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Concussion noname

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  • 1. 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.
  • 2. Sports Concussions in the News
  • 3. 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
  • 4. 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
  • 5. 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
  • 6.
  • 7.
  • 8.
  • 9.
  • 10.
  • 11. Neurometabolic Cascade Following Injury
  • 12. Neurometabolic Cascade Following Injury
  • 13. 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.”
  • 14. 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
  • 15. 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
  • 16. 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)
  • 17. 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)
  • 18. 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)
    • 19. 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,
  • 20. 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).
    • 21. High school athletes demonstrated longer lasting memory deficits compared to college athletes (Sim et al., J. Neurosurgery, 2008)
    • 22. 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).
  • 23. 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
  • 24.
  • 25. 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
    Chronic traumatic encephalopathy?
  • 26.
  • 27. Management of MTBI: Topics of Concern
    • Grading systems ineffective/not data based.
    • 28. CT and MRI insensitive to subtleties of injury.
    • 29. Self-report predicates management directives.
    • 30. Variability in clinician recommendations.
    • 31. Lack of education and awareness of injury.
    • 32. Inadequate/Improper recommendations from ED/Trauma Departments.
  • 33. 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
  • 34. Concussion: The Diagnostic, Management and Return to Play Dilemma
    How to recognize the moods of an Irish setter
  • 35. History and Development
    of ImPACT
  • 36. 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
  • 37. Computer-Based Neurocognitive Testing
    Currently Available Programs
    Cogsport
    Headminders (CRI)
    ANAM
    ImPACT
    Explosion of research since 2001
  • 38. 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
  • 39. 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
  • 40. Large-Scale Programs in US/Abroad
    • Ontario Ice Hockey Federation
    • 41. Ontario Ice Hockey League
    • 42. Western Ice Hockey League
    • 43. Australian Rugby
    • 44. New Zealand Rugby
    • 45. South African Rugby
    • 46. Irish Rugby
    • 47. Swedish World Cup Soccer
    • 48. 600 + Universities in US
    • 49. Many Neuropsychology Clinics
    • 50. Major League Baseball Umpires
    • 51. Army, Navy, Air Force Academies
    • 52. US Military Special Ops (Army)
    • 53. US Military Navy Seals
    • 54. US Olympic Team (sliding sports)
    • 55. All NFL Teams
    • 56. All NHL Teams
    • 57. All Major League Baseball
    • 58. IRL, CHAMP Car (Racing)
    • 59. Formula 1 Racing
    • 60. USA Olympic Ice Hockey
    • 61. USA Ice Hockey
    • 62. 4,000+ High Schools
    • 63. 200+ Clinics
    • 64. USA Ski/Snow Board Team
    • 65. USA Soccer Juniors
    • 66. Major League Soccer
    • 67. Six NBA Teams (Basketball)
    • 68. Cirque Du Soleil
    • 69. WWE (Pro wrestling)
    *Mandated by league or team
  • 70. 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”
  • 71. ImPACT: Design and Structure
    Designed to evaluate multiple aspects
    of cognitive functioning in brief period
    Subtests measures multiple cognitive
    processes
    • Verbal and Visual Memory
    • 72. Cognitive Speed
    • 73. Interaction of Memory and Speed
    (Cognitive Efficiency)©
    • Self-report of symptoms
  • ImPACT: Post-Concussion Evaluation
    Demographic / Concussion History Questionnaire
    Concussion Symptom Scale
    • 21 Item Likert Scale (e.g. headache, dizziness, nausea, etc)
    8 Neurocognitive Measures
    • Verbal Memory, Visual Memory, Reaction Time, Processing Speed Summary Scores
    Detailed Clinical Report
    • Outlines Demographic, Symptom, Neurocognitive Data
    • 74. Automatically Computer Scored
    Desktop and On-Line Versions Available
    • 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
  • 75. 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)
  • 76. 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
  • 77. “When it comes to concussion,
    don’t believe me when I tell
    you that I’m OK ”
    NFL Athlete, 2010
  • 78. Never Believe a Cheerleader (Or any other athlete)
  • 79. 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
  • 80. 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
  • 81.
  • 82. Current Status of Concussion Management
  • 83. LYSTEDT’S LAWState of Washington
    • Zach Lystedt returned to play by coach after two injuries in one game
    • 84. Second injury produced malignant brain swelling and permanent brain damage.
    • 85. State of Washington passed law requiring evaluation prior to return to play.
    • 86. 20 states have passed some type of concussion legislation.
    • 87. 24 states have pending Bills
  • CURRENT LEGLISLATION
  • 88. 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."
  • 89. 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.
  • 90. MANAGING CONCUSSION
    Promoting a Safe Return-to-Play
  • 91.
  • 92. 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
  • 93. ImPACT CONCUSSION PROTOCOLOn The Field of Play
    • On-field evaluation
    - Signs/symptoms evaluation
    - Mental status testing on field
    Orientation, concentration, anterograde/retrograde amnesia
    • Symptoms may worsen with physical exertion
    • 94. Any positive findings should result in removal
    WHEN IN DOUBT SIT THEM OUT!
  • 95. 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)
    • 96. Progress to Moderate exercise (running, lifting)
    • 97. Progress to heavy non-contact (sprinting)
    • 98. Return to practice/play
    If symptoms occur at a level, go back one level
  • 99. OUR TREATMENT PHILOSOPHY
    Initial treatment through REST
    Approximately 85% return to normal
    15% of young patient’s do not recover
    on own (within 3 to 4 weeks)
    • Medication management?
    • 100. Interface with the schools
  • INTERFACING WITH THE SCHOOLS
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  • 127. 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.
  • 128. Copyright © 2011 by ImPACT Applications, Inc. 
    All rights reserved.  No part of this publication maybe reproduced in whole or in part or transmitted in any form or by any means without the prior written permission of ImPACT Applications, Inc.  For information regarding permission, please write to ImPACT Applications, Inc., LRUSSO@impacttest.com
    ImPACT™ and associated logos are trademarks of ImPACT Applications, Inc.
  • 129. 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. 
  • 130. Thank you!
    Questions?
    Joseph Petronio, MD
    Director of Pediatric Neurosurgery
    Children’s Hospitals and Clinics of MN
    joseph.petronio@childrensmn.org
    (612) 343-2121
  • 131. Sports Concussions in the News
  • 132.
  • 133. Fundamentals of Concussion Management