CONCUSSION CONCUSSION MANAGEMENT:MANAGEMENT:

ImPACTImPACT

David R. Wiercisiewski, MDDavid R. Wiercisiewski, MDDirector, Carolina Sports Concussion Director, Carolina Sports Concussion

Program at CNSAProgram at CNSA

STATISTICSSTATISTICS

Incidence in HS football = 6%-8% per year.Incidence in HS football = 6%-8% per year.

Boy’s + Girl’s soccer = football.Boy’s + Girl’s soccer = football.

Girl’s basketball 250% greater risk than Girl’s basketball 250% greater risk than Boy’sBoy’s

Sports and recreational injuries with LOC Sports and recreational injuries with LOC = =

300,000 per year.300,000 per year.

Sports and recreational injuries with and Sports and recreational injuries with and without LOC = 1.6 million per year.without LOC = 1.6 million per year.

DEFINITIONDEFINITION

Complex pathophysiologic Complex pathophysiologic process affecting the process affecting the brain, induced by brain, induced by traumatic biomechanical traumatic biomechanical forces.forces.

COMMON FEATURESCOMMON FEATURES

Caused by a direct or indirect blow to the Caused by a direct or indirect blow to the head, face or neck.head, face or neck.

Results in rapid onset of short-lived Results in rapid onset of short-lived impairment of neurological function.impairment of neurological function.

A concussion may or may not involve LOC.A concussion may or may not involve LOC.

The clinical symptoms reflect a functional The clinical symptoms reflect a functional rather than a structural disturbance.rather than a structural disturbance.

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Mechanism of InjuryMechanism of InjuryRotationalRotational

LinearLinear

Impact decelerationImpact deceleration

Chemical/VascularChemical/Vascular11stst 7-10 days 7-10 days

↑↑K / ↑Ca / ↑glc / ↑glutK / ↑Ca / ↑glc / ↑glut

↓↓CBFCBF

““Period of vulnerability”Period of vulnerability”

CONCUSSIONCONCUSSIONCLASSIFICATIONCLASSIFICATION

Recommendation to abandon the “simple” Recommendation to abandon the “simple” versus “complex” nomenclature with no versus “complex” nomenclature with no endorsement of any other specific endorsement of any other specific classification system.classification system.

PRIMARY AREAS OF FOCUSPRIMARY AREAS OF FOCUS

Rule out more serious intracranial pathologyRule out more serious intracranial pathology

Prevent Second Impact SyndromePrevent Second Impact Syndrome

Prevent repeat injury during post-concussion Prevent repeat injury during post-concussion period of “vulnerability”.period of “vulnerability”.

Prevent against cumulative effects of injuryPrevent against cumulative effects of injuryNeurobehavioral deficitsNeurobehavioral deficits

Lowered threshold to injuryLowered threshold to injury

GENERALGENERALMANAGEMENTMANAGEMENT

Majority of injuries will recover spontaneously.Majority of injuries will recover spontaneously.

Physical Physical andand cognitive rest are required while cognitive rest are required while symptomatic.symptomatic.

When symptom free and improved “functionally” When symptom free and improved “functionally” graduated return to play protocol should be utilized.graduated return to play protocol should be utilized.

Same day return to play—NEVER!!!Same day return to play—NEVER!!!

CONCUSSION CONCUSSION EVALUATIONEVALUATION

PLAN—PLAN—PLAN PLAN—PLAN—PLAN

Agree on an approach to the management of Agree on an approach to the management of concussions with other health care providers on the concussions with other health care providers on the team.team.

Baseline cognitive testing if available.Baseline cognitive testing if available.

Use a standardized PCS symptom scale Use a standardized PCS symptom scale

(i.e. SCAT2)(i.e. SCAT2)

Perform serial assessmentsPerform serial assessments

Identify your referral patterns ahead of timeIdentify your referral patterns ahead of time

CONCUSSIONCONCUSSIONRECOGNITIONRECOGNITION

Symptoms—somatic (headache), cognitive Symptoms—somatic (headache), cognitive (feeling like in a fog) and emotional (lability).(feeling like in a fog) and emotional (lability).

Physical signs—LOC and amnesia.Physical signs—LOC and amnesia.

Behavioral changes—irritability.Behavioral changes—irritability.

Cognitive impairment—slowed reaction times.Cognitive impairment—slowed reaction times.

Sleep disturbance—drowsiness.Sleep disturbance—drowsiness.

EVALUATIONEVALUATION

Neurological assessment Neurological assessment MotorMotor

Pupillary responsePupillary response

Coordination/postural controlCoordination/postural control

Mental status testingMental status testingAttentionAttention

MemoryMemory

Processing speedProcessing speed

MENTAL STATUS TESTINGMENTAL STATUS TESTING

Be familiar with the different screening tools Be familiar with the different screening tools and their requirements.and their requirements.

Use tools that have been validated and Use tools that have been validated and published in peer-reviewed literature.published in peer-reviewed literature.

Results should be interpreted and integrated Results should be interpreted and integrated into the other relevant clinical information.into the other relevant clinical information.

NEUROCOGNITIVE NEUROCOGNITIVE COMPUTERIZED TESTINGCOMPUTERIZED TESTING

ImPACT (UPMC)ImPACT (UPMC)

CogSport (Australia)CogSport (Australia)

CRI (Headminder)CRI (Headminder)

ANAM (NRH) ANAM (NRH)

COMPUTERIZED TESTINGCOMPUTERIZED TESTING

Format allows portability and efficiency.Format allows portability and efficiency.

Each vendor has their unique menu of Each vendor has their unique menu of cognitive domains that their product measures.cognitive domains that their product measures.

20 – 30 minutes to administer.20 – 30 minutes to administer.

Used as a “tool” to measure recovery and not Used as a “tool” to measure recovery and not to make a diagnosis or solely direct to make a diagnosis or solely direct management.management.

FEATURES OFFEATURES OFCOGNITIVE TESTINGCOGNITIVE TESTING

Must assess pertinent Must assess pertinent domains.domains.

Baseline testing Baseline testing improves evaluation.improves evaluation.

Limitations:Limitations:““Normal” rangeNormal” range

SensitivitySensitivity

SpecificitySpecificity

Learning effectsLearning effects

Early return to baseline Early return to baseline while still symptomaticwhile still symptomatic

Without baseline testing it Without baseline testing it can be more difficult to can be more difficult to interpretinterpret

CAROLINA SPORTSCAROLINA SPORTSCONCUSSION PROGRAMCONCUSSION PROGRAM

First sports concussion program in the greater Charlotte area.First sports concussion program in the greater Charlotte area.Began in February 2007.Began in February 2007.First year provided post-injury care only.First year provided post-injury care only.Subsequent years we have provided Subsequent years we have provided freefree baseline tests to baseline tests to middle and high school athletes participating in “high risk” middle and high school athletes participating in “high risk” sports through monies donated by SunTrust Bank.sports through monies donated by SunTrust Bank.Baseline testing program currently offered in 5 counties.Baseline testing program currently offered in 5 counties.Utilize the ImPACT neurocognitive testing tool.Utilize the ImPACT neurocognitive testing tool.

IMMEDIATE POST-IMMEDIATE POST-CONCUSSION ASSESSMENT and CONCUSSION ASSESSMENT and COGNITIVE TESTING (ImPACT)COGNITIVE TESTING (ImPACT)

8 separate tests8 separate testsWord memoryWord memory

Design memoryDesign memory

X’s and O’sX’s and O’s

Symbol MatchSymbol Match

Color MatchColor Match

Three LettersThree Letters

Interference testsInterference tests

6 composite scores6 composite scoresVerbal memoryVerbal memory

Visual memoryVisual memory

Visual motor speedVisual motor speed

Reaction timeReaction time

ImpulsivityImpulsivity

Total symptom scoreTotal symptom score

CONCUSSION SYMPTOM SCALECONCUSSION SYMPTOM SCALE

Standardized survey with Standardized survey with 0-6 scale rating 0-6 scale rating

Developed by Lovell and Developed by Lovell and Collins in 1998Collins in 1998

Sensitive tool to measure Sensitive tool to measure recoveryrecovery

Symptoms generally Symptoms generally classified into 3 main classified into 3 main categories: Physical, categories: Physical, Cognitive, and Cognitive, and Emotional/BehavioralEmotional/Behavioral

OVERVIEW OF ImPACTOVERVIEW OF ImPACT

Proven in measures of reliability and validityProven in measures of reliability and validityProvides useful concussion screening and Provides useful concussion screening and management informationmanagement informationValidated with multiple peer-reviewed studiesValidated with multiple peer-reviewed studiesDoes not substitute for medical evaluation and Does not substitute for medical evaluation and treatmenttreatmentDoes not substitute for comprehensive Does not substitute for comprehensive neuropsychological testingneuropsychological testing

PREDICTING RECOVERY PREDICTING RECOVERY TIMELINESTIMELINES

ALL ATHLETES ARE NOT ALL ATHLETES ARE NOT CREATED EQUALLYCREATED EQUALLY

CONCUSSIONCONCUSSIONMODIFIERSMODIFIERS

Symptoms—Number, duration (>10 days) and Symptoms—Number, duration (>10 days) and severity.severity.

Signs—Prolonged LOC (>1 min.), amnesia.Signs—Prolonged LOC (>1 min.), amnesia.

Sequelae—Concussive convulsions.Sequelae—Concussive convulsions.

Temporal—Frequency (number of Temporal—Frequency (number of concussions), concussions),

Timing/”recency”Timing/”recency”

CONCUSSIONCONCUSSIONMODIFIERSMODIFIERS

Threshold—Repeated concussions occurring with Threshold—Repeated concussions occurring with less force or slower recovery.less force or slower recovery.Age—Child and adolescent < 18 years old.Age—Child and adolescent < 18 years old.Co-morbidities—Migraine, depression or other Co-morbidities—Migraine, depression or other mental health disorders, ADHD, learning mental health disorders, ADHD, learning disabilities and sleep disorders.disabilities and sleep disorders.Medication—Psychoactive drugs and Medication—Psychoactive drugs and anticoagulants.anticoagulants.Behavior—Style of play.Behavior—Style of play.Sport—Contact or collision sport, high-risk.Sport—Contact or collision sport, high-risk.

SPECIAL SPECIAL POPULATIONSPOPULATIONS

CHILD AND ADOLESCENTCHILD AND ADOLESCENTATHLETESATHLETES

Clinical evaluation should include academic Clinical evaluation should include academic performance and behavior in school.performance and behavior in school.

Neurocognitive testing may be performed earlier to Neurocognitive testing may be performed earlier to aid in academic accommodations during recovery.aid in academic accommodations during recovery.

Return to exertion or game play should be slower Return to exertion or game play should be slower when compared to the adult athlete. Also there when compared to the adult athlete. Also there should be particular focus on “cognitive rest”.should be particular focus on “cognitive rest”.

Never return to play on same day!Never return to play on same day!

ELITE vs. NON-ELITEELITE vs. NON-ELITEATHLETESATHLETES

Both groups should Both groups should follow the same follow the same treatment and return to treatment and return to play paradigmplay paradigmNeurocognitive testing Neurocognitive testing is preferred but is preferred but providing for non-elite providing for non-elite athletes may be athletes may be restricted by financial restricted by financial resourcesresources

CASE STUDIESCASE STUDIES

RETURN TO PLAY RETURN TO PLAY PROTOCOLPROTOCOL

No activity while symptomatic.No activity while symptomatic.

Light aerobic exercise.Light aerobic exercise.

Sport-specific exercise—no head impact drills.Sport-specific exercise—no head impact drills.

Non-contact training drills.Non-contact training drills.

Full contact practice.Full contact practice.

Return to game play.Return to game play.

NFL CONCUSSIONNFL CONCUSSIONGUIDELINESGUIDELINES

Established in 2009.Established in 2009.

No same day return to No same day return to practice or game play.practice or game play.

Players encouraged to Players encouraged to be honest and report be honest and report symptoms.symptoms.

Independent neurology Independent neurology opinion for each injury.opinion for each injury.

CHRONIC TRAUMATIC CHRONIC TRAUMATIC ENCEPHALOPATHYENCEPHALOPATHY

CHRONIC TRAUMATIC CHRONIC TRAUMATIC ENCEPHALOPTHYENCEPHALOPTHY

NFL Survey—NFL Survey—> 50 = 5x risk> 50 = 5x risk30-49 = 19x risk30-49 = 19x risk

Comparative data from Comparative data from the Framingham heart the Framingham heart study.study.Concept of Concept of subconcussivesubconcussive trauma. trauma.Sports Legacy Institute.Sports Legacy Institute.

CTECTETAU PROTEINTAU PROTEIN

Protein that invades Protein that invades cortical nerve cells and cortical nerve cells and shuts them down shuts them down effectively killing them.effectively killing them.Unlike Alzheimer’s Unlike Alzheimer’s disease and the disease and the neurofibrillary tangles neurofibrillary tangles associated with that associated with that disease, the build up of disease, the build up of tau is related to trauma tau is related to trauma or injury.or injury.

DISQUALIFICATIONDISQUALIFICATIONLONG TERMLONG TERM

3 fold risk to have 3 fold risk to have concussion if have 3 concussion if have 3 concussions in previous concussions in previous 7 years7 years2 or more concussions 2 or more concussions have longer recovery have longer recovery timestimes3 or more concussions:3 or more concussions:

8 fold risk of LOC8 fold risk of LOC5.5 fold risk of PTA5.5 fold risk of PTA5.1 risk of confusion5.1 risk of confusion

INJURY PREVENTIONINJURY PREVENTION

Protective Equipment—Mouthguards and Protective Equipment—Mouthguards and helmets.helmets.Rule changes.Rule changes.Risk CompensationRisk Compensation—use of protective —use of protective equipment results in a behavioral change and equipment results in a behavioral change and may subsequently result in a paradoxical may subsequently result in a paradoxical increase in injury rates.increase in injury rates.Aggression versus violence in sports.Aggression versus violence in sports.

FUTURE DIRECTIONSFUTURE 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 Concussion surveillance using consistent definitions

and outcome measures.and outcome measures. Long-term outcomes.Long-term outcomes. Formal review of “concussion in sport” guidelines Formal review of “concussion in sport” guidelines

and update prior to December 1, 2012 by panel of and update prior to December 1, 2012 by panel of international experts.international experts.

PROTECTING THE “3 LB. UNIVERSE”PROTECTING THE “3 LB. UNIVERSE”OBSERVATIONS FROM CLINICOBSERVATIONS FROM CLINIC

Moving the mountain.Moving the mountain.Improved awareness and increase in concussion recognition.Improved awareness and increase in concussion recognition.Gap in club sports.Gap in club sports.

Dealing with the devil.Dealing with the devil.The sickness of our sports culture.The sickness of our sports culture.

Creating a road map.Creating a road map.Defining expectations of recovery based on the individual’s unique Defining expectations of recovery based on the individual’s unique medical history and mechanism of injury.medical history and mechanism of injury.

Kids are real people too!Kids are real people too!Emotional response to the injury.Emotional response to the injury.

My “uneasy” chair.My “uneasy” chair.How many is too many?How many is too many?

THANK YOUTHANK YOU