Transcript CONCUSSION UPDATE ZURICH 2008

CONCUSSION
MANAGEMENT:
ImPACT
David R. Wiercisiewski, MD
Director, Carolina Sports Concussion
Program at CNSA
STATISTICS
Incidence in HS football = 6%-8% per year.
Boy’s + Girl’s soccer = football.
Girl’s basketball 250% greater risk than Boy’s
Sports and recreational injuries with LOC =
300,000 per year.
Sports and recreational injuries with and without
LOC = 1.6 million per year.
DEFINITION
Complex pathophysiologic
process affecting the
brain, induced by
traumatic biomechanical
forces.
COMMON FEATURES
Caused by a direct or indirect blow to the head,
face or neck.
Results in rapid onset of short-lived
impairment of neurological function.
A concussion may or may not involve LOC.
The clinical symptoms reflect a functional
rather than a structural disturbance.
PATHOPHYSIOLOGY
Mechanism of Injury
Rotational
Linear
Impact deceleration
Chemical/Vascular
1st 7-10 days
↑K / ↑Ca / ↑glc / ↑glut
↓CBF
“Period of vulnerability”
CONCUSSION
CLASSIFICATION
Recommendation to abandon the “simple”
versus “complex” nomenclature with no
endorsement of any other specific
classification system.
PRIMARY AREAS OF FOCUS
Rule out more serious intracranial pathology
Prevent Second Impact Syndrome
Prevent repeat injury during post-concussion
period of “vulnerability”.
Prevent against cumulative effects of injury
Neurobehavioral deficits
Lowered threshold to injury
GENERAL
MANAGEMENT
Majority of injuries will recover spontaneously.
Physical and cognitive rest are required while
symptomatic.
When symptom free and improved “functionally”
graduated return to play protocol should be utilized.
Same day return to play—NEVER!!!
CONCUSSION
EVALUATION
PLAN—PLAN—PLAN
Agree on an approach to the management of
concussions with other health care providers on the
team.
Baseline cognitive testing if available.
Use a standardized PCS symptom scale
(i.e. SCAT2)
Perform serial assessments
Identify your referral patterns ahead of time
CONCUSSION
RECOGNITION
Symptoms—somatic (headache), cognitive
(feeling like in a fog) and emotional (lability).
Physical signs—LOC and amnesia.
Behavioral changes—irritability.
Cognitive impairment—slowed reaction times.
Sleep disturbance—drowsiness.
EVALUATION
Neurological assessment
Motor
Pupillary response
Coordination/postural control
Mental status testing
Attention
Memory
Processing speed
MENTAL STATUS TESTING
Be familiar with the different screening tools
and their requirements.
Use tools that have been validated and
published in peer-reviewed literature.
Results should be interpreted and integrated
into the other relevant clinical information.
NEUROCOGNITIVE
COMPUTERIZED TESTING
ImPACT (UPMC)
CogSport (Australia)
CRI (Headminder)
ANAM (NRH)
COMPUTERIZED TESTING
Format allows portability and efficiency.
Each vendor has their unique menu of
cognitive domains that their product measures.
20 – 30 minutes to administer.
Used as a “tool” to measure recovery and not
to make a diagnosis or solely direct
management.
FEATURES OF
COGNITIVE TESTING
Limitations:
Must assess pertinent
domains.
Baseline testing
improves evaluation.
“Normal” range
Sensitivity
Specificity
Learning effects
Early return to baseline
while still symptomatic
Without baseline testing it
can be more difficult to
interpret
CAROLINA SPORTS
CONCUSSION PROGRAM
First sports concussion program in the greater Charlotte area.
Began in February 2007.
First year provided post-injury care only.
Subsequent years we have provided free baseline tests to
middle and high school athletes participating in “high risk”
sports through monies donated by SunTrust Bank.
Baseline testing program currently offered in 5 counties.
Utilize the ImPACT neurocognitive testing tool.
IMMEDIATE POSTCONCUSSION ASSESSMENT and
COGNITIVE TESTING (ImPACT)
8 separate tests
Word memory
Design memory
X’s and O’s
Symbol Match
Color Match
Three Letters
Interference tests
6 composite scores
Verbal memory
Visual memory
Visual motor speed
Reaction time
Impulsivity
Total symptom score
CONCUSSION SYMPTOM SCALE
Standardized survey
with 0-6 scale rating
Developed by Lovell
and Collins in 1998
Sensitive tool to
measure recovery
Symptoms generally
classified into 3 main
categories: Physical,
Cognitive, and
Emotional/Behavioral
OVERVIEW OF ImPACT
Proven in measures of reliability and validity
Provides useful concussion screening and
management information
Validated with multiple peer-reviewed studies
Does not substitute for medical evaluation and
treatment
Does not substitute for comprehensive
neuropsychological testing
PREDICTING RECOVERY
TIMELINES
ALL ATHLETES ARE NOT
CREATED EQUALLY
CONCUSSION
MODIFIERS
Symptoms—Number, duration (>10 days) and
severity.
Signs—Prolonged LOC (>1 min.), amnesia.
Sequelae—Concussive convulsions.
Temporal—Frequency (number of
concussions),
Timing/”recency”
CONCUSSION
MODIFIERS
Threshold—Repeated concussions occurring with
less force or slower recovery.
Age—Child and adolescent < 18 years old.
Co-morbidities—Migraine, depression or other
mental health disorders, ADHD, learning
disabilities and sleep disorders.
Medication—Psychoactive drugs and
anticoagulants.
Behavior—Style of play.
Sport—Contact or collision sport, high-risk.
SPECIAL
POPULATIONS
CHILD AND ADOLESCENT
ATHLETES
Clinical evaluation should include academic
performance and behavior in school.
Neurocognitive testing may be performed earlier to
aid in academic accommodations during recovery.
Return to exertion or game play should be slower
when compared to the adult athlete. Also there
should be particular focus on “cognitive rest”.
Never return to play on same day!
ELITE vs. NON-ELITE
ATHLETES
Both groups should
follow the same
treatment and return to
play paradigm
Neurocognitive testing
is preferred but
providing for non-elite
athletes may be
restricted by financial
resources
CASE STUDIES
RETURN TO PLAY
PROTOCOL
No activity while symptomatic.
Light aerobic exercise.
Sport-specific exercise—no head impact drills.
Non-contact training drills.
Full contact practice.
Return to game play.
NFL CONCUSSION
GUIDELINES
Established in 2009.
No same day return to
practice or game play.
Players encouraged to
be honest and report
symptoms.
Independent neurology
opinion for each injury.
CHRONIC TRAUMATIC
ENCEPHALOPATHY
CHRONIC TRAUMATIC
ENCEPHALOPTHY
NFL Survey—
> 50 = 5x risk
30-49 = 19x risk
Comparative data from
the Framingham heart
study.
Concept of
subconcussive trauma.
Sports Legacy Institute.
CTE
TAU PROTEIN
Protein that invades
cortical nerve cells and
shuts them down
effectively killing them.
Unlike Alzheimer’s
disease and the
neurofibrillary tangles
associated with that
disease, the build up of
tau is related to trauma
or injury.
DISQUALIFICATION
LONG TERM
3 fold risk to have
concussion if have 3
concussions in previous
7 years
2 or more concussions
have longer recovery
times
3 or more concussions:
8 fold risk of LOC
5.5 fold risk of PTA
5.1 risk of confusion
INJURY PREVENTION
Protective Equipment—Mouthguards and
helmets.
Rule changes.
Risk Compensation—use of protective
equipment results in a behavioral change and
may subsequently result in a paradoxical
increase in injury rates.
Aggression versus violence in sports.
FUTURE DIRECTIONS
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Gender effects on injury, severity and outcome.
Pediatric injury and management paradigms.
Validation of SCAT2 as a sideline assessment tool.
Concussion surveillance using consistent definitions
and outcome measures.
Long-term outcomes.
Formal review of “concussion in sport” guidelines
and update prior to December 1, 2012 by panel of
international experts.
PROTECTING THE “3 LB. UNIVERSE”
OBSERVATIONS FROM CLINIC
Moving the mountain.
Improved awareness and increase in concussion recognition.
Gap in club sports.
Dealing with the devil.
The sickness of our sports culture.
Creating a road map.
Defining expectations of recovery based on the individual’s unique
medical history and mechanism of injury.
Kids are real people too!
Emotional response to the injury.
My “uneasy” chair.
How many is too many?
THANK YOU