Concussion Frisco Talk - Slide 1


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Concussion Frisco Talk - Slide 1

  1. 1. Developing a Concussion Management Program Bill Borowski MBA;ATC;LAT;LPTA 411 N Washington Suite 4000 Dallas TX 75246
  2. 2. CONCUSSION • Concussion (cerbrum commotum) “shaking of the brain” Acute metabolic dysfunction due to post- traumatic hyperglycolysis and decreased cerebral blood flow. MTBI –Mild Traumatic Brain Injury Confusion and amnesia are the hallmarks of concussion (recovery)
  3. 3. IMPORTANT DOCUMENTS 1. “Summary and Agreement Statement of the 2nd International Conference on Concussion in Sport, Prague 2004 (Prague Statement) 2. National Athletic Trainers’ Association Position Statement of Sport-Related Concussion (NATA Statement) • 3. • 4. CDC’s Toolkit (free)
  4. 4. ASESSMENT AND EVALUATION Objectives Clinical History Sideline-Assessment Strategies Balance Testing Neuroimaging Techniques Neuropsychological testing Return to Play decisions
  5. 5. CLINICAL HISTORY • Concussion assessment about history of previous head injuries With Multiple Concussed Athletes, Ask did the subsequent concussions: Occur with lighter impacts? Occur close in time to previous injury? Require lengthier recovery time? Have less complete recovery with each subsequent concussion?
  6. 6. RECOGNITION OF A CONCUSSION PHYSICAL COGNITIVE EMOTIONAL SLEEP •Headache • Nausea • Vomiting • Balance Problems • Dizziness • Visual Problems • Fatigue • Sensitivity to light • Sensitivity to noise • Numbness/Tingling • Dazed or Stunned •Feeling mentally "foggy" • Feeling slowed down • Difficulty concentrating • Difficulty remembering • Forgetful of recent information or conversations • Confused about recent events • Answers questions slowly • Repeats questions •Irritability • Sadness • More emotional • Nervousness •Drowsiness • Sleeping less than usual • Sleeping more than usual • Trouble falling asleep Cognitive Impairment (altered or decreased cognitive function)
  7. 7. SIDELINE ASSESSMENT Maddocks’ Questions Orientation, anterograde and retrograde amnesia, concentration, memory
  8. 8. SIDELINE ASSESSMENT Standardized Assessment of Concussion (SAC) (Quantitative) Also assesses strength, coordination, sensation, and the presence of amnesia r. Michael McCea and colleagues (1998) AAN/1991 Colorado Guidelines Brief standard neurological screening measure of: Orientation Concentration Immediate Memory Delayed Recall
  10. 10. SIDELINE ASSESSMENT **See Handout McGill Sport medicine Clinic-Montreal, Quebec Canada McGill Abbreviated Concussion Evaluation (ACE) Immediate memory Concentration Delayed Memory Tasks Orientation Amnesia Concussion Symptoms
  11. 11. BALANCE/VESTIBULAR *A postural stability study revealed that concussed athletes showed significant decrements in measures of composite balance and the vestibular ratio from a sensory organization test *McCrea et al. [21] found balance scores to be significantly lower in concussed subjects when compared with controls as well. Balance Testing Romberg Test of postural stability Balance Error Scoring System
  12. 12. MANAGEMENT AND REFERAL Transport immediately to ED if: LOC-Spineboard Condition is changing/deteriorating (athlete unstable) Deterioration of neurological function or consciousness Decrease or irregularity in respirations or pulse Unequal, dilated, or unreactive pupils Signs or symptoms of associated injuries, spine or skull fracture, or bleeding Mental status changes: lethargy, difficulty maintaining arousal, confusion or agitation Seizures or cranial nerve deficits
  13. 13. RECOMMENDATIONS Number Recommendation #1 No return play after sustaining a concussion #2 Stop activities that cause symptoms to increase #3 School activities may need to be modified #4 Neurocognitive testing is an important component of concussion management #5 No RTP until they symptom free, both at rest and with exercise and have normal neurocognitive testing. #6 All sports and health education programs should teach students the specific signs and symptoms of concussions Dr. Lee is a pediatrician with Pediatric Healthcare Associates in Southport, Connecticut specializing in adolescent and sports medicine. He is a charter member of AMSSM and Medical Director of the Student Health Center at Fairfield University
  14. 14. • Decreased Processing Speed • Short-Term Memory Impairment • Concentration Deficit • Irritability/Depression • Fatigue/Sleep Disturbance • General Feeling of “Fogginess” • Academic Difficulties LATER SIGNS OF CONCUSSION: Post-Concussion Syndrome
  15. 15. Neuroimaging Techniques STRUCTURAL: CT Scans, MRI • Good for ruling out brain bleeds or emergency situations (e.g.-scull fractures etc). Usually normal with most concussions FUNCTIONAL: (Metabolic) Position Emission Tomography (PET) –glucose utilization Single Proton Emission Computed Tomography (SPECT) – Blood flow to brain • Measures brain activity (fMRI)-oxygen utilization • Functional testing not used widely due to expense, lack of availability, and research status of some tests. ***Functional Testing : Will likely be the way of the future for concussion assessment
  16. 16. Neuropsychological Testing • Neurocognitive Tests –Indirect measures of brain functioning via paper and pencil, Q&A or computer- based tests. SPORT CONCUSSION: Attention Span Sustained and Selective Attention Span Reaction Time Concentration Response variability Working Memory Learning Quickness Non-verbal problem-solving Memory
  17. 17. Return to Play Rehabilitation Stage Functional exercise Objective of stage 1. No activity Complete cognitive (e.g. mental) rest Recovery 2. Light aerobic exercise Walking, swimming or stationary bicycle keeping intensity less than 70% of maximum predicted heart rate Increase heart rate 3. Sport-specific exercise Skating drills in ice hockey, running drills in soccer. No head impact activities Add movement 4. Non-contact training drills Progression to more complex training drills, e.g. passing drills in football and ice hockey Exercise, coordination and use of brain 5. Full contact practice Following medical clearance, participate in normal training activities Restore confidence and assess functional skills by coaching staff 6. Return to Play Normal game play Decision to RTP needs to be a consensus between the Sportsmedicine team and cleared by physician
  18. 18. Clinical Presentations and Concerns School personnel observe for: Change in personality/mood Increased difficulty paying attention/concentrating, remembering/learning new information Longer time required to complete tasks Increase in symptoms (e.g., headache, fatigue) during schoolwork Greater irritability (less tolerance for stressors)
  19. 19. SCHOOL CONSIDERATIONS Modification Options Time off from school/shortened day Longer time to complete coursework/assignments and tests Reduced homework/class work load No significant classroom or standardized testing at this time Home care-decrease stimulus (phone, TV, video games, computer etc)
  20. 20. DOCUMENTATION CLINIC FORMS Sideline Assessment Cards (Maddocks, SCAT, SAC, ACE) Fact Sheets (Athlete, Parent, Coach) Clinical Protocol/Health History Post-Concussion Exertional Activity form Individualized Health Plan Form (classes etc) Patient Excuse from School Form Patient Excuse from Physical Activity Form Patient Permission to Return to Activity Form Written Concussion Management Plan
  21. 21. IMPACT TESTING • ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) • Developed in the early 1990's (Drs. Mark Lovell and Joseph Maroon) • 20-minute test that is a standard tool used in comprehensive clinical management of concussions for athletes of all ages. • Allows management concussions on an individualized basis (baseline testing and/or post-injury neurocognitive testing) • Objectively evaluate the concussed athlete's post-injury condition and track recovery for safe return to play, thus preventing the cumulative effects of concussion. • ImPACT can be administered by an athletic trainer, school nurse, athletic director, team coach, team doctor, or anyone trained to administer baseline testing.
  22. 22. 22 Module 1 (Word Discrimination)  Evaluates attentional processes/verbal recognition memory  Utilizes a word discrimination paradigm.  Twelve target words are presented for 750 milliseconds (twice to facilitate learning of the list)  The subject is then tested for recall via the presentation of the 24-word list that is: comprised of 12 target words and 12 non-target words  Words chosen from the same semantic category as the target word.  EX: the word “ice” is a target word, while the word “snow” represents the non-target word.  The subject responds by mouse-clicking the “yes” or “no” buttons  Individual scores are provided both for correct “yes” and “no” responses -In addition, a total percent correct score is provided.  There are five different forms of the word list. Delay Condition: Following the administration of all other test modules (approximately 20 minutes), the subject is again tested for recall via the same method described above. The same scores that are described above are provided for the delay condition.
  23. 23. 23 Module 2 (Design Memory)  Evaluates attentional processes and visual recognition memory  Utilizes a design discrimination paradigm.  Twelve target designs are presented for 750 milliseconds (twice to facilitate learning)  The subject is then tested for recall via the presentation of the 24-designs comprised of 12 target designs and 12 non-target designs EX: target designs that have been rotated in space The subject responds by mouse-clicking the “yes” or “no” buttons Individual scores are provided both for correct “yes” and “no” responses In addition, a total percent correct score is provided There are five different forms of this task
  24. 24. 24 Module 3 (X’s and O’s)  Measures visual working memory, visual processing speed, and visual memory paradigm  Encorporates a distractor task.  The subject can practice the distractor task prior to presentation of the memory task  The distractor is a choice reaction time test: the subject is asked to click the left mouse button if a blue square is presented and the right mouse button if a red circle is presented.  Once the subject has completed this task, the memory task is presented.  Memory task: a random assortment of X’s and O’s is displayed for 1.5 seconds  For each trial: three of the X’s or O’s are illuminated in YELLOW (the subject has to remember the location of the illuminated objects).  Immediately after the presentation of the 3 X’s or O’s, the distractor task re-appears on the screen.  Following the distractor task, the memory screen (X’s and O’s) re-appears and the subject is asked to click on the previously illuminated X’s and O’s.  Scores are provided for correct identification of the X’s and O’s (memory), reaction time for the distractor task, and number of errors on the distractor task.  For each administration of ImPACT, the subject completes 4 trials.
  25. 25. 25 Module 4 (Symbol Matching)  Evaluates visual processing speed, learning and memory  Initially, the subject is presented with a screen that displays 9 common symbols (triangle, square, arrow, etc).  Directly under each symbol is a number button from 1 to 9  .Below this grid, a symbol is presented. The subject is required to click the matching number as quickly as possible and to remember the symbol/number pairings Correct performance is reinforced through the illumination of a correctly clicked number in GREEN. Incorrect performance illuminates the number button in RED. Following the completion of 27 trials, the symbols disappear from the top grid. The symbols again appear below the grid and the subject is asked to recall the correct symbol/number pairing by clicking the appropriate number button.  This module provides an average reaction time score and a score for the memory condition.
  26. 26. 26 Module 5 (Color Match)  Represents a choice reaction time task and measures impulse control/response inhibition  First, the subject is required to respond by clicking a red, blue or green button as they are presented on the screen. This procedure is completed to assure that subsequent trials would not be affected by color blindness  Next, a word is displayed on the screen in the same colored ink as the word (e.g. RED), or in a different colored ink (GREEN or BLUE)  The subject is instructed to click in the box as quickly as possible only if the word is presented in the matching ink.  In addition to providing a reaction time score, this task also provides an error score.
  27. 27. QUESTIONS? Bill Borowski Baylor SportsCare 411 N Washington Ste 4000 Dallas TX 75246 214-820-7333