Concussion in Sports: A review of the AMSSM Position Statement and AAN Guidelines

James W. Bryan IV, MDLittle Rock, AR

Consensus Statement on Concussion in Sport: The 4th International Conference, Nov 2012, Zurich

Concussion is a brain injury and is defined a a complex pathophysiological process affection the brain, induced by biomechanical forces.

Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive injury include:

Concussion defined

Consensus Statement on Concussion in Sport: The 4th International Conference, Nov 2012, Zurich

Caused by either a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head

Typically results in the rapid onset of short-lived neurological function that resolves spontaneously Symptoms and signs may evolve over minutes to

hours May result in neuropathological changes

Reflect a functional disturbance rather than a structural injury

No abnormalities are typically seen on standard neuroimaging studies

Concussion defined:common features

Concussion defined:Neurometabolic cascade

Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic Athletic and Spine Injuries. St Louis, MO: WB Saunders Co; 2000:80–100

Concussion defined:Neurometabolic cascade

Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic Athletic and Spine Injuries. St Louis, MO: WB Saunders Co; 2000:80–100

Consensus Statement on Concussion in Sport: The 4th International Conference, Nov 2012, Zurich

Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness.

Resolution of the clinical and cognitive symptoms typically follows a sequential course

In some cases the symptoms may be prolonged The majority of cases resolve in a 7-10 day

period The recovery time frame may be longer in

children and adolescents

Concussion defined:common features

*First concussion symposium: Vienna, 2001-International Ice Hockey Association, FIFA (soccer), and the International Olympic

Committee*Second symposium: Prague, 2004

-Sideline assessment tool (SCAT)*Third symposium: Zurich, 2008

-SCAT revised (SCAT 2)-Designed to follow US NIH consensus criteria

*Each produced a summary-and-agreement statement on concussion in sport.

Background

The Fourth Conference: Zurich 2012 Used the same format as previously:

32 international experts 2 full days of new research presentations Extensive structured discussion Drafted a consensus paper, edited until all were in

agreement Updated version of SCAT (SCAT 3)-with 3 distinct

tools Final drafting of 12 critical review papers, co-

published in multiple journals

Background

British Journal of Sports Medicine April 2013; 47: 250-258Panel included Stanley Herring and Margot Patukian from AMSSM

Kimberly G Harmon, Jonathan A Drezner, Matthew Gammons, Kevin M Guskiewicz*, Mark Halstead, Stanley A Herring, Jeffrey S Kutcher*, Andrea Pana, Margot Putukian*, William O Roberts

Endorsed by the National Trainers’ Athletic Association and the American College of Sports Medicine

Press release December 13, 2012 British Journal of Sports Medicine April 2013, 47, 15-26 Clinical Journal of Sport Medicine Jan 2013, 23 issue 1,

1-18 [Asterisk indicates Zurich 2012 participants]

American Medical Society for Sports Medicine position statement: concussion in sport

To provide an evidence-based, best practices summary to assist physicians with the evaluation and management of sports concussion

To establish the level of evidence, knowledge gaps and areas requiring additional research

AMSSM Position Statement: concussion in sport--Purpose--

While directed toward sports physicians, it may help other health care providers in the care of concussed patients

Care is ideally performed those with specific training and experience—not dictated by specialty

Sports physicians are trained to provide care from the time of injury to return-to-play

AMSSM Position Statement: concussion in sport--Importance--

AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

Both human and animal studies support the concept of postconcussion vulnerability A second blow sustained before recovery results in

worsening metabolic changes within the neuron This concept is distinct from “second impact

syndrome” The concussed brain is less responsive to usual

neuron activation Prolonged dysfunction may result from premature

cognitive activity or vigorous physical activity

Pathophysiology

AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

3.8 million sports related concussions annually in the USA

Estimated that up to 50% are unreported or unrecognized

Concussions occur in all sports Football, hockey, rugby , soccer, and

basketball

Incidence

AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

History of previous concussion The greater the number, severity, and

duration of symptoms predict a prolonged recovery

In sports with similar rules, female athletes experience a higher incidence of concussion

Certain positions within a sport present a greater exposure risk

Risk factors for sports-related concussion

AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

Pre-injury mental health conditions complicate the diagnosis and management of concussion

Youth athletes have additional considerations More prolonged recovery Greater susceptibility to concussion

accompanied by catastrophic injury

Risk factors for sports-related concussion

AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

Concussion is a clinical diagnosis Diagnosis is ideally made by a healthcare provider

who is familiar with the athlete knowledgeable in the recognition and evaluation of

concussion Graded symptoms checklists [e.g. SCAT3]

Objective tool for assessing a variety of symptoms Useful in tracking the severity of symptoms over

serial exams

Diagnosis of concussion

AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

Standardized assessment tools Can provide a helpful structure in evaluation Limited valuation of the assessment tools is available Examples include

The Maddocks Questions Standardized Assessment of Concussion (SAC) Balance Error Scoring System (BESS, modified BESS) SCAT2, SCAT3, SCAT3 Child, CRT (lay person) NFL Sideline Concussion Assessment Tool Glasgow Coma Score

Diagnosis of concussion

Diagnosis of concussion

SCAT3 http://bjsm.bmj.com/content/47/5/259.full.pdf+

html SCAT3-CHILD

http://bjsm.bmj.com/content/47/5/263.full.pdf+html

Pocket Concussion Recognition Tool http://bjsm.bmj.com/content/47/5/267.full.pdf+

html

AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

NP testing is an objective measure of brain-behavior relationships

More sensitive for subtle cognitive impairment than clinical exam

Should be used as part of a comprehensive management strategy and not relied upon alone

Ideal timing, frequency and type of NP testing is not established

Unknown if NP testing helps prevent recurrent concussion, catastrophic injury, or long-term complications

Neuropsychological testing

AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

Paper and pencil NP tests Can be more comprehensive Can test different domains and assess for other

conditions which may mask or complicate the assessment of concussion

May provide added value to assess cognitive function and recovery

Helpful in the management of patients with prolonged symptoms and complicated courses

Neuropsychological testing

AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

Computerized NP testing should be interpreted by providers trained and familiar with The type of the test The individual test limitations The reliable change index The baseline variability False-positive and false-negative rates

Neuropsychological testing

96118 Neuropsychological testing, interpretation and reporting per hour by a psychologist ($92/unit)

96119 Neuropsychological testing per hour by a technician ($74/unit)

96120 Neuropsychological testing by a computer, including time for the psychologist’s interpretation and reporting ($103) Formal NP testing, scoring, interpretation and

conference may require up to 4-8 hours

Neuropsychological testingCPT ® codes

http://www.apapracticecentral.org/update/2012/11-29/medicare-payment.aspx, accessed 5/14/13

AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

Students will require a period of cognitive rest

May require academic accommodations Reduced workload Extended time to complete tests Protections afforded under Section 504 / ADA

Return to class

Education

Arkansas ACT 1435 Sen. David Sanders/SB1158 Rep. Gary Deffenbaugh

Signed April 23, 2013 Requires the State

Department of Health to develop concussion protocols to all youth athletes involved in youth athletic activities

Based on existing AAA guidelines for sanctioned sports in grades 7-12 enacted in 2012As of April 2013, 47 states have

enacted legislation

Education

“Heads Up” Tool Kit for Youth Sports CDC

Coaches, athletes and parents

Online videos Fact sheets, wallet

cards

NFLEvolution.com Promotion of the Lystedt Law’s three

tenets Inform and educate youth athletes,

their parents and guardians and require them to sign a concussion information form

Removal of a youth athlete who appears to have suffered a concussion from play or practice at the time of the suspected concussion

Requiring a youth athlete to be cleared by a licensed health care professional trained the evaluation and management of concussions before returning to play or practice.

Education

AMSSM 2014 AMSSM 23rd

Annual Meeting April 5-9, 2014 Hyatt Regency New Orleans New Orleans, LA

Advance Team Physicians Course Cosmopolitan Hotel Las

Vegas, NVDecember 5-8, 2013

• 2013 AAFP Scientific Assembly: Concussion and Minimal Brain Injury• Thursday, September 26, 2013,

San Diego Convention Center

Summary of evidence-based guideline update: Evaluation and management of

concussion in sports

Christopher C. Giza, MD, Jeffrey S.

Kutcher, MD, Stephen Ashwal, MD, FAAN, Jeffrey Barth,

PhD, Thomas S.D. Getchius, Gerard A. Gioia, PhD, Gary S.

Gronseth, MD, FAAN, Kevin Guskiewicz, PhD, ATC, Steven

Mandel, MD, FAAN, Geoffrey Manley, MD, PhD, Douglas B.

McKeag, MD, MS, David J. Thurman, MD, FAAN and Ross

Zafonte, DO

Neurology; Published online before print March 18, 2013

Objective: To update the 1997 AAN practice parameter regarding sports concussion focusing on 4 questions

AAN Guideline Update:4 questions

1. What factors affect risk?

2a.What diagnostic tools identify those with concussion and (2b)those at increased risk?

3.What clinical factors identify those at increased risk for severe/ prolonged early impairments, neurological catastrophe, recurrent concussion, or chronic impairment?

4.What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae?

Neurology, Mar 18, 2013

AAN Concussion Guidelines

Preparticipation Counseling Number and type of

previous concussions Symptoms and

duration Other neurologic

conditions (e.g. seizures)

Assessment Post-Concussion Symptom

Scale or Graded Symptom Checklist

Standardized Assessment of Concussion

Neuropsychological testing Balance Error Scoring

System Sensory Organization Test Combination of measures

Neurology, Mar 18, 2013

AAN Concussion GuidelinesManagement of suspected concussion

Train inexperienced licensed HCPs to use a standardized assessment tool

Use standardized assessment tools

Warm handoff from sideline HCP and clinical HCP

Obtain baseline scores Remove athlete from play No RTP without clearance

by licensed HCP Don’t perform imaging

to make concussion diagnosis

Do perform imaging to rule out suspected TBI

Neurology, Mar 18, 2013

No RTP until resolved & asymptomatic

Conservative approach for youth and high school

Assessment tools specific for preteens

Consider NP testing Individualize

management plan No indication for

“absolute rest”

AAN Concussion Guidelines:DIAGNOSED CONCUSSION

Neurology, Mar 18, 2013

AAN Concussion Guidelines:Multiple concussions

Professional athletes: Refer for neurologic

and neuropsychological evaluation

Contact-sports with chronic impairment: RETIREMENT

Amateur athletes: Formal

neurologic/cognitive assessment

Offer risk factor counseling

Neurology, Mar 18, 2013

Numerous organizations have published guidelines regarding the management of sports-related concussions

Emerging consensus that education is a key factor

Treatment considerations differ slightly between youth, adolescent, and adult/professional athletes

Inconclusive data regarding long-term risk

Conclusions