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Concussion Management in the U.S.A.

Margot Putukian, M.D., F.A.C.S.M. Director of Athletic Medicine, Princeton University

Assoc Clin Professor, Robert Wood Johnson, UMDNJ Past President American Medical Society for Sports Medicine

Chair, US Lacrosse Sports Science & Safety Committee

NFL Head, Neck & Spine Committee

No financial

disclosures

to report

Goals Concussion management in the U.S.A.

Sideline

management

Return to Play

What’s New?

Princeton’s

Concussion

Program

Challenges & Future Directions

Introduction:

Concussion is an

elusive injury

Variability in

presentation, can

be very subtle

No clear marker, no

definitive test

Management & RTP

decisions challenging

Overview

Evolving research/tools

Unclear answers to

important questions

Spectrum of injury

& recovery?

What effects recovery

Long term / cumulative

effects

When is it safe?

Overview: Take Home

Individualized treatment

EDUCATION; know when

an injury occurs

Remove athletes with

suspected concussion from

play, have them evaluated

Have a plan, (EAP), that

includes concussion

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Overview; Take Home

Multifaceted assessment Symptoms

Cognitive function

Balance

Gradual RTP progression

More caution in the

young athlete, situations

where resources limited

CULTURE CHANGE

Georgia Sports 3:11 a.m. 12/26/2011

“Some NFL players still willing to

hide concussions”

Updated: January 6, 2011,

5:40 PM ET

Coming to a head Scientists are competing

with one another for concussion cures and treatments By Peter Keating ESPN The Magazine

Is it time for more rule changes? Definition of Concussion; Team Physician Consensus Statement, 2011

Pathophysiological process affecting the brain caused by direct or indirect biomechanical forces Common features: Rapid onset of usually short-lived neurological impairment, which typically resolves spontaneously Clinical symptoms that reflect a functional disturbance rather than structural injury Range of symptoms that may or may not involve loss of consciousness (<10%) Standard neuroimaging is usually normal

Recognition Diagnosis; Sometimes

it’s easy

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Diagnosis; Sometimes it’s easy

Diagnosis of Concussion

Evaluation by ATC/MD

staff of obviously

symptomatic athlete

Self-report by athlete

Report by others

Heavy emphasis on

symptoms

Unreported Injuries;

McCrea ’04; Self report of concussion in HS football players; incidence 15.4% 52.7% did not report injury 66.4% of those felt injury not serious enough to report 41% didn’t want to be held out of sport 36% unaware symptoms due to concussion

Diagnosis / Recognition

Sometimes easy, but

not always

Hallmark confusion

Differential dx; Trauma-induced

headache

Head injury w/

resultant HA

Intracranial bleed

Complications of Brain Injury;

Cervical Spine

Injuries

Skull Fractures

Seizures

Post-concussion

Syndrome

Second Impact

Syndrome

Complications of Brain Injury;

Long term effects

of concussion,

effects of cumulative

injury unclear

“punch drunk”

syndrome described

in boxers

Retired NFL players;

risk for depression

& suicide (Guskiewicz ’07)

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Youth Sports Concussions Complications

Prolong recovery in student athletes

What are the #’s?

~300,000 per yr in organized sport

CDC: 1.6-3.8 million concussions in sport/recreational activities (CDC 2006)

8.9% of HS, 5.9% of college injuries (Gessel ’07)

11.7% of all recurrent injuries (Swenson ’09)

Gender Differences?

Women have an

increased incidence

of concussion vs

men in sports with

same rules Reporting bias

Hormonal influence

Head size / neck strength

Concussion Rate for Soccer Games

1998-99 / 2002-03

0

0.5

1

1.5

2

2.5

1998-99 1999-00 2000-01 2001-02 2002-03

Inju

ry R

ate

(per

1,0

00 A

-E)

MSO

WSO

Concussion Rate for Basketball Games

1998-99 / 2002-03

0

0.5

1

1.5

2

2.5

1998-99 1999-00 2000-01 2001-02 2002-03

Inju

ry R

ate

(per

1,0

00 A

-E)

MBB

WBB

Marar et al, AJSM, 2012

What about helmets?

NCAA ISS Data 1988-1989 through 2002-2003

Helmet TBI in G /1000 AE

No Helmet TBI in G /1000 AE

Football 2.3 Wrestling 1.27

MIH 1.47 M Soccer 1.08

WIH 2.72 W Soccer 1.42

M Lax 1.08 W Lax 0.76

Softball 0.25 F Hockey 0.52

Baseball 0.19 W B-ball 0.54

M B-ball 0.32

Concussion; Myths Putting a helmet on an athlete will protect them from head injury / concussion Mouthguards prevent head injury / concussion or limit severity The higher the impact force, the more likely the athlete will have a head injury / concussion

Concussion Program

Education

Baseline Testing

Sideline Management

Disposition Decisions

Follow Up Care

Return to Play

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Poster &

Fact Sheet

for NFL

Players

Completed 8/2010

Baseline Assessment Modified Sideline Concussion Assessment Tool 2 (SCAT2)

Symptoms

GAD, PHQ9

Modifiers

Cognitive

Evaluation

(SAC)

Balance (BESS)

Finger to nose

Components of BL SCAT2

Sideline Evaluation

ABC’s

Neurologic & mental status

R/O c-spine, skull fx, bleed Transport to appropriate

facility if necessary Remove from play; close

observation

Detailed history & cognitive evaluation

Standardized symptom scale

Sideline Evaluation SCAT2, BJSM ‘09

Is the athlete acting differently?

Was there loss of

consciousness?, If

so, for how long?

Was there problems

with balance or

unsteadiness?

What mo, date, day, year, time is it?

Sideline Evaluation SCAT2, BJSM ‘09

Modified Maddocks; What venue? What ½ ?, who

just scored?, who did we play

last week? did we win?

Cognitive Evaluation 5 word recall, 3 trials

Months backwards Digit Span Backwards

Delayed recall

Balance Evaluation BESS Finger to nose X 5

Sideline Evaluation Modified BESS (Guskiewicz) in SCAT2, BJSM ‘09

Eyes Closed, hands

on hips

Error scoring

3 Stances; 20 sec each

Double leg stance

Single leg stance; stand

on non-dominant leg

Tandem stance; non-

dominant foot in back

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♦Determine severity of injury once all sx have cleared, neurologic exam & cognitive eval nml ♦Nature, burden, duration of sx may be more indicative of severity

Severity When to Refer to ER SCAT2, BJSM ‘09

Worsening headache

Very drowsy or can’t be

awoken

Can’t recognize people or

places

Develop nausea/vomiting

Behave unusually, more

confused or irritable

Develop seizures, slurred

speech, weakness, or

unsteady gait

Disposition

Athlete should be

improving & monitored

If any deterioration,

consider transport for

emergency evaluation /

exclude more serious

brain injury

Post Injury Care

Post Injury Care

Plan for f/u care

Home care;

When to go to ER

Avoid aspirin, alcohol

No exertion / lifting

Avoid cognitive work

Follow up care

Neuropsychological

testing

Neuropsychological Testing

Provides reliable

assessment &

quantification of

brain functioning

by examining brain-

behavior relationships

Neuropsychological Testing

Types of tests Computerized

Paper / pencil

Hybrid

Measure broad range of cognitive function:

Speed of information processing

Memory recall

Attention & concentration

Reaction Time

Scanning & visual tracking ability

Problem solving abilities

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Neuropsychological Testing Many factors to consider in NP testing

Not uncommon to see deficits in cognitive function

by NP testing persist after symptoms have abated

Opposite also true

Can’t be used alone to make diagnosis or “clear” athlete. “One tool in the toolbox”

Collins AJSM ’03, Collins CJSM ’03, Echemendia ’01, Lovell ’03,

McCrory ’05, Broglio ’07, VanKampen ’06, Echemendia NAN 10/21/08

Return to Play Decisions; My take

Athlete is 100% asymptomatic

Consider delay depending on symptoms,

previous history, individual factors

How severe was injury?

Disproportionate force clinical result

What’s their timeline?

Use of Neuropsychological testing in

comparison with baseline if available

Team Physician Consensus Conference; 3/2011 Modifiers

TABLE 1. RISK FACTORS THAT MAY PROLONG OR COMPLICATE

RECOVERY FROM CONCUSSION

FACTORS MODIFIER

Concussion History

Total number, proximity, severity (duration)

Symptoms Total number, severity (intensity and especially duration)

Signs Prolonged LOC (>1 min)

Susceptibility Concussions occurring with lower impact magnitude and/or requiring longer recovery.

Age Youth and adolescent athletes may recover more slowly.

Pre-existing conditions

Migraine, depression, anxiety/panic attacks, attention

deficit hyperactivity disorder (ADHD), learning

disabilities (LD)

Concussion Management

Physical & cognitive rest until sx resolve

Recovery modifiers

What’s New?

NFL 12/09 Press release

NCAA follows suit;

creates mandates &

“best practices”

NHFS; no same day RTP

Zack Lystedt Law

Legislative efforts across

the country

Rule changes in sports;

change the culture,

exposures

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What’s New: NHFS All 17 Rulebook Additions ’10-11

Athlete w/signs, symptoms, behaviors c/w a concussion immediately removed from contest and shall not return to play until cleared by appropriate health-care professional

NCAA 4/29/10

Concussion management plan on file

(written team physician directed plan)

Coaches educated re: concussion plan

SA sign agreement to report symptoms

SA w signs/sx or behaviors c/w concussion

shall be removed from play & evaluated by

athletics healthcare provider w/ experience

in evaluation & mgmt concussion

Athletes dx w/ concussion; do not RTP

Medical clearance by team MD /designee

NFL Leadership

NFL: 12/09 mandate

Emphasis for

education, research,

assessment &

management

of concussion

No same day RTP

for concussion

Recent Guidelines

Most recent Guidelines; 3rd ICC - Zurich 2009

TPCC 2011

No same day RTP

No grading or “cookbook”

approach

Consider “modifiers”

4th ICC – Zurich 10/2012

Individualized mgmt & RTP decisions

NFL Sideline Assessment Tool

Princeton Concussion Program

Education

Baseline Testing as part of PPE

Baseline sideline assessment including

“modifiers” that effect recovery

Computerized neuropsychological

Testing (ImPACT)

Post-injury Assessment Sideline assessment, Hybrid NP testing

(ImPACT & paper/pencil)

Consultation / Team Approach

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Education Princeton Protocol

All concussions seen by

team physician

All post injury NP tests are interpreted by neuropsychologist

Repeat NP if abnormal Cardiovascular challenge once

symptom free (depending on

clinical picture) Repeat NP tests at beginning

of next season

Princeton NP Battery

ImPACT &

Additional Tests;

Hopkins

BVMT

Digit Span

Trails A & B

PSU Cancellation

DSMT

Stroop

Prevention Strategies; Better detection & management Decreasing head impacts will decrease concussion Rule changes / enforcement Proper techniques Coaching & officials education /support

Fish Oil

Omega-3 fatty acids associated w/ in

resilience of brain to withstand insult

Protective mechanism at cellular &

neuronal levels including modulation of

inflammatory cascade (Bailes 2010, Mills 2011, Babcock 2006)

Animal models show improvement in

outcome (Wu 2007, Belayev 2009, Cao 2004)

Neck Strengthening

Potential role for neck

strengthening

If musculature tenses prior

to contact, using F = mass x

acceleration, skull

potentially

sees less

force with

blow?

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Predicting Recovery

Cognitive rest important in

school aged athlete

Emotional readiness often

not evaluated

Risk factors for athletes w/

delayed recovery unknown

More sophisticated tools (fMRI, DTI,

MR-spectroscopy) may provide answers

fMRI; Control v Concussed, Simple task

Difference in regional activation patterns

? additional areas activated in order to solve task

Control; axial, sagittal, coronal images

Concussed; axial, sagittal, coronal images

Diffusion Tensor Imaging Cubon et al, J Neurotrauma, 2011: 28:1-13

Tract Based Spacial Statistics (TBSS) analysis: Increased Mean Diffusivity in white matter tracts in Left hemisphere including parts of inferior / superior longitudinal and fronto-occipital fasiculi, renticular part of internal capsule and posterior thalamic & acoustic radiations

Current Research NJ Brain Trauma Research Grant

Evaluating concussions prospectively

Concussed athletes participate in the

imaging component voluntarily

Control, non-contact sport athletes

followed using same timeline

Evaluated by fMRI & DTI within 96

hrs of injury, then at 2 wks and 2 mo

w/ repeat NP testing and SCAT2

28.11

26.17

28.67 27.22 27.55

26.24 26.49

23.05

SAC Balance

SAC Score (of 30) and Balance (of 30)

Control BL Control Post Conc BL Conc Post 0.91

0.94 0.96

0.75

SCAT2 Scores (as %, no errors BL = 83, no errors post inj = 100)

Control BL Control Post Conc BL Conc Post

Princeton Data 2010-2011; Validation of SCAT2 Putukian, et al, unpublished Challenges / Future Directions

Education / awareness

Equipment

Strength & Conditioning

Changing the Culture of

the game

Rule Changes

Decreasing

exposures

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Ivy League to Limit Full-Contact Football Practices By KEN BELSON

The Ivy League will announce on Wednesday that, in an effort to minimize head injuries

among its football players, it will sharply reduce the number of allowable full-contact

practices teams can hold. Yale linebacker Jesse Reising suffered a concussion against Harvard in

2010. In an effort to sharply reduce head injuries, the Ivy League will sharply reduce the number of allowable full-contact practices.

The changes, to be implemented this season, go well beyond the rules set by the N.C.A.A. and are believed to be more stringent than those of any other conference. The league will also review the rules governing

men’s and women’s hockey, lacrosse and soccer to determine if there are ways to reduce hits to the head and concussions in those sports.

Published: July 19, 2011

Greg M. Cooper/Associated Press

Unanswered Questions:

How many is too many?

Genetic, gender & other

factors (migraine, LD…)?

Neuropsychological testing?

Role of fMRI, DTI, MR Spect?

Protective factors (helmets,

mouthguards, turf...)?

Depression & suicide?

Role of omega 3’s?

Conclusions:

Concussion important injury Physical and cognitive rest

Gradual return to school/play

Individualized management

Sideline Assessment Symptoms

Cognitive Assessment

Balance Assessment

New imaging tools identify

injury, implications unclear

Thank You!!