Concussions in the Office: Who, What, Where, When, and How Do I Know

1. Concussions in the Office:Who, What, Where, When, and How Do I Know Daniel E. Kraft M.D. Riley Hospital for Children Sports Medicine

2. Athletes at Games • “I can remember what happened, so I do not have a concussion” • “I just got my bell rung, that is not really a concussion” • “Are you sure you know what a concussion is because I don’t think you are right” • “I still know my birthday so I can’t have a concussion”

3. History of Concussions • 2006- Zackery Lystedt suffers permanent disability due to “second concussion syndrome” • 2007- questions start about chronic brain injuries in NFL players • 2009- NFL passes new concussion guidelines • 2009- Washington state passes Lystedt Law

4. Recent Developments • 2010- NCAA develops new rules prohibiting same day return to play with concussion symptoms • 2010- IHSAA follows National High School Federation recommendation for same day concussion rule • 2011- Madden Football video game adds concussion rule

5. Indiana State Concussion Law • Passed as law in 2011 • Begins enforcement July 1, 2012 • 3 Main Features of Law • Education: all student athletes and parents must receive yearly concussion education • All athletes with concussion symptoms must be removed from game • All athletes diagnosed with concussion must be cleared by appropriate medical personel before return to play

6. Concussions • In the United States, the annual incidence of sports-related concussion is estimated at 300,000. • Likelihood of an athlete in a contact sport experiencing a concussion may be as high as 19% per season. • One study at Nationwide Children’s Hospital showed 41% of young athletes go back to sports too soon • Second Impact Syndrome has led to 30-40 deaths over the past decade.

7. Danger of Concussions • Most importantly, athletes may not understand the potential consequences of concussion and often minimize or deny symptoms so that they can return to play. • Such under-reporting of symptoms is a common practice at all levels of sport participation.

8. Second Impact Syndrome • Suffering a second blow to the head while recovering from the initial concussion can have catastrophic consequences. • Athletes that are not fully recovered from an initial concussion are significantly vulnerable for recurrent, cumulative, and even catastrophic consequences of a second concussive injury.

9. Recent Developments That Affect Primary Care Physicians in Indiana • National High School Sports Federation recommends new same day concussion rule • IHSAA requires MD clearance for return to play • New Indiana state law regarding concussions

10. Objectives • What is a concussion? • How do I know if an athlete has suffered a concussion? • How do we treat concussions? • What is computerized neurocognitive testing? • When can athletes return to play after a concussion?

11. Injury to the brain caused by acute trauma More than a “Bruise” on the brain Functional injury, not just structural What is a concussion?

12. Functional Injury to Brain Cells • Affects cell membrane permeability • Affects K+ and Ca+ flow • Ultimately decreases glucose availability to brain cells for energy “energy crisis for the brain”

13. How do you know when a concussion has occurred?“Criteria for Diagnosis” • Acute trauma/injury to the head- athlete is exposed to a force to the head that causes injury • Symptoms- athlete has a reaction to the injury in the form of symptoms

14. Possible Concussion Symptoms • Headache • Dizziness • Disorientation • Dazed • Blurred vision • Memory loss • Confusion • Fatigue • Inability to concentrate • Change in mood • Headache made worse by light or noise • Loss of consciousness

15. Diagnosis • Even athletes who finish games can be diagnosed with a concussion • Some athletes may not report symptoms til after a contest

16. Sideline Diagnosis • Same criteria as in the office • Recommendations at all level of competition and ages is no return to play on same day if any concussion-like symptoms • Most concussions do not need to go to ER, though you must use own judgement

17. Who Has Concussions • All ages, have seen 8 year olds and older • Both males and females • Many different sports: • Football • Soccer • Cheerleading • Basketball • Lacrosse

18. Concussions in Girls • Girls have higher risk for concussion in both basketball and soccer • Cheerleading becoming higher risk sport • Girls sports can be ignored by schools when it comes to neurocognitive testing and risk for concussions

19. What is the goal of medical treatment for concussions? • Try to determine as best we can using available information and testing when an athlete has completely recovered from a concussion before allowing that athlete to participate in any activity with increased risk of concussion (return to play for athletes)

20. What is the goal of medical treatment for concussions • Try to prevent a concussion injury from occurring on top of a concussion that has not healed completely • Manage the athlete’s concussion symptoms and issues to help them try to continue normal academic and daily activities as much as possible while the concussion injury heals

21. Treatment Parameters • New research over past 5-10 years has changed approach to concussion management • Computerized neurocognitive testing has helped gather new information regarding the effects of concussions on athletes • Better realization now about the more significant effects of concussions (both short term and long term)

22. Treatment Parameters • All concussion patients are treated individually with no time standards • No longer 1 week for mild concussion,etc • Athletes must complete 3 phases of treatment/management before return to play • Physical Exam must be normal

23. Physical Exam • Normal neurologic exam • Normal balance exam • Normal vestibular exam

24. Treatment Parameters:3 Phases of Treatment • No symptoms with activities of daily living • No symptoms with exertion testing • Normal neurocognitive testing

25. Phase 1No Symptoms with ADL’s • No headaches (unless hx of headaches) • Normal sleep patterns • No abnormal mood issues different from their baseline • No memory or concentration issues at home or in school

26. Phase 1No Symptoms with ADL’s • No headaches with bright lights or loud noises • Athlete must report that they feel 100% back to their normal self • Parents must state that they believe athlete is 100% back to their normal self

27. Phase 2 No Symptoms with Physical Exertion Testing • Will typically start phase as symptoms with ADL’s are decreasing or at 3-4 weeks if still with significant symptoms • Exertion tests can be done by ATC’s, coaches, or parents • If athlete develops increasing symptoms during exertion, then need to hold for a some days before re-trying

28. Phase 2No Symptoms with Exertion • Athlete is exercised individually with running, stationary bike, elliptical, or weight-lifting • Start light 12-15 minutes and advance both length and intensity of work • Typically must advance to at least 2-3 days of HEAVY exertion with no symptoms to pass

29. Neurocognitive Testing • Concussions are really a functional injury versus a structural injury

30. Phase 3Neurocognitive Testing • Determining the functioning ability of an athlete’s brain requires neurocognitive testing • Using computerized neurocognitive testing is becoming a part in the standard of care for managing athletes with concussions

31. Computerized Neuropsychological Tests • Impact • Axon (Cog Sport) • Others

32. Impact • Proven validity • Most research published • Most widely used in USA • Internet based • Ease of obtaining baseline studies • Established credentialing process for medical personnel to learn to interpret test scores

33. ImPACT • Computerized test of cognition • Not an IQ test • Used in NFL, MLB, NHL, Major League Soccer • Used by military for combat troops

34. How it works • 22-25 minute test • Almost any computer will work • Mouse • Network connectivity • Internet connectivity • Quiet room

35. Evaluates • Attention span • Working memory • Reaction time • Problem solving • Response variability

36. How it works • Objective measure • Accurate to 1/100th of second • No learning effect

37. Who is it for • Mild traumatic brain injury • Athletic related concussion • Current age 11 and up • Best with access to baseline • Compare to normative data • Pediatric test • Calculations for peds population

38. Baseline Testing • Can be done over the internet from any computer and using a mouse • Currently costs no more than $5 per baseline test • Can be completed in Indiana thru various websites • Test scores are stored • Can be organized thru schools or clubs

39. Module 1: Word Discrimination – Twelve target words are shown twice to the athletes. After they have gone through twice they are then shown the twelve words and then twelve non target words and they have to pick the twelve target words. Delay Condition: Following the administration of all other test modules (approximately 20 minutes), the subject is again tested for recall via the same method described above. The same scores that are described above are provided for the delay condition. The Test

40. Design Memory-Twelve target designs are presented twice to facilitate learning. The subject is tested for recognition via the presentation of 24-designs comprised of 12 target designs and 12 non-target designs Delay Condition-Following the administration of all other test modules (approximately 20 minutes), the subject is again tested for recall via the same method described above. The same scores that are described above are provided for the delay condition. Module 2

41. Module 3 • X’S and O’s This module measures visual working memory as well as visual processing speed and consists of a visual memory paradigm with a distracter task. Subject is asked to click the left mouse button if a blue square is presented and the right mouse button if a red circle is presented. Once the subject has completed this task, the memory task is presented. For each of the trials of the memory task, a screen is displayed for 1.5 second that has a computer generated random assortment of X’s and O’s. For each of the trials, three of the X’s or O’s are illuminated in YELLOW on the screen. The subject is asked to remember the location of the illuminated objects

42. Module 4 • Symbol Matching This module evaluates visual processing speed, learning and memory. Subject is shown 9 common symbols, directly under each is the numbers 1-9.The subject is required to click the matching number as quickly as possible and to remember the symbol/number pairings They have 27 trials and following that the symbols disappear and they must recall the number/symbol pairing correctly. Provides an average reaction time score and a score for the memory condition.

43. Module 5 • Color Match This module represents a choice reaction time task and also measures impulse control /response inhibition. Subject is required to respond by clicking a read, blue or green button as they are presented on the screen. This procedure is completed to assure that subsequent trials would not be affected by color blindness. Next, a word is displayed on the screen in the same colored ink as the word (e.g. RED), or in a different colored ink (GREEN or BLUE). The subject is instructed to click in the box as quickly as possible only if the word is presented in the matching ink. In addition to providing a reaction time score, this task also provides an error score.

44. Module 6 • Three Letters/Count Backward Measures working memory and visual-motor response speed. Consists of 25 numbered buttons (5 x 5 grid). The subject is instructed to click as quickly as possible on the numbered buttons in backward order starting with "25. He/she is presented with three consonant letters that are displayed on the screen. They have 18 seconds to complete task and then must be repeated 5 times This module yields a memory score (total number of correctly identified letters) and a score for the average number of correctly clicked numbers per trial from the distracter test

45. Interpretation

46. Interpretation after Injury • Meant to be interpreted by credentialed physicians • Most useful when athlete has baseline test to compare current test scores • Post-injury tests must be at least equal to baseline scores • If no baseline, can develop estimate of baseline based on comparison to athlete’s peer group • Each composite score has a confidence interval

47. ImPact (Neurocognitive) testing is part of concussion management, not the only piece

48. When can athlete return to play? • Athlete must satisfactorily complete all 3 phases of treatment with no symptoms and normal neurocognitive testing • Have normal physical exam • There are no standard time limits anymore before athletes can return to play after a concussion • Athlete should return to full practice before returning to game

49. Risk for Further Concussion • Currently our determination for return to play corresponds to determination of resolution/healing of the concussion • Are athletes at higher risk for another concussion when they return to play? • Do athletes have a lower threshold for further concussion injury?

50. Other Concussion Issues