Transcript Evidence Based Medicine - Brain Injury Alliance of Oregon

Oregon Concussion Awareness
and Management Program:
Making an Impact
Michael C. Koester, MD, ATC, FAAP
6th Annual Pacific Northwest Conference on Brain Injury
February 29th, 2008
Slocum Center for Orthopedics and Sports Medicine
Director, Sports Concussion Program
Eugene, Oregon
The Problem

We now realize that
concussions occur
more often than
previously thought
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Young athletes are at
risk for serious shortterm and long-term
problems
The Problem

There is much variation
in the knowledge of
Health Care Providers
managing concussed
athletes

New and emerging
technologies and
research will lead to a
continuing evolution of
care
The Opportunity



Bill Bowers, Executive Director of the OADA, met
with me last fall and expressed interest in
developing a statewide concussion program similar
to a program implemented in New York state last
year.
I have envisioned a “dream program” for the past
several years, but needed “buy-in” from the involved
parties.
We have willing participants, OSAA & OADA
backing, and multiple media stories trumpeting the
problem--- the time is now!!!!
Extent of the Problem


Like all problems in
sports- what is seen at
the pro level is only a
small part of the
problem
Much more common in
high school than any
other level- due to large
number of participants
Extent of the Problem
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Estimated 300,000
sports-related head
injuries in high school
athletes yearly
9% of all sports injuries
678 head-injuries in
Oregon HS athletes in
2004-5 based on OSAA
participation stats
The Goal

State-wide concussion
management program
involving all high schools
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Establish state-wide
physician network
Uniform evaluation and
management protocol
Consultation service for
coaches, athletes, parents,
and physicians
ImPACT neuropsychologic
testing available for all
contact and collision sport
athletes
How do we achieve our goals?

What happens when
coaches and other
members of the Sports
Medicine Team work
together to promote
safety and injury
prevention?
Episodes of Permanent Paralysis in Football
1976 – implementation of NCAA/High School rule changes and using
coaching techniques eliminating the head as a battering ram
Episodes of Permanent Paralysis in Football
1987-1989 – gradual increase in permanent quadriplegia
Episodes of Permanent Paralysis in Football
1991 – distribution of video “Prevent Paralysis: Don’t Hit with your
Head” and release of educational poster “Play Heads-Up Football”
The Plan
Three Tiers of
Education

Medical Professionals
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Physicians
Nurse
Practioners/Physician
Assitants
Athletic Trainers
Chiropractors
Paramedics/EMT’s
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Educators

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Athletic Directors
Coaches
Principals/Administrators
Counselors
Community
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Parents/Athletes
School Boards
The Plan
Identify Regional Leaders

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Portland- Jim Chessnutt, MD
Eugene- M. Koester, MD, ATC
Bend- Mark Belza, MD
Each regional leader
will “oversee” programs
at the “satellite” sites


Phone/e-mail
consultation
Office evaluation if
desired
Regional Presentations

Teams will carry out
presentations throughout
the state in late Spring
and early Fall 2008

Portland
 Hillsboro
 Gresham
 Wilsonville
 Astoria
 The Dalles
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Eugene
 Corvallis
 Salem
 Roseburg
 Medford
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Bend
 Ontario
 La Grande
 John Day
 Hermiston
 Klamath Falls
Multimedia Campaign
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Presentations at each site
PowerPoint available to
anyone who asks
Brochures
Webcasts of presentations
Podcasts available
Local and regional
television, radio, and
newspaper
Website- Link through
OSAA or our own site
Neuropsychologic Testing
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Immediate Post-Concussion Assessment and Cognitive
Testing
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Used extensively in professional, collegiate, and high
school athletes
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Computerized Neurocognitive Testing
Available on-line- yearly cost of $350-450 per school on average
Vast majority of NFL and NHL teams
Has received significant media attention
Athletes receive “baseline” testing prior to the start of the
sports season

Should be done at least every other year
What can we accomplish?

The opportunity
presents itself for us to
establish a program
which can:
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Maximize the health and
safety of our athletes
Minimize worry and
liability for our coaches
and administrators
Provide a model for other
western states to
emulate
What is a Concussion?

A concussion is a mild
traumatic brain injury
that interferes with
normal function of the
brain

Evolving knowledge“dings” and “bell
ringers” are brain
injuries
What happens to the brain?

A complex physiological process induced by
traumatic biomechanical forces:
 sudden chemical changes- neurotransmitters
and glucose utilization disrupted
 stretching and tearing of brain cells
 Structural brain imaging (CT or MRI) is almost
always normal
 Still many unanswered questions . . .
Increasing Exposure of the Problem
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High profile athletes with
severe or career ending
injuries
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Steve Young
Troy Aikman
Merrill Hodge
Trent Green
ESPN and Sports Illustrated
frequently cover the issuenot always very well
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Highlights of hits
Features in print and
television
Not Just a Football Problem
Injury rate per 100,000
player games in high school
athletes
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Football
Girls soccer
Boys soccer
Girls basketball
Boys basketball
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JAT
47
36
22
21
7
Potential Complications
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15% of all head-injured
athletes suffer longterm complications
Increased risk for future
and more serious
concussions
Learning Disorders
unmasked
Second Impact
Syndrome?
Concussion and “same-day” RTP

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Long held that RTP
after 15 minutes if
“symptom free” is
acceptable standard
(Grade 1 concussion)
43 HS athletes with
Grade 1 concussion
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32 with symptoms at 36
hours
36 with abnormal
ImPACT at 36 hours

AJSM, 2004
Risk for further concussion
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Everyone asks….
Prospective cohort of
2905 FB players at 25
colleges
184 with concussion, 12
with repeat in same
season
Hx of 3 or more
concussions: 3X more
likely to have concussion
Risk for further concussion
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These had slower
recovery:
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30% with hx had
symptoms > 1 week
14.6% without hx had
symptoms > 1 week
11/12 of the repeat
concussions occurred
within 10 days of first

JAMA, 2003
Neuropsychological Testing
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ImPACT, Cogsport,
Headminder
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Traditional “pen and
paper” battery
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Great deal of
controversy due to
aggressive marketing
and no “gold standard”
Neuropsychological Testing
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Assesses 6 domains of
brain function:
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Attention span
Working memory
Sustained and selective attention
time
Response variability
Non-verbal Problem Solving
Reaction time
Not a perfect tool and not to
be used in the absence of an
experienced and
knowledgeable physician.
Neuropsychological Testing
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Computerized tests
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Can be administered to a group or at home
Can be repeated multiple times
Ideally, baseline testing is done before the
season starts
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Test is repeated after concussion and results are
compared to baseline
Can compare to “population norms” if no baseline
ImPACT
for Sports Concussion
Management
Concussion
The
Diagnostic
and
Return to
Play
Dilemma
What ImPACT Is and Isn’t:
IS a useful concussion screening and
management program
IS validated with multiple published
studies
IS NOT a substitute for medical evaluation
and treatment
IS NOT a substitute for comprehensive
neuropsychological testing when needed
ImPACT:
Post-Concussion Evaluation
Demographics
Concussion History Questionnaire
Concussion Symptom Scale
Neurocognitive Measures
 Memory, Working Memory, Attention,
 Reaction Time, Mental Speed
Detailed Clinical Report
 Automatically Computer Scored
Clinical Protocol: Neurocognitive Testing
24-72
Hours
Beyond if
necessary
Baseline
Testing
Not necessary for
decision making
Day
5-10
Concussion
Unique Contribution of Neurocognitive Testing to
Concussion Management
Symptomatic
Testing reveals
cognitive deficits
in asymptomatic
athletes within 4
days postconcussion
N=215
(Lovell et al., 2004)
100
95
90
85
80
75
70
65
60
55
50
Asymptomatic
Verbal
Memory
Visual
Memory
Control
ImPACT ‘Bell-Ringer’ Study
Brief versus Prolonged On-field Mental Status Changes
5-15 min
< 5 min
90
P<.04
85
N = 64
High School
Athletes
P<.02
P<.004
80
75
70
65
60
Baseline
36 Hours
DAY 4
DAY 7
ImPACT Memory-Percent Correct
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
Recovery From Concussion:
How Long Does it Take on ImPACT?
100
90
80
70
60
50
40
30
20
10
0
WEEK 5
WEEK 4
WEEK 1
WEEK 3
WEEK 2
1
3
5
All Athletes
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+
No Previous Concussions
N=134 High School athletes
1 or More Previous Concussions
Collins et al., 2006, Neurosurgery
Neuropsych testing and RTP decisions
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Do I have to use this?
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Not yet standard of care
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Recommended to be used
by current guidelinesPrague, 2004
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Provides extra data
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Think of it like any lab test,
MRI, etc
ImPACT and RTP decisions
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How well does ImPACT
identify concussed
athletes?
Sensitivity
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Identified 80% within 24
hours
68% identified by selfreport of symptoms
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J Neurosurg, 2007
ImPACT and RTP decisions
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“Value-added” effect in
122 concussed HS and
college athletes
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83% abnormal ImPACT
64% with symptoms
93% with combo of both
No one in control group
had abnormal ImPACT
and symptoms
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AJSM, 2006
ImPACT and RTP decisions
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When to use ImPACT?
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Recommended to be used
24-72 hours post-injury, 510 days post injury and
beyond if needed.
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No need to test if athlete is
still symptomatic
 May need to use to show
coaches, parents, etcBE CAREFULL!!
Prague Guidelines, 2004
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What’s a Grade 1
concussion?
Notion of grading systems
has been abandoned
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Simple versus Complex
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Over 20 classifications
Can only be applied
retrospectively
Complex-persistent
symptoms, specific
sequelae, prolonged LOC,
multiple concussions
Graded Return to Activity
Prague Guidelines, 2004
 Simple concussion
 LOC < 1 minute
 resolves in 7-10 days
 first concussion
 Complex concussion
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No athlete
returns in the
current game
or practice
(same day)
LOC > 1 minute
symptoms last longer than 7 – 10 days
history of multiple concussions
increasing “concussability”
Return to Activity Protocol
7 Steps to a Safe Return
Step 1. Complete cognitive
rest. This may include
staying home from school
or limited school hours for
several days. Activities
requiring concentration and
attention may worsen
symptoms and delay
recovery.
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Step 2. Return to school
full-time.
Return to Activity Protocol
7 Steps to a Safe Return (cont)
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Step 3. Light exercise. This
step cannot begin until you
are cleared by your
physician for further activity.
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Step 4. Running in the gym
or on the field. No helmet or
other equipment.
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Step 5. Non-contact training
drills in full equipment.
Weight-training can begin.
Return to Activity Protocol
7 Steps to a Safe Return (cont)
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Step 6. Full contact practice
or training.
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Step 7. Game play. Must be
cleared by your physician
before returning to play.
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Cannot advance to next
level if symptomatic
Progression usually takes
about 1 week
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Return to Activity
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Recommend written and
standardized Return to
Activity Plan for all
concussed athletes
Sets standard and is
understood by all
coaches, parents and
athletes
Cannot advance to next
level if symptomatic
Education
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No such thing as “just a concussion”
Coaches, athletes, AD’s, and parents must
be educated on signs and symptoms, as well
as need for proper management
CDC Tool Kit on Concussion for High School
Coaches
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http://www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm
Prevention
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“Concussion prevention” has become the “holy grail” for
sports equipment marketers
“Special” helmets, soccer head pads, mouth guards- NO
PROVEN PROTECTION FROM CONCUSSION!!
Multiple flaws in recent study looking at “newer helmet
technology.”

Neurosurgery, 2006
Conclusions
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Concussion management continues to evolve.
Health care providers must be knowledgeable of the
most up to date management recommendations.
Neuropsychological testing plays an important role
in concussion management- but cannot stand alone.
Schools should have evaluation and RTP policies
and procedures in place to ensure excellent and
consistent care.
THANK YOU!!!!!!
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Thad Stanford, MD, JD- Salem
Bill Bowers- Executive Director, OADA
Tom Welter- Executive Director, OSAA
Mark Belza, MD- Bend
Mickey Collins, PhD- Pittsburgh
Ron Savage, EdD- New Jersey
Brian Rieger, PhD- New York
Ann Glang, PhD- Eugene