Vanderbilt Sports Concussion Center: Clinical, Educational, and Research Activities. Tennessee Psychological Association Convention October 31, 2013

Transcription

1 Vanderbilt Sports Concussion Center: Clinical, Educational, and Research Activities Tennessee Psychological Association Convention October 31, 2013 Gary Solomon, Ph.D., FACPN Associate Professor of Neurological Surgery, Orthopedic Surgery and Rehabilitation, and Psychiatry Co-Director, Vanderbilt Sports Concussion Center Vanderbilt University School of Medicine Team Neuropsychologist, Nashville Predators Consulting Neuropsychologist, Tennessee Titans

2 Disclosures/Competing Interests Consulting fees from the Nashville Predators and Tennessee Titans Involved in beta testing new versions of ImPACT and receive free use during the testing Member of the ImPACT Professional Advisory Board; reimbursed for expenses associated with board meetings This presentation is not endorsed by any organization with which I am affiliated No support received for today s presentation The information is these slides is effective/accurate as of September17, 2013

3 Three Books and a Movie Rose Moser William Meehan Robert Cantu Chris Nowinski

4 : Practice Parameter Updates NAN, AMSSM, CISG, AAN

5 Update and Overview 4 areas 1. Concussion Laws 2. Concussion in Sport Group (CISG) 4 Overview of changes from CISG 3 3. Vanderbilt Sports Concussion Center Clinical Activities VSCC Educational Activities Local, regional, state, national, and international involvements Grant Activities fmri Study of Sports-Related Concussion Rawlings

6 23 studies 4. V-SCoRE: Vanderbilt Sports Concussion Research Structural Brain Injury in Sports Concussion Pharmacologic Treatment of Sports Concussion Baseline and Post-Concussion Neurocognitive Testing Modifying Factors in SRC NFL Athletes

7 Sports Concussion Laws Sports concussion is the only athletic injury regulated by state law

8 The evolution of sports concussion laws Washington State, 2009 Zackery Lystedt Law House Bill 1824 On May 14th 2009, Gov. Christine Gregoire signed the nation's toughest youth athlete return-to-play law. The new law (House Bill 1824), known as the Zackery Lystedt Law, requires medical clearance of youth athletes suspected of sustaining a concussion, before sending them back in the game, practice or training. Dr. Richard Ellenbogen, his neurosurgeon, would later be named co-chair of the NFL Head, Neck, & Spine Committee

9 States with Concussion Laws: 2009

10 States with Concussion Laws:

11 States with Concussion Laws:

12 States with Concussion Laws:

13 States with Concussion Laws: Spring, 2013 Update: Law passed in SC Source: Education Week, 5/17/13

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15 August 29, 2013

16 Timeline: Tennessee Sports Concussion Law & Neuropsychology July, 2010: Due to the lack of a state law, TSSAA implements concussion management guidelines and a return to play policy for athletes; requires clearance for RTP by a physician January 2011: At the request of Keith Hulse, Ph.D., TPA State Legislative Affairs Director, we met with Bernard Childress, Executive Director of the TSSAA, to discuss including Neuropsychologists in RTP decisions

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18 January, 2012: TN Athletic Trainers Society sponsors first sports concussion bill in TN; House/Senate support from Rep. Maggart and Senator Tracy January-March, 2011: Attended 3 legislative meetings related to bill; supported by TATS, TPA, and TMA March, 2012: Bill withdrawn by Rep. Maggart

19 Sidney Crosby The day Rep. Maggart presented the bill in Committee, every member of the Committee had an amendment prepared to include chiropractors as health care professionals who could make RTP decisions GyroStim Dr. Ted Carrick, Sidney Crosby, Ray Shero, Dr. Micky Collins

20 2013 TATS, TMA, TNAAP

21 February 20, 2013: Adolphus Birch, NFL Senior VP of Labor, Law, Policy, and Government Affairs testifies before TN Senate Education Committee February 28, 2013: Bill 882 passes in Senate 30-0

22 Representative Sexton Bill passes in House, 93-3

23 Law takes effect January 1, 2014

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25 What has yet to be defined for neuropsychologists in TN state law is concussion training

26 Concussion in Sport Group (CISG) 4 Zurich, 2012

27 The first meeting of the CISG was held in Vienna in 2000, convened by the IOC, FIFA, and IIHF The second meeting was held in Prague, It had the same 3 sponsors plus the IRB joined The third meeting was held in Zurich, 2008 (same 4 sponsors). This was a formal consensus meeting following the organizational guidelines set forth by the US National Institutes of Health The fourth meting was held in Zurich, FEI joined as a fifth sponsor A consensus statement has been published after each meeting in multiple sports medicine journals

28 Concussion in Sport Group Authors: Paul McCrory Willem Meeuwisse Mark Aubry Bob Cantu Jiri Dvorak Ruben Echemendia Lars Engebretsen Karen Johnston Jeff Kutcher Martin Raftery Allen Sills Co-Authors: Brian Benson Gavin Davis Kevin Guskiewicz Stanley A. Herring Grant Iverson Barry Jordan James Kissick Michael McCrea Andrew McIntosh David Maddocks Michael Makdissi Laura Purcell Margot Putukian Michael Turner Kathryn Schneider Charles Tator

29 Red = Changed/Deleted Blue = Added Green = Editorial Comments

30 The Neurosurgeon in Sport: An Update from the 2012 Zurich International Concussion Conference Allen Sills, M.D.* Richard Ellenbogen, M.D.** Gary Solomon, Ph.D.* *Vanderbilt University Department of Neurological Surgery and the Vanderbilt Sports Concussion Center **University of Washington Department of Neurological Surgery Neurosurgery, 2013, in press

31 Definition of Concussion: New/Changed Partially The definition of concussion has changed partially, and the information contained in the document applies to athletes 13 years and older (previously age 10 and up) CISG wants to separate the definition of concussion from mild traumatic brain injury (mtbi), believing that the terms should not be used interchangeably However, no discriminating definition was offered It was implied in the definition that concussion involves normal neuroimaging while mtbi involves abnormal neuroimaging

32 Traumatic Brain Injury Glasgow Coma Scale Minimal Mild Mod Severe? Sports concussion Severe GCS 8 Moderate GCS 9-12 Mild GCS Teasdale et al Lancet 1974; ii: 81-4

33 Concussion is a brain injury (added) and is defined as a complex pathophysiological process affecting the brain, induced by traumatic (deleted) biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: 1. Concussion may be caused either (deleted) by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head. 2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. However in some cases, symptoms and signs may evolve over a number of minutes to hours. deleted from the definition, but mentioned later in the document

34 3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen in concussion on standard structural neuroimaging studies (added here; this was the fifth point of the 2008 definition).* 4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course; however, it is important to note that in some (deleted) a small percentage of (added) cases postconcussive (deleted) symptoms may be prolonged.** Editorial Comments: *Point 3 indicates the implied distinction between concussion & mtbi **Point 4 suggests that prolonged symptoms may not be postconcussive

35 Concussion Recognition Tool (CRT): New Signs, Symptoms, Maddocks Questions, Red Flags

36 SCAT3

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38 SCAT2 vs. SCAT3 1 (2) changes Symptoms Signs Glasgow Coma Scale Maddocks Questions SAC Balance: Modified BESS Coordination (Finger to Nose) SAC-Delayed Recall Injury Advice New addition Prominence of symptoms changed Despite adding neck exam, no neck symptoms added to Sx checklist Signs Glasgow Coma Scale Maddocks Questions History Symptoms SAC Neck (ROM, sensation, strength, tenderness) Balance: Modified BESS Coordination (Finger to Nose) SAC-Delayed Recall Injury Advice

39 GCS Childs Maddocks Questions Symptoms: Child Symptoms: Parent Rating SAC-Child Neck Balance Coordination SAC-Delayed Information Return to Play Return to School Injury Advice

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42 Child SCAT3 -Differences Child Maddocks questions Symptom Scale child-specific 4 point rating scale Parent rating of child s symptoms Orientation no time of day question Concentration start with 2 reverse digits Reverse days of the week Modified BESS no single leg stance Patient advice return to school

43 What is Unchanged in the CIS 4 Document Overarching Principles: Consensus based approach Management and return to play decisions remain in the realm of clinical judgment on an individualized basis Concussion Classification: The majority (80-90%) of concussions resolve in a short (7-10 day) period, although the recovery time frame may be longer in children and adolescents

44 Concussion Evaluations: Unchanged with One Deletion Symptoms and Signs of acute concussion On-Field or Sideline Evaluation of acute concussion (except no same-day RTP for adult, professional, or elite athlete previously had exceptions which were deleted) Evaluation in Emergency Room or Office by Medical Personnel

45 Concussion Evaluation: Unchanged Neuroimaging: CT/MRI not necessarily indicated. Updated types of sophisticated functional neuroimaging but all remain investigational Genetic testing, concussion biomarkers, andelectrophysiological investigations are not yet indicated clinically Balance Assessment: Now has its own section in the document but content is unchanged

46 Neuropsych Testing (NPT): Partially Changed It is recommended that all athletes should have a cognitive assessment as part of their overall management (but not necessarily NPT) Baseline NP testing was considered by the panel and was not considered to be required as a mandatory aspect of every assessment, however it may be helpful or add useful information to overall management Editorial Comment: The clinician must do some type of formal cognitive assessment postconcussion, but it does not have to be NPT. There is ongoing lack of specificity regarding neurocognitive testing, cognitive assessment, NPT, comprehensive neuropsychological testing, etc.

47 Concussion Management: Partially Changed The cornerstone of concussion management is physical and cognitive rest until symptoms resolve and then a graded program of exertion prior to medical clearance and RTP The published medical evidence for rest is sparse; this is now a debated topic CISG suggests an initial hour rest period, then a sensible and gradual return to usual activities Previous comments regarding avoidance of texting, video games, school work, television, computer use have been deleted

48 This is a major position change, and represents a toughening up stance. This has occurred in response to over-interpretation of the prior recommendations. The brain is no longer considered to be spun glass. The implication now is that prolonged symptoms may be due to other factors, e.g., psychogenic.

49 Concussion Management: RTP Protocol Unchanged

50 Concussion Management: Unchanged No Same-Day RTP Psychological Management and Mental Health Issues The Role of Pharmacologic Therapy The Role of Preparticipation Concussion Evaluation

51 Modifying factors No factors added or deleted However, in some cases the evidence for their efficacy is limited

52 Chronic Traumatic Brain Injury: changed to CTE Recognized as a distinct tauopathy with unknown incidence in athletic populations It was further agreed that a cause and effect relationship has not yet been demonstrated between CTE and concussions or exposure to contact sports. At present, the interpretation of causation in the modern CTE case studies should proceed cautiously. It was also recognized that it is important to address the fears of parents/athletes from media pressure related to the possibility of CTE.

53 Injury Prevention: Unchanged Protective Equipment: Mouthguards and Helmets Rule Change Risk Compensation Aggression Versus Violence in Sport Knowledge Transfer

54 Questions (with literature reviews published in BJSM and CJSM) What evidence exists for new strategies/technologies in the diagnosis of concussion and assessment of recovery? Advances in the management of sport concussion: what is evidence for concussion therapies? The difficult concussion patient - What is the best approach to investigation and management of persistent (>10 days) post concussive symptoms? Revisiting Concussion Modifiers: how should the evaluation and management of acute concussion differ in specific groups? What are the most effective risk reduction strategies in sport concussion? - from protective equipment to policy? What is the evidence for chronic concussion-related changes- behavioural, pathological and clinical outcomes?

55 March, 2013 issues

56 CISG 4: Concluding Thoughts CISG 4 offers an updated international gold standard statement on sports concussion There is no same day RTP at any level of competition Is designed for use by sports health care professionals with minimal resources The SCAT3 alone may not meet the gold standard of care for sports concussion in communities with enriched resources There has been a toughening up flavor to the statement There is now an implied assumption that symptoms persisting > one month may have a non-concussion (psychiatric) component

57 There has been little empirical validation of some of the modifying factors There remains murkiness in the terms cognitive assessment, neurocognitive testing, baseline testing, and neuropsychological testing Although some components of the SCAT3 have been shown to discriminate concussed vs. non-concussed athletes (e.g., SAC, BESS, and GCS), there is not a single published study attesting to the SCAT s capacity to do so The CISG position on CTE is clear, but the matter is far from resolved Which is the guiding light? CISG vs. AAN vs. AOSSM and/or State laws? Next CISG meeting: 2016