Player Safety: Concussion & Baseline Impact Testing

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

2. Concussion Mild traumatic brain injury Vienna Consensus Statement 2001

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

5. Memory

6. 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?

7. 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

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

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

10. Sideline evaluation Orientation Concentration Month: ___________________ 0 1Digits 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 4-9-3 6-2-9 ______0 1 Time (within 1 hour): _______ 0 1 3-8-1-4 3-2-7-9 _____0 1 6-2-9-7-1 1-5-2-8-6 ______0 1 Orientation Total Score _________ / 5 7-1-8-4-6-2 5-9-1-4-8 _____0 1 Months in reverse order: (entire sequence correct for 1 pt) DecJan 0 1 Concentration Total Score ____ / 5

11. Sideline evaluation Immediate Memory: (all 3 trials are complete regardless of score on trial 1 & 2; total score equals sum across all 3 trials) List Trial 1 Trial 2 Trial 3 Word 1 0 1 0 1 0 1 Exertional maneuvers Word 2 0 1 0 1 0 1 Coordination Word 3 0 1 0 1 0 1 Strength Word 4 0 1 0 1 0 1 Sensation Word 5 0 1 0 1 0 1 Recall of injury Total Immediate Memory Total Score _____ / 15 Delayed recall Word 1 0 1 Word 2 0 1 Word 3 0 1 Word 4 0 1 Word 5 0 1 Delayed Recall Total Score _____/5 McCrea M et al. Summary of Total Scores _____ / 30 Neurology 1997

12. 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

13. DO NOT ALLOW RETURN TO PLAY UNTIL COMPLETELY ASYMPTOMATIC

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

15. 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

16. Catastrophic complications • Epidural • Subdural • Second impact syndrome

17. 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

18. POST CONCUSSIVE SYNDROME Recurrent headaches Dizziness Memory impairment Depression Loss of libido Tinnitus Ataxia Anxiety Alcohol intolerance Photophobia Hyperacousis Concentration

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

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

21. Computerized Neurocognitive Testing • IMPACT • Headminders • Cogsport • http://www.wiyouthsoccer.com/impact.html