CATASTROPHIC BRAIN INJURIES NEW National Athletic Trainers' Association Position Statement

Hector Mejia, M.D. Orthopedic Surgery

Tallahassee Orthopedic Clinic

OVERVIEW CONCUSSIONS

– DEFINITION – PATHOPHYSIOLOGY – SIGNS AND SYMPTOMS – MANAGEMENT – NEUROCOGNITIVE TESTING

OFFICIAL RECOMMENDATIONS

NO DISCLOSURES

Special Thanks to: University of Pittsburgh Sports

Medicine Center Dr. Micky Collins and his fellow

Scott Burkhart for providing slides and helping with this presentation

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Sports Concussions in the News

“Death of Junior Seau once again puts concussions at forefront of controversy”

- “Conservative” approach to management of concussion - Out of play for game/practice with any LOC, amnesia, or confusion - Out of play for game/practice if new and persistent dizziness, headache (particularly if

accompanied by photo/phonophobia, dizziness, nausea, or vomiting) or any other persistent symptoms of concussion

- Follow up evaluation to be conducted by team physician as well as independent “neurological consultant ”

- Clearance for RTP required by both

- Baseline and post-injury neurocognitive testing mandated by league

- No return to play until athlete exhibits normal neurological evaluation and is… 1) asymptomatic at rest

2) asymptomatic with progressive exertion, and 3) neurocognitive test scores back to baseline (within RCI indices on ImPACT)

- Institutions must have concussion plan on file

- Any athlete exhibiting signs/symptoms of concussion shall be removed from practice/game and evaluated by healthcare practitioner with training in management of concussion-no RTP until formal clearance

- Neuropsychological testing is an important component of an institutional concussion management plan.

- “Best Practices” should include a baseline/post injury assessment using, at minimum, sideline tool (e.g. symptom checklist, SAC, SCAT, BESS), and, optimally, formal computerized or paper and pencil neurocognitive testing

FHSAA Concussion Action Plan

Return To Play (RTP) Criteria: Suggested Concussion Management – No athlete should return to play (RTP) or practice on the

same day of a concussion. “When in doubt, sit them out!” – Any athlete suspected of having a concussion must be

evaluated by an appropriate health-care professional (as defined above) as soon as possible and practical.

– Any athlete who has sustained a concussion must be medically cleared by an appropriate health-care professional (as defined above) prior to resuming participation in any practice or competition.

– After medical clearance, return to play should follow a step-wise protocol with provisions for delayed return to participation based upon the return of any signs or symptoms.

LITERATURE

Marar, M. et al, AJSM 2012 – Reported epidemiology in 20 Highschool sports – Estimated 300,000 sports related concussion/yr – Concussions represented 13.2% of all reported

injuries – Total of 1936 concussions – 2.0% of the reported concussion (≈38 athletes)

returned to play the same day

VALID | RELIABLE | SAFE

CONCUSSION 101: DEFINITION PATHOPHYSIOLOGY

J

DEFINITION A concussion is a

disturbance in brain function that occurs following either a blow to the head or as a result of the violent shaking of the head.

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Neurometabolic Cascade Following Cerebral Concussion/MTBI

2 6 12 20 30 6 24 3 6 10 minutes hours days

500

400

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% o

f nor

mal

K+

Glutamate

Glucose

Cerebral Blood Flow

Calcium

UCLA Brain Injury Research Center

(Giza & Hovda, 2001)

PREVENTION

Education for athletes, coaches, and parents Enforcing the standard use of sport-specific

and certified equipment Use of comprehensive, objective baseline,

and postinjury assesment measures Administration of home care and referal

instructions

PREVENTION

Use of graduated return to play progressions Clear records of the evaluation and

management Proper preparedness for on-field management

RECOGNITION

Use of objective concussion measures during preseason and postinjury

Neuropsychological testing is only one component of the evaluation

The inclusion of objective measures of cognitive function and balance prevent premature clearance of an athlete

Rule out more serious intracranial pathology • CT, MRI, neurologic examination primary diagnostic tests

Prevent against Second Impact Syndrome Prevent presence of Post-Concussion Syndrome

Concussion Management: Areas of Focus

TREATMENT Once a concussion is identified, a

comprehensive medical management plan should be implemented

Sideline head injury management is paramount if a more serious condition is identified

Immediate referal to medical facility If sending home, an oral and written

instructions for home care given

Second Impact Syndrome (SIS) Occurs when an athlete suffers a head injury and

returns to play too soon If the second head injury occurs while the individual

still has symptoms from the first impact, the result can be a catastrophic increase in pressure within the brain.

Effects of SIS include physical paralysis, mental disabilities, and epilepsy.

Death can occur approximately 50% of the time. 6-8 high school players die each year.

Second Impact Syndrome (SIS)

Highschool athletes are the most vulnerable because their brains are still developing.

Recovery severely longer in H.S. compared to college

Athletes will play through concussions – Peer Pressure

Post-Concussion Syndrome Chronic Headache (Migraine type) Photo/Phonosensitivity, Nausea Chronic Fatigue Vestibular Deficits Mood Issues-Depression/Anxiety Sleep Deficits Cognitive Deficits (potentially severe) Academic Difficulties

CONCUSSION MANAGEMENT

Management is symptom driven Neurocognitive testing is only a tool to

help in the evaluation/management IT IS NOT A STAND ALONE

TEST FOR CLEARANCE

Commonly Reported Symptoms

- within 3 days of injury

Lovell, Collins et al., 2004; N = 215

SYMPTOM PERCENT # 1 Headache 71 %

# 2 Feeling slowed down 58 % # 3 Difficulty concentrating 57 % # 4 Dizziness 55 % # 5 Fogginess 53 % # 6 Fatigue 50 % # 7 Visual Blurring/double vision 49 % # 8 Light sensitivity 47 % # 9 Memory dysfunction 43 %

# 10 Balance problems 43 %

Symptom Evaluation/Clinical Interview: What is Asymptomatic?

IS NOT “How are you feeling?” or “Do You Have a Headache?”

IS a series of questions inquiring about subtleties of injury

“Do you have a pressure in your head that increases as day progresses?” “Are you more sensitive to lights and noises than normal?” “Do you become dizzy when looking up/down, turning head, standing quickly?” “Do you feel more fatigued than normal at the end of the day?” “Do you have blurred or fuzzy vision while reading or difficulty reading?” “Do you feel more distractible in school than normal?” “Do you feel a sense of fogginess during the day?” “Do you have difficulty falling/staying asleep?” “Have you or your parents noticed that you are more irritable than normal?”

Brief History

Initial concussion management based on “Guidelines” Cantu, AAN, etc.

Evolution of individually based management

Neuropsychological testing the “cornerstone”

Vienna, Prague, Zurich

Widespread adoption of NP testing throughout sports

Dramatic increase in research

Cogsport Headminders (CRI) ANAM CNS Vital Signs

ImPACT (Immediate Post-Concussion

Assessment and Cognitive Testing)

Computer-Based NeurocognitiveTesting

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The Pittsburgh Steelers Program

FIRST PROGRAM TO MONITOR PROFESSIONAL ATHLETES RESULTED IN LEAGUE WIDE PROGRAM IN NFL RESULTED IN ADOPTION BY OTHER SPORTS/LEAGUES RESULTED IN THE DEVELOPMENT OF IMPACT

Immediate Post Concussion Assessment and Cognitive Testing Most NFL teams, SEC and ACC colleges

1994-1996 Test Development 1996-1997 Field Testing (multiple sites) 1998-2000 NCAA/NAN Studies 2000 UPMC Program Established 2001-2006 NIH fMRI Study ($2.8 Million) 2003-2007 CDC Child Study ($2.0 Million) 2000-2005 Reliability/validity data published 1999-2005 32 Peer Reviewed Manuscripts

28 Published Abstracts 3 Textbooks/32 Chapters

DEVELOPMENT OF ImPACT A Tradition of Research

ImPACT: Design and Structure

Pre and post-concussion assessment and cognitive testing 20 minute standardized testing tool Administered by ATC, school

nurse, AD, team physician or neuropsychologist

• Designed to evaluate multiple aspects of cognitive functioning in brief time period • Subtests measures multiple cognitive processes

- Verbal and Visual Memory - Cognitive Speed - Interaction of Memory and Speed (Cognitive

Efficiency)© - Self-report of symptoms

ImPACT: Design and Structure

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Return to Play

Baseline Testing

Concussion

First Follow-Up

Follow-up Testing

as needed

At School

Or clinic

Remove From Play

Evaluation

Pre-season

1-3 Days

• Symptom-Free at Rest • Symptom-Free with

Cognitive/Physical Exertion • Normal Neurocognitive

Data/Objective Evaluation

Criteria for Return to Play

Return to Play Graduated RTP progression May progress to next step if asymptomatic No more than 2 steps on same the day May advance to step 5 if asymptomatic

24hrs after step 4 If symptomatic at any point, must be 24 hrs

symptom-free before allowed to return to step 1

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5 Stage Post-Concussion Exertion Program

Stage Activity Stage 1 Target Heart Rate : 30-40% of maximum exertion Recommendations: 10-15 minutes of cardio exercise; low stimulus environment; no impact activities; balance and vestibular treatment (prn); limit head movement/ position change; limit concentration activities

- Very light aerobic conditioning - Sub-max strengthening - ROM/ Stretching - Very low level balance activities

Stage 2 Target Heart Rate : 40-60% of maximum exertion Recommendations: 20-30 minutes of cardio exercise; exercise in gym areas; use various exercise equipment; allow some positional changes and head movement; low level concentration activities

- Moderate aerobic conditioning - Light weight strength exercise - Stretching (active stretching initiated) - Low level balance activities

Stage 3 Target Heart Rate: 60-80% of maximum exertion Recommendations: any environment ok for exercise (indoor, outdoor); integrate strength, conditioning, and balance / proprioceptive exercise; incorporate concentration challenges

- Moderately aggressive aerobic exercise - All forms of strength exercise (80% max) - Active stretching exercise - Impact activities running, plyometrics (no contact) - Challenging proprio-balance activities

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Stage Activity Stage 4 (Sports Performance Training) Target Heart Rate: 80-90% of maximum exertion Recommendations: continue to avoid contact activity, resume aggressive training in all environments

- Non-contact physical training - Aggressive strength exercise - Impact activities/ plyometrics - Sports specific training activities

Stage 5 (Sports Performance Training) Target Heart Rate: Full exertion Recommendations: Initiate contact activities as appropriate to sport activity; full exertion for sport

- Resume full physical training activities with contact - Continue aggressive strength/ conditioning exercise - Sport specific activities

5 Stage Post-Concussion Exertion Program

Concussion Management Policy Outlining the roles/responsibilities of each member of the

sports medicine team AT documentation:

– Mechanism of injury – Initial signs and symptoms – State of consciousness – Findings of all testing – Instructions given athlete and family – Recommendations of physicians – Details of RTP progression – Any relevant patient PMHx

VA L I D | R E L I A B L E | S A F E

•Does test add any value to the evaluation and management of concussions? •Is it reliable? •Accurate?

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201 concussed high school and collegiate athletes tested with 2 days of injury.

Neurocognitive Testing Increases Diagnostic Yield to 93%

SYMPTOMS

NEUROPSYCH

EITHER

0102030405060708090

100

% Declined frombaseline

65 84

93

Added Value of Neurocognitive Evaluation

(Van Kampen, Lovell, Collins et al, AJSM 2006).

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50556065707580859095

100

VerbalMemory

VisualMemory

Symptomatic Asymptomatic Control

Testing reveals cognitive deficits in asymptomatic athletes within 4 days post-concussion

N=215, MANOVA p<.000000

Unique Contributions of Neurocognitive Assessment to Concussion Management

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Processing Speed

Symptomatic Aysmptomatic Control

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Reaction Time

Symptomatic Asymptomatic Control

MANOVA p<.000000 (ImPACT Test Battery)

Unique Contribution of Neurocognitive Testing to Concussion Management

VA L I D | R E L I A B L E | S A F E

Test Reliability

• Compared ImPACT results for 58 non-concussed • Collegiate football players at preseason, midseason and post season. • All athletes engaged in contact practices/games • Found no statistical differences in test performance across the three evaluations • “ImPACT test scores are not significantly altered by a season of repetitive contact in uninjured collegiate football athletes” • “Impairment of ImPACT scores in concert with clinical symptoms/findings should be interpreted as evidence of a post- concussive event”

Comparison of Preseason, Midseason and Post-Season Neurocognitive Scores in Uninjured Collegiate Football Players

Miller, Adamson, Pink, Sweet, AJSM, 2007

VA L I D | R E L I A B L E | S A F E

ACCURATE?

Positive Predictive Value (90%) (Probability that a concussion is present when test is positive) Negative Predictive Value (82%) (Probability that a concussion is not present when test is negative)

ACCURATE?

Schatz P, Pardini J, Lovell MR, Collins MW. Sensitivity and specificity of the ImPACT test battery in athletes’ concussion status. Archives of Clinical Neuropsychology 2005:21;91-99. Winner, Nelson Butters Award:, Outstanding paper, National Academy of Neuropsychology, 2007.

THE FUTURE

Mouth Guards

Head Impact Telemetry System

Designed for use in both sport and military helmets. As soon as the helmet is hit, sensors record information about the blow and transmit the data to a remote computer terminal. This data will help scientists understand how varying forces contribute to TBI.

The Indicator by Battle Sports Science Microchip embedded in chin strap will measure amount of force sustained in helmet blow. Will indicate if force is above or below usual threshold for concussion. Available Fall of 2011 Cost $40-$50 per helmet.

Discovery Education 3M Young Scientist Challenge 2011 Winner Developed a low cost ampule attached to football helmets that breaks when impact significant enough for concussion.

DETECT (Display Enhanced Testing for Concussion and mild TBI)

Intended for use on the field. The visor blocks out distractions while the user performs a series of digital neuropsychological tests.

Eye Tracking Test

Developed for combat settings. A high resolution camera records the wearer’s eye movements as she tracks a moving red dot. Healthy patients follow the circular motion without problem, but brain trauma victims falter. In development but may be able to provide a critical diagnosis in under a minute.

Blood Markers

Protein S100B – levels are elevated in the blood after nervous system injury. – So reliable that European insurers require it before

authorizing CAT scans Protein UCH-L1 – secreted into the blood after

the brain receives trauma. – 66 patients – worst head injury patients had 16X

more than uninjured patients – Test results within one minute

Progesterone may aid brain recovery

CONCLUSION CONCUSSION IS A TRAUMATIC

ALTERATION IN BRAIN FUNCTION MANAGEMENT OF CONCUSSIONS

INVOLVES THE EVALUATION OF SYMPTOMS WITH THE AID OF NEUROCOGNITIVE TESTING

ImPACT IS A VALIDATED AND RELIABLE NEUROCOGNITIVE TEST THAT CAN AID IN THE EVALUATION AND MANAGEMENT OF CONCUSSION

CATASTROPHIC BRAIN INJURIES NEW National Athletic Trainers' Association Position Statement

OBJECTIVE: To present recommendations for the prevention and screening, recognition, and treatment of the most common conditions resulting in sudden death in organized sports.

Prevention

1. The AT is responsible for coordinating educational sessions with athletes and coaches to teach the recognition of concussion (ie, specific signs and symptoms), serious nature of traumatic brain injuries in sport, and importance of reporting concussions and not participating while symptomatic. Evidence Category:C

Prevention

2. The AT should enforce the standard use of certified helmets while also educating athletes, coaches, and parents that although such helmets meet a standard for helping to prevent catastrophic head injuries, they do not prevent cerebral concussions. Evidence Category: B

Recognition 3. The AT should incorporate the use of a

comprehensive objective concussion assessment battery that includes symptom, cognitive, and balance measures. Each of these represents only one piece of the concussion puzzle and should not be used in isolation to manage concussion. Evidence Category: A

Treatment and Management

4. A comprehensive medical management plan for acute care of an athlete with a potential intracranial hemorrhage or diffuse cerebral edema should be implemented. Evidence Category: B

5. If the athlete’s symptoms persist or worsen or the level of consciousness deteriorates after a concussion, the patient should be immediately referred to a physician trained in concussion management. Evidence Category: B

6. Oral and written instructions for home care should be given to the athlete and to a responsible adult. Evidence Category: C

Return to Play

1. Returning an athlete to participation after a head injury should follow a graduated progression that begins once the athlete is completely asymptomatic. Evidence Category: C

2. The athlete should be monitored periodically throughout and after these sessions to determine whether any symptoms develop or increase in intensity. Evidence Category: C

Thank You