1

Jamie Pardini, Ph.D.UPMC Concussion ProgramUniversity of Pittsburgh Medical Center

Department of Orthopaedic Surgery

UPMC Sports Concussion Program

How I Manage Concussion:

A Neuropsychologist’s Perspective

Concussion:

The

Diagnostic

and

Return to

Play

Dilemma

Pressure to Play in Sports: Can We Trust What the Athlete Tells Us?

2

Evolution of Concussion

Definition and Management

Vienna Meeting-2001

Prague Meeting-2004

Zurich Meeting-2008

1st-3rd International

Symposia

On Concussion

In Sport

Sponsored by FIFA, IOC,

IIHF

Vienna, Prague, Zurich:

Clinical/General Points of Emphasis

1. Abandonment of grading scale approach, recommend individualized

management of injury and determination of severity once symptoms

resolve.

2. When an athlete exhibits any signs/symptoms of concussion,he/she

should be removed from contest and not allowed to return to play in

that same contest (Zurich allows RTP in same game in athletes >18

years after prudent evaluation).

3. Objective tools of assessment via sideline assessment tools, balance

testing, and formal neurocognitive testing significantly contributes to

understanding of recovery from injury.

4. Role of physical and cognitive exertion important to recovery and

once symptom free, athlete should engage in stepwise progression

prior to RTP

5. RTP following concussion in sports is always a clinical decision

RETURN TO PLAY CRITERIAAccording to the Vienna Conference and CIS

guidelines, the athlete has to meet three criteria for return to play:

• Symptom Free at Rest

• Symptom Free with exertion

• Normal Neurocognitive Functioning

3

Immediate Post-Concussion

Assessment and Cognitive Testing

Computerized Neurocognitive Testing

Mark Lovell, PhD - UPMC Dept. of Orthopaedic Surgery (Program Developer)

Micky Collins, PhD - UPMC Dept. of Orthopaedic Surgery (Co-Founder)

Joseph Maroon, MD - UPMC Dept. of Neurological Surgery (Co-Founder)

ImPACT

Disclosure-Mark Lovell, PhD is co-owner of ImPACT Applications, LLC

Concussion Management ProgramsImPACT Computerized Neurocognitive Testing

NFL (All Teams Mandated)

NHL (All Teams Mandated)

MLB (All Major/Minor League Teams Mandated)

Major League Soccer (all teams)

US Ski/Snowboarding Teams

NASCAR, IRL, CHAMP Racing Leagues

USA Rugby/US Lacrosse

USA Soccer

Cirque de Soleil

Irish National Rugby

New Zealand Rugby Football Union

South African Rugby

European Professional Soccer

World Wrestling Federation

Over 2,000 high schools currently using ImPACT

Over 350 Colleges/Universities

201 concussed high

school and collegiate

athletes tested with 2

days of injury.

Abnormal performance

determined by RCI’s (van

Kampen, 2004).

Neurocognitive Testing

Increases Diagnostic

Yield to 93%

% Declined

from baseline

SYMPTOMS

NEUROPSYCH

EITHER

93

82

65

0102030

40

50

60

70

80

90

100

Value Added of Neurocognitive Evaluation

(Lovell et al, AJSM In Press).

4

On-Field and Post-Injury Concussion Management

UPMC and Pittsburgh Steelers Protocol

First

Evaluation

Follow

up

Concussion

Beyond

if

Necessary based on

Guidelines

Baseline

Testing (Not necessary

for decision

making)

Clinical Protocol: Neurocognitive Testing

What Sports?Which Athletes?

•HIGH SCHOOLS

•COLLEGE

•MIDDLE SCHOOL

•CLUB TEAMS

•AGES 10-60

5

On-field Assessment (Usually ATC)

Signs/Symptoms Evaluation

Neurologic Examination

Mental Status Testing

Orientation, Concentration, Anterograde / Retrograde Amnesia

Serial Evaluation Necessary

Possible Exertional Testing

Any Positive Findings Preclude Return to Play

UPMC Return to Play Protocol

Stage ONE Sideline Testing

1. ImPACT AssessmentEvaluation should occur in first few days after concussion

Clinical Interview, ImPACT

Referral (as needed) to other specialists

Recommendations Regarding Cognitive and Physical Activity

School Attendance

Gym Class Attendance

Academic Accommodations

Athletic Participation

2. Future Evaluations As Recommended

3. Return to Baseline (or estimated preinjury status)Symptom data AND Cognitive data

4. Progress through Exertion/Practice

5. Return to Competition

UPMC Return to Play Protocol

Stage TWO Follow Up Evaluation

Somatic Symptoms• Visual Problems

• Dizziness

• Balance Difficulties

• Headaches

• Light Sensitivity

• Nausea

Emotionality• More emotional

• Sadness

• Nervousness

• Irritability

Sleep Disturbance • Difficulty falling asleep

• Sleeping less than usual

Factor Analysis, Post-Concussion Symptom Scale (Lovell, Pardini et al. 2004)

N=327, High School and University Athletes Within 7 Days of Concussion

Cognitive Symptoms• Attention Problems

• Memory dysfunction

• “Fogginess”

• Fatigue

• Cognitive slowing

6

Managing Kids• Need a Dedicated, Educated Team

• Coaches

• Athletic Trainers

• School Nurses

• Teachers

• Guidance Counselors

• Neuropsychologists

• Physicians

• Parents

• Athletes

• School Administrators

RETURN TO PLAY CRITERIAAccording to the Vienna Conference and CIS

guidelines, the athlete has to meet three criteria for return to play:

• Symptom Free at Rest

• Symptom Free with exertion

• Normal Neurocognitive Functioning

7

The Role of the

Neuropsychologist:

Neuro

ATCPCP

PM&R

PT

Parent

School

Vestibular

Tx

Coach

Cog

Rehab

Academic

Accommodations

• Recommendations made based on

symptoms and pattern of test performances

• Acutely, accommodations are usually more restrictive

• Attendance recommendations

• Cognitive load

• Proper accommodations should allow student to continue learning “core” information, while controlling symptoms and maintaining grades.

• Balancing restrictions and involvement… PE class, watching practice, extra-curricular activities, social activities

• “Healthy” appearance of student is usually a difficulty, not advantage, in terms of self- and other-expectations

Sports-Concussion Rehabilitation

• Exertion Based

• Physical Therapy (Stages 1-3)

• Sports Performance (Stages 4-5)

• Specialized/Individualized

• Vestibular Evaluation/PT

• Medication management

• Monitoring recovery thru

Computerized Neurocognitive

Testing

8

UPMC Concussion Program

Treatment/Rehabilitation Protocol

NOTE:*Off-label use

Emotionality

SSRIs

Escitalopram (Lexapro)

Sertraline (Zoloft)

Therapy

Sleep Disturbance

Melatonin

Trazodone

Cognitive Symptoms

Neurostimulants

Amantadine*

Methylphenidate*

Atomoxetine (Strattera)*

Somatic Symptoms

Headaches Prophylaxis

Propranolol*

Verapamil*

Amitriptyline*

Escitalopram (Lexapro)

Sertraline (Zoloft)

Vestibular Therapy

Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003

Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32:47-54,2004

It was just a “ding;” I don’t feel so

bad: Why do I have to go through

this program?

ImPACT Memory Composite ScoresBrief versus Prolonged On-field Mental Status Changes

60

65

70

75

80

85

90

Baseline 36 Hours DAY 4 DAY 7

5-15 min < 5 min

ImPACT Memory-Percent Correct

N = 64

High

School

Athletes

P<.02 P<.004

P<.04

Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003

Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32;47-54,2004

9

ImPACT Symptom Scale ScoresBrief versus Prolonged On-field Mental Status Changes

0

5

10

15

20

25

30

35

40

Baseline 36 hours DAY 4 DAY 7

5-15 min < 5 min

N = 64

High School

Athletes

P<.003

P<.061

NS

Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003

Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32;47-54, 2004

NS

Recovery from Concussion

in Athletes:

How Long Does it Take?

Collins, Lovell, Iverson, Ide, Maroon et al, Neurosurgery, In Press

10

Recovery From Concussion:

How long does it take?

0

10

20

30

40

50

60

70

80

90

100

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+

All Athletes No Previous Concussions 1 or More Previous Concussions

N=134 High School athletes

WEEK 1

WEEK 2

WEEK 3

WEEK 4

WEEK 5

Collins et al., 2006, Neurosurgery

Age

History of prior concussion

History of headache

Pre-existing psychiatric condition

History of learning disability

Genetics?

Factors That Affect Recovery

Thank YouJamie Pardini Ph.D. 412-432-3681

pardinij@upmc.edu