At the conclusion of the session, participants should be able to: 1. Understand the pathophysiology of concussions in children and the significance with regard to symptoms, management and recovery. 2. Understand the clinical and diagnostic tools available to assist in the evaluation and management of children with concussions. 3. Understand the signs and symptoms of concussive or minor traumatic brain injuries in children. 4. Be aware of the new MN Concussion Law for children and return to activity requirements. 5. Understand the role of adjunctive assessment tools in the management of children with concussions, including computerized neuropsychological testing.
Concussions in Sports CDC estimates 3.8 million sports- and recreation-related concussions in U.S. every year Team sports with most ER visits Ice hockey Football Soccer Cheerleading Snow skiing, bicycling, playground
Concussions in Sports Youth hockey: 23.15 concussions/1000 player game-hours NHL: 29.59 concussions/1000 player game-hours Women’s hockey has highest rate of concussion of any NCAA sport, even though checking is not allowed
VALID | RELIABLE | SAFE Mark R. Lovell, Ph.D., FACPN Professor and Director UPMC Sports Medicine Concussion Program Chairman and Developer ImPACT Applications, InC. WHAT IS A CONCUSSION? A Mild Traumatic Brain Injury A Change in brain function that occurs when there is a blow to the head and the brain is shaken violently This results in chemical changes in the brain The brain is more vulnerable to injury while it is recovering Additional injury during the recovery period is very dangerous
Evolving Definition of Concussion CDC Physicians Toolkit 2007 REGARDING CEREBRAL CONCUSSION…… A concussion (or mild traumatic brain injury) is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. Disturbance of brain function is related to neurometabolic dysfunction, rather than structural brain injury, and is typically associated with normal structural imaging findings (CT Scan, MRI). Concussion may or may not involve a loss of consciousness. Concussion results in a constellation of physical, cognitive, emotional, and sleep-related symptoms. Recovery is a sequential process and symptoms may last from several minutes to days, weeks, months, or even longer in some cases.”
Commonly Reported Symptoms High School and College Athletes-within 3 days of injury 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 % Lovell, Collins et al., 2004; N = 215
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?” “Asymptomatic” is not an easily defined term, although it is at the core of concussion management
COMMON SIGNS/SYMPTOMS? Headache Dizziness Confusion Memory Loss (amnesia) Blurred or double vision, seeing stars Nausea Light or noise sensitivity Balance problems Loss of consciousness is rare (<10 percent)
Risk Factors for Poor Recovery Effects of Multiple injuries (more is not better) Younger Age? (being young is not always better) Gender? (its just not a boys injury)
Cumulative Effects of Repetitive Injury Past studies have suggested that repetitive trauma in athletes is associated with poorer outcome.
Athletes with 3 or more mTBI’s were 3 times more likely to have an additional injury (Guskiewicz et al, JAMA, 2003)
Athletes with 3 or more prior mTBI’s were more likely to
demonstrate markers of concussion during the period of our study (Collins, Lovell et al., Neurosurgery,
Age and Recovery from mTBI Younger age has been associated with prolonged recovery.
High school athletes had prolonged recovery times compared to college athletes (Field et al., J. Pediatrics, 2004).
High school athletes demonstrated longer lasting memory deficits compared to college athletes (Sim et al., J. Neurosurgery, 2008)
High school athletes had prolonged recovery times compared to NFL athletes (Pellman, Lovell et al.,Neurosurgery, 2003).
Sex and Recovery from mTBI Initial studies have suggested that females may be at greater risk compared to males.
In sports played by both sexes, females sustained a higher
rate of mTBI than males (Comstock et al, JAT, 2007). Based on high school and NCAA data.
In a large sample of Junior high, HS and Collegiate soccer
athletes, females had longer recovery time than males (Colvin, Lovell et al., AOSSM, 2008).
Neuropsychological Test PerformanceMale vs. Female AthletesT Scores with Mean of 50 and S.D. of 10(Colvin, Lovell et al., AJSM, 2009) p.<.004 NS NS p.<.00001 Reaction Time Symptoms Verbal Memory Proc. Speed N=238 (143 Females, 95 Males) Groups were not different at baseline and were matched for age and BMI
Inadequate/Improper recommendations from ED/Trauma Departments.
CONCUSION EVALUATION TIMELINE Pre-Season 1-3 Days Follow-ups As needed First Follow-up Baseline Testing CONCUSSION REMOVE FROM PLAY Re-Evaluation Rest Gradual Exertion At school or clinic Return to Play
Concussion: The Diagnostic, Management and Return to Play Dilemma How to recognize the moods of an Irish setter
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
Computer-Based Neurocognitive Testing Currently Available Programs Cogsport Headminders (CRI) ANAM ImPACT Explosion of research since 2001
Immediate Post-Concussion Assessment and Cognitive Testing Mark R. Lovell, Ph.D., FACPN, CEO, Chairman and Developer Joseph C. Maroon, M.D., Co-Founder Michael W. Collins, Ph.D., Co-Founder ImPACT was developed to provide a scientific way of evaluating readiness to return-to-play following concussion
Development of ImPACT:A Tradition of Research 1988- 1994 Steelers Project (pre-ImPACT) 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 - 2010 Reliability/Validity Data Published 1999 - 2010 Over 80 Peer Reviewed Manuscripts 3 Textbooks / 55 Chapters
Why Bother with ImPACT? Dispelling Common Myths of Concussion “The athlete’s know when they are better” “Just wait two weeks and return them to play” “Don’t test the athlete until they are symptoms free”
ImPACT: Design and Structure Designed to evaluate multiple aspects of cognitive functioning in brief period Subtests measures multiple cognitive processes
Extensive normative data available from ages 11-60
What ImPACT Is and Isn’t: IS a useful and reliable/validconcussion management program. IS atoolto help determine recovery from injury. IS a toolto help manage concussion-(e.g. return to exertion, return to academics, return to play). IS atoolto help communicate post-concussion status to coaches, parents, clinicians. IS NOT a substitute for medical evaluation/treatment
Myths and Misperceptions about ImPACT “ImPACT is unreliable” (multiple studies have showed that it is) “ImPACT has not been validated” (it has) “ImPACT is Too Expensive” (it is not)
Pressure to Play in Sports: Can We Trust What the Athlete Tells Us? We can’t trust a concussed athlete to diagnose their own injury Athletes are notorious for hiding symptoms Studies suggest that up to50% of athletes experience concussion symptoms per yearbut only 10 percent report Most SIS cases are known to have played with symptoms
“When it comes to concussion, don’t believe me when I tell you that I’m OK ” NFL Athlete, 2010
Never Believe a Cheerleader (Or any other athlete)
Pros/Cons of ImPACT Testing When Symptomatic PROS Helps todetermine severityof injury Helps to determines prognosis for outcome (Iverson, Collins Lovell et al, CJSM 2007) Guides management for levels of physical/cognitive exertion Helps to determine specific academic needs/accommodations Objectifies injury (it becomes real when they Legitimizes injury to athletes, parents, coaches, physicians Helps to establish therapeutic bond amongst all parties CONS Potential for exacerbation of symptoms Requires time commitment from ATC/Physician, etc
Unique Contribution of Neurocognitive Testing to Concussion Management Testing reveals cognitive deficits in asymptomatic athletes within 4 days post-concussion N=215, MANOVA p<.000000 (Fazio, Lovell, Collins et al., Neurorehabilitaiton, 2007
What’s happening in Minnesota? 15-year-old Kayla Meyer of New Prague: "just need to realize that their health is more important than the game sometimes. They need to really take care of themselves for the future."
Minnesota Concussion Law Signed Gov Dayton on May 11 2001 –effective Sept 1st 2011 Applies to any organization that organizes a youth athletic activity for which an activity fee is charged Coaches must have training on concussions Information must be made available to the parent regarding the risks of concussions. Must remove player (18 and under) from all activity if they have symptoms or suspected of having a concussion Must have evaluation by a provider trained and experienced in evaluating and managing concussions and permission to again participate in the activity.
MANAGING CONCUSSION Promoting a Safe Return-to-Play
CURRENT MANAGEMENT GUIDELINES “When in doubt, sit them out” No athlete should play with symptoms (both at rest and following exertion) Athlete should be back to baseline level on neurocognitive testing (e.g. ImPACT) 1st-3rd International Symposia On Concussion in Sport
ImPACT CONCUSSION PROTOCOLOn The Field of Play
- Signs/symptoms evaluation - Mental status testing on field Orientation, concentration, anterograde/retrograde amnesia
Symptoms may worsen with physical exertion
Any positive findings should result in removal
WHEN IN DOUBT SIT THEM OUT!
OFF THE FIELD OF PLAY Evaluate athlete with ImPACT
Consultation with Neuropsychologist
Compare results to baseline Evaluate symptoms and assess balance WHEN SYMPTOM FREE FOR TWO DAYS:
Begin light exercise (walking, jogging, etc)
Progress to Moderate exercise (running, lifting)
The ImPACT Applications, Inc. software is a diagnostic tool that provides basic data related to neurocognitive functioning. The software does not provide treatment recommendations or a specific medical diagnosis with respect to any particular end user. Training provided or facilitated by ImPACT Applications, Inc. on the use of its software is intended to provide users with the ability to properly administer the tests embedded in the software and to become familiar with the types of data generated by the software. Treatment decisions that you and/or your organization make based on the data generated by the software is in you and/or your organization’s sole and absolute discretion. By participating in the training, you and your organization acknowledge and agree that ImPACT Applications, Inc., its officers, directors, employees, or agents and affiliates and their respective successors and assigns will not be held liable for claims of medical malpractice, practicing medicine without a license or similar claims made by you, your organization or any third party. To the fullest extent permitted by applicable law, you and your organization agree to hold ImPACT Applications, Inc., its officers, directors, employees, agents, and affiliates and their respective successors and assigns harmless and to indemnify ImPACT Applications Inc. and its officers, directors, employees, agents, and affiliates and their respective successors and assigns against any and all such claims.
ImPACT™ and the ImPACT Logo are trademarks of ImPACT Applications, Inc. and are used herein with the express written permission of ImPACT Applications, Inc. and may not be duplicated, removed or altered without ImPACT Applications, Inc.’s written consent.
Thank you! Questions? Joseph Petronio, MD Director of Pediatric Neurosurgery Children’s Hospitals and Clinics of MN firstname.lastname@example.org (612) 343-2121