When it comes to concussion, don’t believe me when I tell you that I’m OK ” NFL Athlete, 2010 23

24. Return to Play Following mTBI: Can we safely rely on symptoms alone? • In some cases (not all), athletes will minimize difficulties • Athletes are naïve to the subtleties of the injury • Young athletes lack insight into self-assessment of MTBI symptoms • Studies suggest that up to 50% of athletes experience concussion symptoms per year but only 10 % report having an injury • Need for comprehensive understanding of athletes recovery status

25. Computer-Based Neurocognitive Testing CURRENTLY AVAILABLE PROGRAMS: Cogsport (Axon) Headminders (CRI) ANAM CNS Vital Signs ImPACT Extensive research since 2001

26. Immediate Post-Concussion Assessmentand Cognitive TestingComputerized Neurocognitive Testing Mark Lovell, PhD, FACPN, Dsci, Software Developer, ImPACT Micky Collins, PhD - UPMC Dept. of Orthopaedic Surgery Joseph Maroon, MD - UPMC Dept. of Neurological Surgery ImPACT

27. Demographic / Concussion History Questionnaire Concussion Symptom Scale 21 Item Likert Scale (e.g. headache, dizziness, nausea, etc) 8 Neurocognitive Measures Verbal Memory, Visual Memory, Reaction Time, Processing Speed Summary Scores Detailed Clinical Report Outlines Demographic, Symptom, Neurocognitive Data Automatically Computer Scored Internal baseline validity checks built into program Desktop and On-Line Versions Available Extensive normative data available from ages 11-60 Over 100 peer-reviewed research articles/books/chapters, published since 2000 Extensive data published on reliability, validity, sensitivity/specificity of test ImPACT: Post-Concussion Evaluation

28. Neurocognitive Testing: What it is and Isn’t

29. Concussion Evaluation Timeline Pre-season 1-3 Days Return to Play Remove From Play Evaluation Supervised at School Or clinic

30. Measuring Neurocognitive Recovery from Sports mTBI How Long Does it Take?

31. Concussion Recovery Rates Vary by Age/Dependent Measure

32. Three-year prospective study in Western PA. • 17 high school football teams (2,141 total sample) • 134 athletes with diagnosed concussion (6.2%) • All athletes referred for evaluation at UPMC • Recovery determined by “Back to Baseline” on computer • neurocognitive test scores & symptom inventory • Determined by Reliable Change Index Scores-RCI’s) Collins, Lovell, Iverson, Ide, Maroon et al, Neurosurgery, 2006:58;275-283

33. Individual Recovery From Sports MTBI: How Long Does it Take? WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 80% RECOVERED 60% RECOVERED N=134 High School Male Football Athletes 40% RECOVERED Collins et al., 2006, Neurosurgery

34. Functional MRI and Sports Concussion Lovell, Collins, Eddy, Becker, Pardini, Maroon, Field, Marion, and Boada (2001-2006) RO1 HD 42386-05

35. Brain Metabolism is Related to Recovery • Over 200 High School Athletes Studied using fMRI • Tested w/in 7 days of concussion and at point of clinical recovery • Hyperactivation predicts CLINICAL recovery time • Resolution of hyperactivation correlates with recovery on ImPACT Lovell et al., Neurosurgery, 2007

36. Recovery: fMRI Subsample (UPMC Program)(Lovell, Pardini, Collins et al; Neurosurgery 2007) Mean Age: 16.2 yrs Gender: 78% male N = 208

37. Prognosticating Concussion Outcomes: An Evidence-Based Analysis Micky Collins, Ph.D. University of Pittsburgh Medical Center Associate Professor Department of Orthopaedic Surgery Department of Neurological Surgery Director UPMC Sports Concussion Program

38. Researching/Determining Prognosis for Sports Concussion: Why is it Important? • Helps to set up clear communication to player, coaches, and medical personnel regarding recovery expectations • May help to alleviate some pressure on RTP issue • May help to immediately provide individualized clinical management recommendations (e.g. need for academic accommodations/physical rest, etc.) • Begins to create a risk profile for sports concussion and may set stage to effectively research treatment and rehabilitation strategies. • Because it is the next stage in our scientific understanding of this injury….

39. Lau B, Kontos A, Lovell MR, Collins MW, AJSM: 2011 Which On-Field Symptoms Predict Protracted Recovery (i.e. Post-Concussion Syndrome)?

40. Which On-Field Symptoms Increase Risk of Post Concussion Syndrome in High School Football Players? • 176 Male HS Football Players (Mean Age = 16.2 years) • Athletes had baseline ImPACT testing and were revaluated within 3 days of injury. • All followed until clinical recovery (Mean = 4.1 evaluations) • Within RCI of baseline on ImPACT for neurocognitive/symptom scores • 32% of sample required < 7 days until recovery (N =56) “Rapid Recovery” (Mean = 4.9 days) • 39% of sample required 7-14 days until recovery (N = 68) • 17% of sample required > 21 days until recovery (N = 31) “Protracted Recovery” • (Mean = 33.2 days) • 12% lost to follow up (e.g. did not RTP or no follow-up in clinic) (N = 21) • MANOVA used to determine differences between rapid/> 3 week recovery • ATC’s documented on-field markers (e.g. LOC, Amnesia) and on-field Symptoms (e.g. headache, dizziness, etc) Lau B, Kontos A, Lovell MR, Collins MW, AJSM 2011

41. Which On-Field Markers/Symptoms Predict 3 or More WeekRecovery from MTBI In High School Football Players **p<.01 The total sample was 107. Due to the normal difficulties with collecting on-field markers, there were varying degrees of missing data. The number of subjects who had each coded ranged from 92-98. The N column represents the number of subjects for whom data were available for each category. Markers of injury are not mutually exclusive. Lau, Kontos, Collins, Lovell , AJSM 2011

42. On-Field Symptom Summary • Brief LOC (<30 sec) not predictive of subacute or protracted outcomes following sports-concussion • Amnesia important for sub-acute presentation, but may not be as predictive of protracted recovery • On-Field dizziness best predictor of protracted recovery and • “post concussion syndrome” • Etiology of dizziness? • Migraine variant? • Central Vestibular Dysfunction? • Peripheral Vestibular Dysfunction? • Cervico-genic? • Psychiatric?

43. Lau B, Lovell MR, Collins MW; Pardini J; CJSM 2009 (3):216-21 Which SubacuteSymptoms Predict Protracted Recovery?

44. 108 concussed high school football players • Athletes had baseline ImPACT testing and were revaluated within 3 days of injury (Mean = 2.2 days) • All followed until clinical recovery • - Within Reliable Change Score of baseline for neurocognitive/symptom scores • 43.5% of sample recovered < 10 days = “Quick” • - Mean = 5.9 Days • 56.5% of sample required >10 days until recovery = “Protracted” • - Mean = 29.2 Days • MANOVA conducted on which individual symptoms and neurocognitive domains predicted “quick” versus “protracted” recovery Lau B, Lovell MR, Collins MW; Pardini J; CJSM 2009 (3):216-21

45. Post-Concussion Symptom Scale

46. Top 11 Symptom Predictors of Protracted Recovery Expressed as Effect Sizes (Cohen’s D). Only includes symptoms with large (greater than .80) effect sizes. Sample is composed of 108 male HS football athletes. Lau, Lovell, Collins et al. 2009, CJSM

47. “Fogginess” Athlete Descriptions • “It is like going from a high definition TV world • to standard TV world” • “Feeling one step removed from my surroundings” • “It is like my vision is impaired, but it isn’t” • “Feeling like I am underwater” Iverson, Lovell, Collins. JINS (2004),10, 94-906.

48. Factor Analysis, Post-Concussion Symptom Scale (Pardini, Lovell, Collins et al. 2004) N=327, High School and University Athletes Within 7 Days of Concussion

49. Rank Order of Most Predictive Symptoms of Outcome Lau, Lovell, Collins et al. CJSM, 2009 *Symptoms with the largest contributions to differences between “quick” and “protracted” recovery in each symptom factor.

50. The Role of Sub-Acute Migraine-Symptoms in Determining Outcomes Following Concussion Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; data in preparation for publication