Prevention and Concussion

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1 Update on Concussion Prevention and Concussion Management Kevin Guskiewicz, PhD, ATC Matthew Gfeller Sport-Related TBI Research Center UNC-Chapel Hill Challenges Elusive injury No clear marker Variability in presentation Signs & symptoms may be delayed Sensitivity & specificity of sideline evaluation

Changing sports concussion philosophy Concussions are all the same: minor injuries that resolve on their own Not all concussions are the same: try to grade them

Hematoma Arterial bleed and faster Subdural Hematoma Usually venous and slower bleed Second Impact Syndrome Loss of auto-regulation of blood flow throughout the

sports) % (n) Total % (n) Rapid (< 1 day) 28.3 (53) 17.4 (64) 21.0 (17) 21.1 (134) Gradual (> 1 day, < 7 days) 60.4 (113) 68.1 (250) 55.6 (45) 64.

2 Changing sports concussion philosophy Concussions are all the same: minor injuries that resolve on their own Not all concussions are the same: try to grade them Concussions are diverse and unique injuries: treat them individually Concussed athletes are each unique: understand what makes them different Severe TBI Epidural Hematoma Arterial bleed and faster Subdural Hematoma Usually venous and slower bleed Second Impact Syndrome Loss of auto-regulation of blood flow throughout the brain Post-Concussion Recovery Course Category of Postinjury Recovery NCAA (College FB only) % (n) CPI (6 HS & 6 College sports) % (n) HS Project Sideline (6 HS sports) % (n) Total % (n) Rapid (< 1 day) 28.3 (53) 17.4 (64) 21.0 (17) 21.1 (134) Gradual (> 1 day, < 7 days) 60.4 (113) 68.1 (250) 55.6 (45) 64.3 (408) Prolonged (1week 1 month) 9.6 (18) 11.7 (43) 18.5 (15) 11.9 (76) Persistent PCS (> 1 month) 1.6 (3) 2.7 (10) 4.9 (4) 2.7 (17) Concussion Prevention Initiative: Guskiewicz, McCrea, and Marshall

3 Why all the concussion concern? Short Term Risks of Mismanagement Worsening of post-concussive signs and symptoms Long Term Risks of Mismanagement Prolonged concussion symptoms (daily basis) Repeat concussion with post concussion syndrome Depression, cognitive impairment, dementia, CTE School-related issues in student athletes Long-term academic issues in student athletes Second Impact Syndrome (younger athletes) Decreased Quality of Life Managing Concussion with Objective Tools Pre-Concussion Testing Tool Box 1-3 Days Day 5-10 Day Concussion

Clinical Recovery Symptoms Amnesia Sex LOC Balance Concussion Hx Brief Mental Status Pre-Season Preparation Have a written Emergency Action Plan (EAP) Have a written Concussion Policy and RTP

4 Clinical Recovery Symptoms Amnesia Sex LOC Balance Concussion Hx Brief Mental Status Pre-Season Preparation Have a written Emergency Action Plan (EAP) Have a written Concussion Policy and RTP Protocol Be prepared for c-spine & more serious brain injury Education of athletes, coaches & other medical personnel Baseline assessment & Return to Play Protocol 15 Important Components of the Sideline/Initial Assessment Important components evaluating / managing the concussed athlete? Preparation Recognition of injury / Triggers Evaluation tools Disposition decision making Return to play? Multi-modal Assessment Paradigm History Observation Symptoms Predispositions ROM & Strength of Neck Palpation Postural Control/Balance Stress Tests Cognition Coordination Cranial Nerves Functional Testing

Graded Symptom Scales Graded Post Concussion Scale; (Lovell et al 2006) SCAT2/3; (McCrory et al, 2009; 2012) Symptoms Consistent evidence of relationship between # and severity of symptoms following

recovery McCrea 12, Guskiewicz 11, Makdissi 10, Iverson 07, Makdissi 13 Symptoms; Post Concussion Scale Most frequent sx after concussion: Headache Fatigue Feeling slowed down Drowsiness Difficulty

5 Graded Symptom Scales Graded Post Concussion Scale; (Lovell et al 2006) SCAT2/3; (McCrory et al, 2009; 2012) Symptoms Consistent evidence of relationship between # and severity of symptoms following concussion and overall severity Athletes reporting > 4 symptoms more likely to have prolonged recovery Amnesia, prolonged HA, fatigue or fogginess, memory problems, dizziness associated w/ prolonged recovery McCrea 12, Guskiewicz 11, Makdissi 10, Iverson 07, Makdissi 13 Symptoms; Post Concussion Scale Most frequent sx after concussion: Headache Fatigue Feeling slowed down Drowsiness Difficulty concentrating Feeling mentally foggy Dizziness These sx endorsed in 58-86% of cases Lovell et al, 06; Guskiewicz et al, 11; McCrea et al, 03 What are the observable red flags? Decreasing level of consciousness Increasing confusion Increasing irritability LOC or fluctuating level of consciousness Pupils becoming unequal in size Repeated vomiting Seizures Slurred speech or inability to speak Inability to recognize people/places Worsening headache NATA Position Statement, 2014

Sideline Cognitive Testing Sideline tools (SAC or SCAT3)evaluate domains of cognitive function susceptible to effects of concussion: orientation, working

Limitations due to time constraints Ceiling effect Do not take the place of more comprehensive Neuropsychological (NP) testing McCrea 01, Daniel 02, Hecht

if signs and symptoms indicate balance dysfunction Limitations Effected by fatigue, exercise Practice effects Reliability concerns Guskiewicz 01, 11;

Assessment Metrics (ANAM) Balance Error Scoring System (BESS) Clinical Test Battery Six 20 sec trials using 3 different stances (double, single, tandem)

6 Sideline Cognitive Testing Sideline tools (SAC or SCAT3)evaluate domains of cognitive function susceptible to effects of concussion: orientation, working memory, attention & concentration, new learning & memory, processing speed & executive functioning. Limitations due to time constraints Ceiling effect Do not take the place of more comprehensive Neuropsychological (NP) testing McCrea 01, Daniel 02, Hecht 04, Shehata 09, Putukian AMSSM 12, McCrea 13 Balance Assessment Utility of balance testing Deficits return to baseline within 3-7 days Especially useful if signs and symptoms indicate balance dysfunction Limitations Effected by fatigue, exercise Practice effects Reliability concerns Guskiewicz 01, 11; Peterson 03, McCrea 03, McCrory 09 Broglio 09, Davis 09, Finnoff 09, Susco 04, Wilkins 04 Computerized cognitive testing Automated Neuropsychological Assessment Metrics (ANAM) Balance Error Scoring System (BESS) Clinical Test Battery Six 20 sec trials using 3 different stances (double, single, tandem) on 2 different surfaces (firm, foam) Recorded Errors - Hands lifted off iliac crests - Opening eyes - Step, stumble, or fall - Moving into >30 deg. of hip flexion or abduction - Remaining out of testing position for >5 secs.

Symptom, Cognitive, and Postural Stability Recovery in Concussion and Control Participants McCrea, M, Guskiewicz, K, et al. JAMA 2003;290:2556-2563. Copyright restrictions may apply.

7 Symptom, Cognitive, and Postural Stability Recovery in Concussion and Control Participants McCrea, M, Guskiewicz, K, et al. JAMA 2003;290: Copyright restrictions may apply. Standard Baseline Assessment Pre-season assessment including history (e.g. concussion history, migraine, seizures, learning disability, anxiety/depression) & examination (baseline sideline) & baseline concussion testing Symptom Checklist Sideline Cognitive Exam Sideline Balance Assessment Other baseline abnormalities (e.g. cervical spine, motor/sensory deficits) Baseline Neuropsychological Testing Shehata 09, NFL Sideline Assessment, Jinguji 2012, Valovich-McLeod 12, McCrory 09, Herring 11 Incidence, Clinical Course, and Predictors of Prolonged Recovery Time Following Sport-related Concussion in High School & College Athletes McCrea, Guskiewicz, Randolph et al, J Int Neuro Soc (2013),19:22-33 McCrea, Guskiewicz, Barr, et cal., JINS (2012) Prolonged Recovery group Prolonged Recovery group Fig. 1 Symptom recovery curve comparing typical recovery (open circles), prolonged recovery (filled circles), and normal control (Xs) groups. Group x time interaction, p <.001. Higher scores indicate more severe symptoms on the GSC. GSC = Graded Symptom Checklist; CC = time of concussion; 3 HR = 3 hours post-injury. Error bars indicate 95% confidence interval. Fig. 2 Cognitive recovery curve comparing typical recovery (open circles), prolonged recovery (filled circles), and normal control (Xs) groups. Group x time interaction, p <.001. Lower scores indicate poorer cognitive test performance on the SAC. SAC = Standardized Assessment of Concussion; CC = time of concussion; 3 HR = 3 hours post-injury. Error bars indicate 95% confidence interval. Fig. 3 Postural stability/ balance recovery curve comparing typical recovery (open circles), prolonged recovery (filled circles), and normal control (Xs) groups. Group x time interaction, p <.001. Higher scores indicate poorer balance test performance on the BESS. BESS = Balance Error Scoring System; CC = time of concussion; 3 HR = = 3 hours postinjury. Error bars indicate 95% confidence interval. SomaticSymptoms Frequency (%) Headache 56 (60.0%) Nausea 12 (13.0%) Vomiting 0 (0.0%) Balance problems 31 (33.0%) Sensitivity to light 24 (26.0%) Sensitivity to noise Tinnitis Dizziness Blurred vision Neck pain 20 (22.0%) 5 (5.0%) 32 (34.0%) 17 (18.0%) 35 (37.0%) Neurobehavioral Symptoms Frequency (%) Sleep disturbance 24 (26.0%) Purpose: Examine the proportion of concussed athletes with impairment disagreements across various clinical concussion assessment measures. Drowsiness 40 (43.0%) Fatigue 23 (25.0%) Sadness Irritable 6 (6.0%) 19 (20.0%) Cognitive Symptoms Frequency (%) Difficulty concentrating 46 (49.0%) Difficulty remembering 31 (33.0%) Methods: N= 100 concussed collegiate aged athletes assessed at BL & <72 hrs post-injury on GSC, computerized NP, and balance

Assessment Domains & Implications for RTP NATA Position Statement, 2014 Divided attention tasks

response times, efficient gait strategies and postural control > in concussed participants

Dual task assessments in some cases were more reliable than single task assessments.

Symptoms Assessment Implications for RTP Neurobehavioral Somatic Headache Nausea Vomiting Balance

8 Assessment Domains & Implications for RTP NATA Position Statement, 2014 Divided attention tasks useful in concussion management. response times, efficient gait strategies and postural control > in concussed participants specifically under divided attention conditions. Dual task assessments in some cases were more reliable than single task assessments. Effect sizes vary depending on timing of assessment and the measures used. Symptoms Assessment Implications for RTP Neurobehavioral Somatic Headache Nausea Vomiting Balance Problems Sensitivity to Light Sensitivity to Noise Numbness/Tingling Sleeping more Drowsiness Fatigue Piland et al, 2007 Sadness Nervousness Trouble Sleeping Cognitive Feeling Slowed Down Feeling in a Fog Difficulty Concentrating Difficulty Remembering

Cognitive Assessment & Implications for RTP Neuropsychological Deficit Functional School Problem Management Strategy Attention/ Concentration Short focus on lecture, classwork, homework Shorter

information, accessing learned info when needed Repetition, written instructions, use of calculator, short reading passages Smaller chunks to learn, recognition cues Processing Speed Keep pace with

breaks Courtesy of Dr` Gerry Gioia; (2011) Why the graduated return?

9 Cognitive Assessment & Implications for RTP Neuropsychological Deficit Functional School Problem Management Strategy Attention/ Concentration Short focus on lecture, classwork, homework Shorter assignments, break down tasks, lighter work load Working Memory Holding instructions in mind, reading comprehension, math calculation, writing Memory Consolidation/ Retrieval Retaining new information, accessing learned info when needed Repetition, written instructions, use of calculator, short reading passages Smaller chunks to learn, recognition cues Processing Speed Keep pace with work demand, process verbal information effectively Extended time, slow down verbal info, comprehensionchecking Fatigue Decreased arousal/ activation to engage basic attention, working memory Rest breaks Courtesy of Dr` Gerry Gioia; (2011) Why the graduated return? Physical Importance No symptoms present Reaction time and comfort level with activity Fitness assessment Strength assessment With increases in heart rate, what happens to symptoms? Functional Assessment Implications for RTP Why the graduated return? Psychological Importance Mental readiness for return Comfort level with physical readiness and ability to perform Practice and performance

10 McCrory, 2013 How many steps per day can be performed? Consensus Driving Best Practice Gold Standard: Rest Followed by Graded Exertion Controversies in Concussion Management 2. Point: The treatment for a concussion is complete brain rest ( cocoon therapy ).(1) Recommended actions include staying home from school in a darkened room without TV, smart phone, or other electronic devices until all symptoms clear. No video games. Do not have conversations for more than 10 minutes. Don t watch sports where you have to track a ball with your eyes. Decrease or remove flourescent lights from your house. Listen to speakers only on low volume, no headphones.

DEFINITION: What is rest? DOSE: How much to do I take? DURATION: How long should I take it? DISCONTINUE: How will I know when to stop it?

pressure regulation, blood flow homeostasis, and metabolic waste clearance.

11 DEFINITION: What is rest? DOSE: How much to do I take? DURATION: How long should I take it? DISCONTINUE: How will I know when to stop it? ESSR; October 2015 Regular exercise performed at moderate to high intensity attenuates an agerelated reduction in regional brain volume, deterioration of WM integrity, and cognitive decline. Cardiovascular adaptations to aerobic exercise training make for a favorable systemic and cerebral hemodynamic environment, where the brain may benefit from the improvements in arterial pressure regulation, blood flow homeostasis, and metabolic waste clearance. Activity (When Done Right) Outdoes Rest Studies Supporting Graduated RTP: Indirect Evidence Most repeat concussions occur within 7-10 days (Guskiewicz, 2003) Concussion risk increases if there is a previous history of concussion (Zemper, 2003; Guskiewicz, 2003; Tsushima, 2016) Many concussions (>50%) are not initially reported (McCrea, 2004; Register-Mihalik, 2013) Retrospectively, no activity and highest activity groups have worse outcomes; light activity may benefit (Majerske, 2008) Benefits of rest (Moser, 2012)

Frontier for the Graduated RTP: A Graded Exercise Progression Incidence, Clinical Course, and Predictors of Prolonged Recovery Time Following Sport-related Concussion in High School & College

1 Symptom recovery curve comparing typical recovery (open circles), prolonged recovery (filled circles), and normal control (Xs) groups. Group x time interaction, p <.001.

2 Cognitive recovery curve comparing typical recovery (open circles), prolonged recovery (filled circles), and normal control (Xs) groups. Group x time interaction, p <.001.

12 Frontier for the Graduated RTP: A Graded Exercise Progression Incidence, Clinical Course, and Predictors of Prolonged Recovery Time Following Sport-related Concussion in High School & College Athletes McCrea, Guskiewicz, Randolph et al, J Int Neuro Soc (2012),19:22-33 Prolonged Recovery group Prolonged Recovery group Buffalo Concussion Treadmill Test (BCTT) Fig. 1 Symptom recovery curve comparing typical recovery (open circles), prolonged recovery (filled circles), and normal control (Xs) groups. Group x time interaction, p <.001. Higher scores indicate more severe symptoms on the GSC. GSC = Graded Symptom Checklist; CC = time of concussion; 3 HR = 3 hours post-injury. Error bars indicate 95% confidence interval. Fig. 2 Cognitive recovery curve comparing typical recovery (open circles), prolonged recovery (filled circles), and normal control (Xs) groups. Group x time interaction, p <.001. Lower scores indicate poorer cognitive test performance on the SAC. SAC = Standardized Assessment of Concussion; CC = time of concussion; 3 HR = 3 hours post-injury. Error bars indicate 95% confidence interval. Fig. 3 Postural stability/ balance recovery curve comparing typical recovery (open circles), prolonged recovery (filled circles), and normal control (Xs) groups. Group x time interaction, p <.001. Higher scores indicate poorer balance test performance on the BESS. BESS = Balance Error Scoring System; CC = time of concussion; 3 HR = = 3 hours post-injury. Error bars indicate 95% confidence interval. 46 Frontier for the Graduated RTP: Dual-Tasks? Concussion Rehabilitation: Dual Task (cognition & motor) Performance Divided attention is difficult when: Tasks are similar Tasks are difficult When both tasks require conscious attention Divided attention is easier when: Tasks are dissimilar Tasks are simple When at least one of the tasks does not require conscious attention Tasks are practiced

Demonstrate the safety and feasibility of active intervention protocols when introduced during the sub-acute recovery period after SRC, as part of an multidimensional rehabilitation protocol.

13 Efficacy of active rehabilitation during sub-acute recovery window? Specific Aim 1 Specific Aim 2 Compare the effects of a multidimensional rehabilitation protocol versus enhanced graded exertion on clinical recovery, return to play, and patient outcomes after SRC. Demonstrate the safety and feasibility of active intervention protocols when introduced during the sub-acute recovery period after SRC, as part of an multidimensional rehabilitation protocol. *Enhanced graded exertion will encompass the Zurich RTP guidelines, enhanced to include guided activity in Stage 1 and more sport specific concepts throughout the return to play process, consistent with common current day practice. Active Rehabilitation Divided attention program (4 weeks) for individuals with symptoms lasting at least 3 weeks Did/do provoke symptoms, but not beyond tolerance Each time, symptom reports decrease and functionality increases Patients report it feels like they have something to do N=6 (certainly need more data); future research control group Cluster-Randomized Controlled Trial 2-yr prospective study period Arm 1: Enhanced Graded Exertion (n=100; 25 from each cohort) Arm 2: Multidimensional Active Rehab + Enhanced Graded Exertion (n=100; 25 from each cohort) Randomized by Team / School Retrospective study period Existing prior standard of care data on concussion incidence and return-to-play will be provided for each cohort by the cohort investigators 01 July 2016 Randomization will occur at the level of the team for professional and elite cohort sports and at the level of the school for High School and College.

Overview of Study Arms & Interventions Historical Standard of Care Arm 1: Enhanced Graded Exercise Group Data obtained from retrospective datasets Arm 2: Multidimensional Active Rehab Group Education

14 Overview of Study Arms & Interventions Historical Standard of Care Arm 1: Enhanced Graded Exercise Group Data obtained from retrospective datasets Arm 2: Multidimensional Active Rehab Group Education & Information Education & Information Initial Rest with Guided Activity (focus on ablement not disablement; activity as tolerated) Initial Rest with Guided Activity (focus on ablement not disablement; activity as tolerated) Symptom Guided Activity Continues Symptom Guided Activity Continues + Active rehabilitation progression Once asymptomatic begin step 2 of enhanced GRTP with sport/skill specific activities incorporated Return to Play* Return to Play* Once asymptomatic begin step 2 of enhanced GRTP with active rehabilitation progression continuing and sport specific activities incorporated Enhanced Graded Exertion Progression All Participants Graded Exertion/Activity Phase Functional Exercises 1. No Activity* Complete physical and cognitive rest 2. Light aerobic activity Walking, swimming, stationary biking, & sport specific activity (<80% MHR) 3. Sport specific exercise Running drills and sport specific activity, etc. 4. Non-contact training drills Passing drills, can begin resistive exercise with focus on sport specific activities 5. Full contact practice Following medical clearance, full practice 6. Return to play Return to full participation, including games/competitions *In the Multidimensional group, this phase (1) will include symptom guided activity and beginning of mutlidimensional rehab once symptoms stabalize. In the enhanced graded exertion group, this phase will include symptom guided activity. Sport specific activities will also be mapped out for each phase. Randomization & Study Procedures *School/Team Randomization Arm 2: Multidim. Rehab Group Pre-Season Baseline Testing Arm 1: Enh. Graded Ex. Group Pre-Season Baseline Testing Concussion Occurs & Immediate Assm. Concussion Occurs & Immediate Assm Hr. Assessment Hr. Assessment Guided Activity + Multi Dim. Rehab (when sx stable) Guided Activity (when sx stable) Asymptomatic Assessment Enhanced GRTP Begin (St 2-5) Asymptomatic Assessment Enhanced GRTP Begin (St. 2-5) Full RTP Full RTP 1-month Assessment 1-month Assessment *Randomization prior to the season at the institution/team level to avoid contamination within research sites Acute (Stage 1 GRTP) Multidimensional Rehabilitation Arm Progression Rehabilitation Intervention (Stage 1 RTP if symptomatic; to be integrated with stages 2-5 GRTP once symptoms resolve) Symptoms Unstable/Declining Symptoms Stable for 24 hour period Symptoms Stable after (24h) at least 1 Phase I Session Symptoms Stable after (24h) at least 1 Phase II Session Symptoms Stable after (24h) at least 1 Phase III Session Symptoms Stable after (24h) at least 1 Phase IV Session 15 minute sessions Phase I Phase II Phase III Phase IV Phase V Cognitive Dual-Task Simple Math Digit Span 100 by 7 Physioball Foam Pad Tandem Gait Pursuits Pencil Push Scanning 100 by 7 COWAT Simon Balance Foam Pad Tandem Gait Rocker Board Visual/Vestibular Pencil Push Gaze Stability Ball Toss Simon N-Back Stroop Rocker Board + Bosu Ball Ball Toss Gaze Stability Scanning Tandem Gait + Simple Math Convergence + Bosu Ball Gaze Stability + Foam Pad COWAT + Rocker Board Ball Toss + Bosu Visual/Vestibular Activities Rocker Board + Gaze Stability + Stroop Ball Toss + Bosu N-Back + Foam Pad COWAT + Bosu Lunges Simon + Tandem Gait Visual/Vestibular Activities * Acute Guided Activity Phase (includes general stretching and non-provocative exercise) Cervicogenic Manual Therapy of the Cervical Spine (Massage/Stretching) Trigger Point Release

Exertion Progression Simple Math 1+2; 3+1

Say yes if color the same as the word BLUE

see is the same as the one you immediately

Outcome Measures Primary outcomes Time to

available) Feasibility Outcomes Compliance

15 Cognitive Techniques Balance Techniques Visual Techniques Active Rehab + Graded Exertion Progression Simple Math 1+2; 3+1 Foam EC: DL, SL, Tandem Gaze Stability Active Rehab Group Only Dual-Task Techniques Rocker Board + Stroop We expect that each session will last minutesminutes, Stroop regardless of phase Say yes if color the same as the word BLUE Ball Toss N-Back State if the letter you see is the same as the one you immediately saw before- A B A A Bosu Ball Pencil-Push Bosu/Dynadisc lunges + COWAT Serial 7s Count backwards from 100 by 7: , etc Outcome Measures Primary outcomes Time to Asymptomatic Time to Full Return to Play Exploratory outcomes Subsequent/Repeat Injury Occurrence (only in subset, where available) Feasibility Outcomes Compliance Intervention Feasibility Patient Satisfaction Multi-dimensional Rehab Activities Photos here WSJ

16 Thank You Kevin Guskiewicz, PhD, ATC

Pre and Post Concussion Management

Pre and Post Concussion Management Timothy A. Tolbert, Ph.D., ATC Clinical Coordinator Marshall University Athletic Training Program 1 Concussion A complex pathophysiological process affecting the brain,