Sport-Related Concussion

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1 Sport-Related Concussion Bill Meehan, MD Micheli Center for Sports Injury Prevention Sports Concussion Clinic, Boston Children s Biomechanics Biomechanics Rotational acceleration Slaughterhouses free to move, accelerate Denny-Brown 1941 medicine, acceleration Holburn 1943 thought experiment, rotational Ommaya and Genarelli definitive Normal Physiology 1

2 Normal Physiology Normal Physiology Normal Physiology 2

3 Pathophysiology Biomechanical injury Ion flux, K+, Na+ Excitatory neurotransmitters NMDA Ca++ influx, further EAA release Exacerbates efflux of K+ Depolarization spreading depression Glyolysis -pump restoration Decreased flow 3

4 1/24/2013 DISCLOSURE 1. INDIANAPOLIS COLTS, NEUROSURGICAL CONSULTANT 2. NFL HEAD, NECK, AND SPINE MEDICAL COMMITTEE, RETURN TO PLAY SUBCOMMITTEE, MEMBER HANK FEUER, MD I.U.-METHODIST SPORTS MEDICINE GOODMAN CAMPBELL BRAIN AND SPINE INDIANA SPORTS CONCUSSION NETWORK JANUARY 28, 2013 THE NFL PERSPECTIVE TRYING TO SET AN EXAMPLE BECAUSE OF HUGE TELEVISION AUDIENCE, POPULARITY WE CAN DO NO WRONG, BUT THIS SEASON, ATC SPOTTER WITH VIDEO MONITOR ON THE SIDELINE ipads ON THE SIDELINE 1

5 1/24/2013 THE NFL ADVANTAGE COMPARED TO COLLEGE, HIGH SCHOOL AND MIDDLE SCHOOL: RECOGNIZING THE CONCUSSION SIDELINE STAFF: TEAM PHYSICIANS ATHLETIC TRAINERS FIRST ON THE FIELD THE NFL ADVANTAGE COMPARED TO COLLEGE, HIGH SCHOOL AND MIDDLE SCHOOL: RECOGNIZING THE CONCUSSION SIDELINE STAFF: ATHLETIC TRAINERS TEAM PHYSICIANS FIRST ON THE FIELD THE NFL ADVANTAGE COMPARED TO COLLEGE, HIGH SCHOOL AND MIDDLE SCHOOL: RECOGNIZING THE CONCUSSION SIDELINE STAFF: ATHLETIC TRAINER TEAM PHYSICIAN (MAYBE) FIRST ON THE FIELD REFEREE 2

6 1/24/2013 THE NFL ADVANTAGE COMPARED TO COLLEGE, HIGH SCHOOL AND MIDDLE SCHOOL: RECOGNIZING THE CONCUSSION SIDELINE STAFF: COACH COMPARISON OF SETTINGS SIDELINE EMERGENCY DEPARTMENT OFFICE THE GAME FACE (player focused on the game) IS THE CRITICAL ISSUE IT S YOUR RESPONSIBILITY!! THE ATC CAN DEFINITELY HELP! RECOGNIZING WHEN THE CONCUSSION HAPPENS 3

7 1/24/2013 DON T ASSUME THAT A CONCUSSION HAS OCCURRED BY THE WAY THE HIT LOOKS CROWD REACTION VIDEO REPLAYS WHERE APPLICABLE WHEN TO CHECK PLAYER MOVEMENT AFTER HIT SLOW TO GET UP INITIAL STAGGERING UNSTEADINESS HEAD MOVEMENT HEAD SHAKING GRABBING THEIR HEAD EYE BLINKING EYE SQUINTING RUBBING THEIR EYES GLAZED LOOK LOOKING AROUND AS THOUGH THEY CAN T FOCUS ASKING FOR AMMONIA CAP WHAT TO DO THE DOWNED ATHLETE 4

8 1/24/2013 WHAT TO DO ON THE SIDELINE CALM THE ATMOSPHERE SIT THE ATHLETE DOWN TAKE THE HELMET AWAY WHERE TO EXAMINE DISTRACTIONS MOST PLAYERS LOOK OK TO ALL THOSE AROUND THOROUGHNESS OF EXAM TREAT THE ATHLETE APPROPRIATELY DEPENDENT ON INITIAL RESPONSE 5

9 1/24/2013 DON T CUT CORNERS DOING IT THE RIGHT WAY MAY SAVE FROM MANY WEEKS OFF IN THE FUTURE NFL SIDELINE CONCUSSION ASSESSMENT TOOL: 2012 MUST HAVE BASELINE TRYING TO MAKE IT EASY 6

10 1/24/2013 AUTOMATIC DISQUALIFIERS LOSS OF CONSCIOUSNESS OR UNRESPONSIVENESS CONFUSION AMNESIA NEW AND/OR PERSISTENT SYMPTOMS ABNORMAL NEUROLOGICAL FINDING PROGRESSIVE, PERSISTENT, OR WORSENING SYMPTOMS 7

11 1/24/2013 SCREENING FOR A POSSIBLE CONCUSSION A SHORTENED VERSION? STARTING WITH WHAT HAPPENED? WOULD IT BE ACCEPTABLE? RETURN TO PLAY? NOTHING SUGGESTIVE OF CONCUSSION NOTICED PASSES YOUR SCREEN PASSES THE SCAT II-BESS ALWAYS CONSIDER LEVEL OF PLAY IF IN DOUBT DOCUMENT THE EXAM 8

12 1/24/2013 FREQUENT CHECKS TO THE LOCKER ROOM TO THE EMERGENCY DEPARTMENT 9

13 1/24/2013 THE TAKE HOME INSTRUCTION SHEET CONCLUSION RECOGNIZE THE CONCUSSION DO THE APPROPRIATE ON-FIELD EXAMINATION EXAMINE IN THE LOCKER ROOM CONTINUE TO MONITOR MORE COMPREHENSIVE EXAMINATION OFF THE FIELD, ESPECIALLY BEFORE THE PLAYER GOES HOME IF YOU HAVE HAD A CONCUSSION AND DO NOT TELL ANYONE AND THEN FUMBLE, DROP A PASS, MISS A TACKLE, OR MAKE THE WRONG MANEUVER 10

14 An Interdisciplinary Approach to Sports Concussion: Subacute Office Evaluation Josh Bloom, MD, MPH, CAQSM Carolina Sports Concussion Clinic Carolina Family Practice & Sports Medicine VuMedi January 28, 2013 Disclosures Scientific Advisor Board Member, i1biometrics Subacute Office Evaluation: Key Issues Confirm Concussion Diagnosis Thoroughly evaluate the extent of the injury Assess Concussion Risk Factors Identify the deficits Use all the tools you have available Symptom score Neurocognitive testing Exam Neurologic exam Vestibular/oculomotor exam Subacute evaluation pearls 1

15 Confirm Diagnosis Review Mechanism, Acute/Subacute Symptoms High risk mechanism (eg double hit, occipital blow/rotational component) On-field dizziness Amnesia Fogginess day #3 Migraine presentation (HA, dizziness, photo/phonophobia) Symptom checklist (recommend full, direct query) Assess Concussion Risk Factors Previous (especially recent) concussion Age Headache (migraine) history, LD, ADHD, Psych d/o, seizure d/o, other underlying neuro d/o Identify the deficits Concussions are like snowflakes every one is different Evaluate the deficits prognostic value and will allow you to tailor therapy Physical/Migraine Cognitive Sleep Emotional/Psych Use all the tools you have Computerized Neurocognitive Evaluation Why? Increase diagnostic yield Increase in diagnostic yield 65% symptoms alone to 93% with addition of neuropsychological testing Van Kampen, Lovell, Collins et al, AJSM 2006 Tailor therapy, assess severity, predict recovery 3 or more composites exceed RCI > 90% protracted recovery >10 days Iverson ImPACT Data and cut-off scores Academic accommodations Identify subclinical deficits/rtp implications Testing reveals deficits in asymptomatic athletes within 4 days post-concussion Fazio, Lovell, et al 2007 When computerized neurocognitive testing is utilized, athletes are less likely to return to play within a week 13.6% vs 32.9% Meehan et al, AJSM

16 Computerized Neurocognitive Testing How? Best used in conjunction with baseline Control the testing environment Increases awareness/education Valuable even without baseline Does not need neuropsychologist interpretation Do NOT use in isolation should be one of many tools used in eval Multiple different tests (ImPACT, Headminder, Cogsport, ANAM, CNS Vital Signs, etc) Vestibular/oculomotor evaluation Balance, visual system frequently involved in sports concussion Huge component to acute and subacute evaluation Important part of sideline evaluation Great way to convince an athlete they are concussed Remember cognition can be intact, but still concussed Does not need to be technology intensive/expensive Experience/practice is important Fatigability Evaluate after neurocognitive testing Vestibular/oculomotor evaluation Video 3

17 Take home points Concussions are all different Comprehensive evaluation will give prognostic information and allow you to tailor therapy Use multiple tools ces/tools-for-healthcare-providers/ RTP more than just asymptomatic at rest/with exertion Look for subclinical deficits (neurocognitive, vestibular/oculomotor testing) Prove to me you re 100% Management has become more conservative over time 4

Sports-Related Post-Concussion Syndrome: Risk Profiles and Clinical Management Micky Collins, PhD University of Pittsburgh Medical Center Department of Orthopaedic Surgery Department of Neurological

18 Sports-Related Post-Concussion Syndrome: Risk Profiles and Clinical Management Micky Collins, PhD University of Pittsburgh Medical Center Department of Orthopaedic Surgery Department of Neurological Surgery Program Director UPMC Sports Concussion Program Disclosure Statement Micky Collins, PhD is a Co-Founder and Board Member of ImPACT Applications, a computerized neurocognitive test battery designed to assess sports concussion and Mild Traumatic Brain Injury. Measuring Recovery from Sports mtbi 1

100 90 80 70 60 50 40 30 20 10 0 WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 40% RECOVERED 60% RECOVERED 80% RECOVERED 3 Year Prospective

Athletes No Previous Concussions 1 or More Previous Concussions Post-Concussion Symptom Groups More emotional Sadness Nervousness

Fatigue Cognitive slowing N=327, High School and University Athletes Within 7 Days of Concussion Difficulty falling asleep Sleeping

19 WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 40% RECOVERED 60% RECOVERED 80% RECOVERED 3 Year Prospective Study of 17 High School Football Teams N=2, Concussed Athletes All Athletes No Previous Concussions 1 or More Previous Concussions Post-Concussion Symptom Groups More emotional Sadness Nervousness Irritability Headaches Visual Problems Dizziness Noise/Light Sensitivity Nausea Attention Problems Memory dysfunction Fogginess Fatigue Cognitive slowing N=327, High School and University Athletes Within 7 Days of Concussion Difficulty falling asleep Sleeping less than usual (Pardini, Lovell, Collins, et al. 2004) Which On-Field Symptoms Predict Protracted Recovery (i.e. Post-Concussion Syndrome)? 2

20 Which On-Field Symptoms Increase Risk of Post Concussion Syndrome in High School Football Players? 176 Male HS Football Players (Mean Age = 16.2 years) Athletes had baseline ImPACT testing and were revaluated within 3 days of injury. All followed until clinical recovery (Mean = 4.1 evaluations) Within RCI of baseline on ImPACT for neurocognitive/symptom scores 32% of sample required < 7 days until recovery (N =56) Rapid Recovery (Mean = 4.9 days) 39% of sample required 7-14 days until recovery (N = 68) 17% of sample required > 21 days until recovery (N = 31) Protracted Recovery (Mean = 33.2 days) 12% lost to follow up (e.g. did not RTP or no follow-up in clinic) (N = 21) MANOVA used to determine differences between rapid/> 3 week recovery ATC s documented on-field markers (e.g. LOC, Amnesia) and on-field Symptoms (e.g. headache, dizziness, balance, photosensitivity, etc.) Lau B, Kontos A, Lovell MR, Collins MW, AJSM 2011 Which On-Field Markers/Symptoms Predict 3 or More Week Recovery from MTBI In High School Football Players On-Field Marker N Chi 2 P Odds Ratio 95% Confidence Interval Posttraumatic Amnesia Retrograde Amnesia Confusion LOC On-Field Symptom N Chi 2 P Odds Ratio 95% Confidence Interval Dizziness** **p<.01 Headache Sensitivity LT/Noise N = 107 Visual Problems Fatigue Balance Problems Personality Change Vomiting The total sample was 107. Due to the normal difficulties with collecting on-field markers, there were varying degrees of missing data. The number of subjects who had each coded ranged from The N column represents the number of subjects for whom data were available for each category. Markers of injury are not mutually exclusive. Lau, Kontos, Collins, Lovell, AJSM 2011 Which Symptoms at 3 Days Post-Injury Predict Protracted Recovery? 3

Current Symptoms Headache Nausea Vomiting Balance Problems Dizziness Fatigue Trouble falling asleep Sleeping more than usual Sleeping less than usual Drowsiness Sensitivity to light Sensitivity to

or double vision) 2 FOGGY DIFF CONC VOMIT DIZZY NAUSEA HEADACHE SLOWNESS BALANCE LIGHT SENS NOISE SENS NUMBNESS 1.5 1 0.5 0 Expressed as Effect Sizes (Cohen s D).

21 Current Symptoms Headache Nausea Vomiting Balance Problems Dizziness Fatigue Trouble falling asleep Sleeping more than usual Sleeping less than usual Drowsiness Sensitivity to light Sensitivity to noise Irritability Sadness Nervousness Feeling more emotional Numbness or tingling Feeling slowed down Feeling mentally foggy Difficulty concentrating Difficulty remembering Visual problems (blurry or double vision) 2 FOGGY DIFF CONC VOMIT DIZZY NAUSEA HEADACHE SLOWNESS BALANCE LIGHT SENS NOISE SENS NUMBNESS Expressed as Effect Sizes (Cohen s D). Only includes symptoms with large (greater than.80) effect sizes. Sample is composed of 108 male HS football athletes. Determination of Neurocognitive Cutoff Scores that Predict Protracted Recovery (at 2 days post injury) Lau B, Collins MW, Lovell MR Neurosurgery 2012;Feb 70(2):

22 Cutoff Values of ImPACT Neurocognitive Scores at 3 Days Post Injury That Predict Protracted Recovery 75% Sensitivity 80% Sensitivity 85% Sensitivity Neurocognitive Domain Cutoff Cutoff Cutoff Verbal Memory Visual Memory Processing Speed Reaction Time Sensitivity is defined as the ability of the cutoff to accurately identify protracted recovery (>14 days; Mean = 1 month) in an athlete. Lau B, Collins MW, Lovell MR. Neurosurgery Constitutional Risk Factors That Predict More Complicated Recovery Age - Field, Lovell, Collins et al. J of Pediatrics, Pellman, Lovell et al. Neurosurgery, 2006 Migraine History & Symptoms - Mihalik, Collins,Lovell et al, J Neurosurgery, Kontos, Collins, Elbin, French, Simenski, In Press Learning Disability - Collins, Lovell et al, JAMA, Kontos, Elbin, Collins, Data submitted for publication Repetitive Concussion - Collins, Lovell et al, Neurosurgery, Iverson et al, CJSM, Moser et al, JCEN, 2011 Gender - Colvin, Lovell, Pardini, Mullin, Collins, AJSM, Covassin et al, CJSM, 2009 Outcomes are highly variable Vestibular-related symptoms following injury predict more protracted recoveries Migraine-type symptoms (and potentially preexisting history of migraine) may place individuals at increased risk of injury and longer recovery Neurocognitive testing is valuable in determining prognosis and recovery with sports-related mtbi Clinical management key to preventing poor outcomes The mild injuries may become severe and the severe injuries may become mild 5

Risk Factors Using Concussion Clinical Trajectories to Inform

Trajectories Treatment and Rehab Pathways Vestibular Ocular

Concussion Program Department of Orthopaedic Surgery The UPMC

Schools Emergency Departments Over 18,000 patient visits Per year

Parents Primary /Schools Care Sports Med PM & R Vestibular /

23 Risk Factors Using Concussion Clinical Trajectories to Inform Targeted Treatment Pathways Concussion Concussion Clinical Trajectories Treatment and Rehab Pathways Vestibular Ocular Cognitive Fatigue Migraine Anxiety/ Mood Cervical The UPMC Sports Concussion Program Department of Orthopaedic Surgery The UPMC Sports Concussion Program Pediatric Practices ATC from Contracted Schools Emergency Departments Over 18,000 patient visits Per year UPMC Concussion Program (Neuropsych) Primary Care Physicians Parents Primary /Schools Care Sports Med PM & R Vestibular / Physical Therapy Neuro Radiology Orthopaedic /Neuro Surgery Behavioral Neuro- Optometry 6

Comprehensive Assessment and Treatment Approach Vestibular Physical Exertion Concussion Neurocognitive Ocular- Motor

2003 Echemendia 2001 Guskiewicz et al. 2003 Bleiberg et al. 2005 Iverson et al. 2006 McClincy et al.

Pencil NP 94 College Balance BESS 64 College Computer NP (ANAM) 30 High School Computer NP (ImPACT) 104 High School

24 Comprehensive Assessment and Treatment Approach Vestibular Physical Exertion Concussion Neurocognitive Ocular- Motor Symptoms Authors Sample Size Population Tests Utilized Total Days Cognitive Resolution Total Days Symptom Resolution Lovell et al McCrea et al Pro (NFL) Paper and Pencil NP 1 day 1 day 94 College SAC <1 Day 7 days McCrea et al Echemendia 2001 Guskiewicz et al Bleiberg et al Iverson et al McClincy et al Lovell, Collins et al 2008 Covassin et al 2011 Maugans et al College Paper and Pencil NP 29 College Paper and Pencil NP 94 College Balance BESS 64 College Computer NP (ANAM) 30 High School Computer NP (ImPACT) 104 High School Computer NP (ImPACT) 208 High School Computer NP (ImPACT) 72 High School Computer NP (ImPACT) 12 Ages Computer NP (ImPACT) 5-7 days 7 days 3 days 3 days 3-5 Days 7 Days 3-7 days Did Not Evaluate 10 days 7 Days 14 days 7-10 Days 26 days 17 Days 21 days 7 Days 30 days 14 Days 7

25 Three-year prospective study in Western PA. 17 high school football teams (2,141 total sample) 134 athletes with diagnosed concussion (6.2%) All athletes referred for evaluation at UPMC Recovery determined by Back to Baseline on computer neurocognitive test scores & symptom inventory Determined by Reliable Change Index Scores-RCI s) 8

Concussion Research Moving Forward: Evidence Informing Practice Anthony P. Kontos, Ph.D.

Surgery University of Pittsburgh Disclosure I have no specific conflict to declare regarding the current

the conclusion of this activity, participants should be able to: 1.

26 Concussion Research Moving Forward: Evidence Informing Practice Anthony P. Kontos, Ph.D. Assistant Research Director UPMC Sports Medicine Concussion Program Associate Professor Department of Orthopaedic Surgery University of Pittsburgh Disclosure I have no specific conflict to declare regarding the current presentation, however, I have current funding for concussion research from the following sources: Objectives At the conclusion of this activity, participants should be able to: 1. Explain the role of post-traumatic migraine as a prognostic factor for concussion. 2. Apply evidence to support the use of post-exertion neurocognitive testing to inform return to play decisions. 1

Prognosis for Concussion: The Role of Post-traumatic Migraine (PTM) Post-traumatic Migraine (PTM) Defined Post-traumatic Migraine Headache, nausea, AND sensitivity to light OR noise (Int l Headache

27 Prognosis for Concussion: The Role of Post-traumatic Migraine (PTM) Post-traumatic Migraine (PTM) Defined Post-traumatic Migraine Headache, nausea, AND sensitivity to light OR noise (Int l Headache Society) PTM has been associated with poor outcomes following concussion (Mihalik et al., 2005) Does sub-acute PTM influence recovery time and is PTM worse than headache alone? Study Overview 138 athletes with neurocognitive and symptom scores at: Baseline 1-7 days 8-14 days Divided into mutually exclusive groups: PTM, Headache, or No PTM/Headache groups 97 athletes met Rapid or Protracted Criteria for Recovery Time: Rapid ( 7 days)= 61 Protracted ( 21 days)= 36 Kontos, Elbin, Lau, Simensky, Freund, French, Collins; In review 2

How does PTM compare to No Headache and Headache groups in predicting Protracted (>21 days) Recovery from Sports Concussion? (N= 97) Variable Wald p PTM v. No Headache/PTM Headache v.

54 Kontos, Elbin, Lau, Simensky, Freund, French, Collins; In review Comparison of Visual Memory scores for PTM, Headache, and No PTM or Headache groups (λ=.88, F= 4.24, p=.002, η 2 =.

28 How does PTM compare to No Headache and Headache groups in predicting Protracted (>21 days) Recovery from Sports Concussion? (N= 97) Variable Wald p PTM v. No Headache/PTM Headache v. No Headache/PTM Odds Ratio 95% CI PTM v. Headache Kontos, Elbin, Lau, Simensky, Freund, French, Collins; In review Comparison of Visual Memory scores for PTM, Headache, and No PTM or Headache groups (λ=.88, F= 4.24, p=.002, η 2 =.06, n= 138)* *PTM significantly different than both groups at 1-7 and 8-14 days Kontos, Elbin, Lau, Simensky, Freund, French, Collins; In review Comparison of Reaction Time scores for PTM, Headache, and No PTM or Headache groups (λ=.87, F= 4.96, p=.001, η 2 =.07) *PTM significantly different than both groups at 1-7 and 8-14 days Kontos, Elbin, Lau, Simensky, Freund, French, Collins; In review 3

29 Conclusion Athletes with PTM were 7.3x and 2.6x more likely to have a prolonged recovery than those without and those with Headache only, respectively Athletes with PTM experienced more severe and prolonged visual memory and reaction time deficits than those without and those with Headache only It s more than just headache! Clinicians need to assess PTM in all athletes Kontos, Elbin, Lau, Simensky, Freund, French, Collins; In review Return to Play: The Importance of Post- exertion Neurocognitive Testing Return to Play (RTP) Guidelines Criteria for RTP (McCrory et al., 2009): Neurocognitive and symptom scores back to baseline or normal at rest Symptom free following exertion But can clinicians rely on symptoms to avoid premature RTP when the concussed brain is vulnerable? Can neurocognitive testing provide additional RTP information? 4

Study Overview (N= 55 Concussed Pts) M= 3.15 days (SD= 2.45) M= 13.23 days (SD= 8.82) M= 18.78 days (SD = 14.

30 Study Overview (N= 55 Concussed Pts) M= 3.15 days (SD= 2.45) M= days (SD= 8.82) M= days (SD = 14.57) BASELINE neurocog, symptoms POST- CONCUSSION (P1) neurocog, symptoms Moderate Exertion 20 min of : Stationary Cycling Treadmill or Elliptical RETURN TO BASELINE (RTB) neurocog, symptoms POST- EXERTION (PE) neurocog, symptoms 16 FAIL (1+ RCI) and 39 PASS (NO RCI) McGrath, Dinn, Lovell, Collins, Elbin, Kontos, Brain Injury; 2013 Results 27% of athletes who were back to neurocognitive baseline and reported no symptoms at rest FAILED a post-exertion (PE) ImPACT test in spite of reporting no symptoms (after exertion) McGrath, Dinn, Lovell, Collins, Elbin, Kontos, Brain Injury; 2013 Verbal Memory Scores for Post- Exertion Pass and Fail Groups* *p<.05 McGrath, Dinn, Lovell, Collins, Elbin, Kontos, Brain Injury; in press. 5

Visual Memory Scores for Post- Exertion Pass and Fail Groups* 62 57 *p<.

McGrath, Dinn, Lovell, Collins, Elbin, Kontos, Brain Injury; 2013 Conclusion We need post-exertion neurocognitive testing to inform safe

31 Visual Memory Scores for Post- Exertion Pass and Fail Groups* *p<.05 McGrath, Dinn, Lovell, Collins, Elbin, Kontos, Brain Injury; 2013 Self-reported Symptom Scores remain low- I m fine. McGrath, Dinn, Lovell, Collins, Elbin, Kontos, Brain Injury; 2013 Conclusion We need post-exertion neurocognitive testing to inform safe RTP Should not rely on symptoms Tests that focus on Symptom Reports and RT/Processing Speed may fail to detect PE impairment Only memory impairments were evident McGrath, Dinn, Lovell, Collins, Elbin, Kontos, Brain Injury;

Prognosticating Protracted Recoveries from Sports Concussion: What are we Learning?

Prognosticating Protracted Recoveries from Sports Concussion: What are we Learning? Associate Professor UPMC Department of Orthopaedic Surgery UPMC Department of Neurological Surgery Director UPMC Sports