Concussion: Pressure to Play in Sports: Can We Trust What the Athlete Tells Us? How I Manage Concussion: A Neuropsychologist s Perspective

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1 How I Manage Concussion: A Neuropsychologist s Perspective Jamie Pardini, Ph.D. UPMC Concussion Program University of Pittsburgh Medical Center Department of Orthopaedic Surgery UPMC Sports Concussion Program Concussion: The Diagnostic and Return to Play Dilemma Pressure to Play in Sports: Can We Trust What the Athlete Tells Us? 1

Evolution of Concussion Definition and Management Vienna Meeting-2001 Prague Meeting-2004 Zurich Meeting-2008 1 st -3 rd International Symposia On Concussion In Sport Sponsored by FIFA, IOC, IIHF

2 Evolution of Concussion Definition and Management Vienna Meeting-2001 Prague Meeting-2004 Zurich Meeting st -3 rd International Symposia On Concussion In Sport Sponsored by FIFA, IOC, IIHF Vienna, Prague, Zurich: Clinical/General Points of Emphasis 1. Abandonment of grading scale approach, recommend individualized management of injury and determination of severity once symptoms resolve. 2. When an athlete exhibits any signs/symptoms of concussion,he/she should be removed from contest and not allowed to return to play in that same contest (Zurich allows RTP in same game in athletes >18 years after prudent evaluation). 3. Objective tools of assessment via sideline assessment tools, balance testing, and formal neurocognitive testing significantly contributes to understanding of recovery from injury. 4. Role of physical and cognitive exertion important to recovery and once symptom free, athlete should engage in stepwise progression prior to RTP 5. RTP following concussion in sports is always a clinical decision RETURN TO PLAY CRITERIA According to the Vienna Conference and CIS guidelines, the athlete has to meet three criteria for return to play: Symptom Free at Rest Symptom Free with exertion Normal Neurocognitive Functioning 2

ImPACT Immediate Post-Concussion Assessment and Cognitive Testing Computerized Neurocognitive Testing Mark Lovell, PhD - UPMC Dept.

of Neurological Surgery (Co-Founder) Disclosure-Mark Lovell, PhD is co-owner of ImPACT Applications, LLC Concussion Management Programs ImPACT Computerized Neurocognitive Testing NFL (All Teams

Soccer Cirque de Soleil Irish National Rugby New Zealand Rugby Football Union South African Rugby European Professional Soccer World Wrestling Federation Over 2,000 high schools currently using

3 ImPACT Immediate Post-Concussion Assessment and Cognitive Testing Computerized Neurocognitive Testing Mark Lovell, PhD - UPMC Dept. of Orthopaedic Surgery (Program Developer) Micky Collins, PhD - UPMC Dept. of Orthopaedic Surgery (Co-Founder) Joseph Maroon, MD - UPMC Dept. of Neurological Surgery (Co-Founder) Disclosure-Mark Lovell, PhD is co-owner of ImPACT Applications, LLC Concussion Management Programs ImPACT Computerized Neurocognitive Testing NFL (All Teams Mandated) NHL (All Teams Mandated) MLB (All Major/Minor League Teams Mandated) Major League Soccer (all teams) US Ski/Snowboarding Teams NASCAR, IRL, CHAMP Racing Leagues USA Rugby/US Lacrosse USA Soccer Cirque de Soleil Irish National Rugby New Zealand Rugby Football Union South African Rugby European Professional Soccer World Wrestling Federation Over 2,000 high schools currently using ImPACT Over 350 Colleges/Universities Value Added of Neurocognitive Evaluation Neurocognitive Testing Increases Diagnostic Yield to 93% 201 concussed high school and collegiate athletes tested with 2 days of injury. Abnormal performance determined by RCI s (van Kampen, 2004). (Lovell et al, AJSM In Press) % Declined from baseline EITHER NEUROPSYCH SYMPTOMS 3

(Not necessary for decision making) Concussion Beyond if Necessary based on Guidelines

4 On-Field and Post-Injury Concussion Management UPMC and Pittsburgh Steelers Protocol Clinical Protocol: Neurocognitive Testing First Evaluation Follow up Baseline Testing (Not necessary for decision making) Concussion Beyond if Necessary based on Guidelines Which Athletes? What Sports? HIGH SCHOOLS COLLEGE MIDDLE SCHOOL CLUB TEAMS AGES

UPMC Return to Play Protocol Stage ONE Sideline Testing On-field Assessment (Usually ATC) Signs/Symptoms Evaluation Neurologic Examination Mental Status Testing Orientation, Concentration,

ImPACT Assessment Evaluation should occur in first few days after concussion Clinical Interview, ImPACT Referral (as needed) to other specialists Recommendations Regarding Cognitive and Physical

5 UPMC Return to Play Protocol Stage ONE Sideline Testing On-field Assessment (Usually ATC) Signs/Symptoms Evaluation Neurologic Examination Mental Status Testing Orientation, Concentration, Anterograde / Retrograde Amnesia Serial Evaluation Necessary Possible Exertional Testing Any Positive Findings Preclude Return to Play UPMC Return to Play Protocol Stage TWO Follow Up Evaluation 1. ImPACT Assessment Evaluation should occur in first few days after concussion Clinical Interview, ImPACT Referral (as needed) to other specialists Recommendations Regarding Cognitive and Physical Activity School Attendance Gym Class Attendance Academic Accommodations Athletic Participation 2. Future Evaluations As Recommended 3. Return to Baseline (or estimated preinjury status) Symptom data AND Cognitive data 4. Progress through Exertion/Practice 5. Return to Competition Factor Analysis, Post-Concussion Symptom Scale (Lovell, Pardini et al. 2004) N=327, High School and University Athletes Within 7 Days of Concussion Emotionality More emotional Sadness Nervousness Irritability Somatic Symptoms Visual Problems Dizziness Balance Difficulties Headaches Light Sensitivity Nausea Cognitive Symptoms Attention Problems Memory dysfunction Fogginess Fatigue Cognitive slowing Sleep Disturbance Difficulty falling asleep Sleeping less than usual 5

Managing Kids Need a Dedicated, Educated Team

Guidance Counselors Neuropsychologists Physicians

PLAY CRITERIA According to the Vienna Conference

criteria for return to play: Symptom Free at Rest

6 Managing Kids Need a Dedicated, Educated Team Coaches Athletic Trainers School Nurses Teachers Guidance Counselors Neuropsychologists Physicians Parents Athletes School Administrators RETURN TO PLAY CRITERIA According to the Vienna Conference and CIS guidelines, the athlete has to meet three criteria for return to play: Symptom Free at Rest Symptom Free with exertion Normal Neurocognitive Functioning 6

The Role of the Neuropsychologist: Vestibular Tx PCP ATC PT Coach School Neuro Cog Rehab

test performances Acutely, accommodations are usually more restrictive Attendance

learning core information, while controlling symptoms and maintaining grades.

activities, social activities Healthy appearance of student is usually a difficulty, not

Exertion Based Physical Therapy (Stages 1-3) Sports Performance (Stages 4-5)

7 The Role of the Neuropsychologist: Vestibular Tx PCP ATC PT Coach School Neuro Cog Rehab PM&R Parent Academic Accommodations Recommendations made based on symptoms and pattern of test performances Acutely, accommodations are usually more restrictive Attendance recommendations Cognitive load Proper accommodations should allow student to continue learning core information, while controlling symptoms and maintaining grades. Balancing restrictions and involvement PE class, watching practice, extra-curricular activities, social activities Healthy appearance of student is usually a difficulty, not advantage, in terms of self- and other-expectations Sports-Concussion Rehabilitation Exertion Based Physical Therapy (Stages 1-3) Sports Performance (Stages 4-5) Specialized/Individualized Vestibular Evaluation/PT Medication management Monitoring recovery thru Computerized Neurocognitive Testing 7

UPMC Concussion Program Treatment/Rehabilitation Protocol Somatic Symptoms Headaches Prophylaxis Propranolol* Verapamil*

(Zoloft) Therapy Sleep Disturbance Melatonin Trazodone Cognitive Symptoms Neurostimulants Amantadine* Methylphenidate* Atomoxetine

Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003 Lovell, Collins, Iverson, Johnston, Bradley;

5 min N = 64 High School Athletes 85 80 75 70 P<.02 P<.004 P<.

8 UPMC Concussion Program Treatment/Rehabilitation Protocol Somatic Symptoms Headaches Prophylaxis Propranolol* Verapamil* Amitriptyline* Escitalopram (Lexapro) Sertraline (Zoloft) Vestibular Therapy Emotionality SSRIs Escitalopram (Lexapro) Sertraline (Zoloft) Therapy Sleep Disturbance Melatonin Trazodone Cognitive Symptoms Neurostimulants Amantadine* Methylphenidate* Atomoxetine (Strattera)* NOTE: *Off-label use It was just a ding; I don t feel so bad: Why do I have to go through this program? Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98: ,2003 Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32:47-54,2004 ImPACT Memory Composite Scores Brief versus Prolonged On-field Mental Status Changes min < 5 min N = 64 High School Athletes P<.02 P<.004 P< Baseline 36 Hours DAY 4 DAY 7 ImPACT Memory-Percent Correct Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98: ,2003 Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32;47-54,2004 8

ImPACT Symptom Scale Scores Brief versus Prolonged On-field

Athletes 40 35 30 25 20 15 10 5 0 P<.003 P<.

Iverson, Field, Podell, Cantu, Fu; J Neurosurgery;

Amer J Sports Med; 32;47-54, 2004 Recovery from Concussion in

9 ImPACT Symptom Scale Scores Brief versus Prolonged On-field Mental Status Changes 5-15 min < 5 min N = 64 High School Athletes P<.003 P<.061 NS NS Baseline 36 hours DAY 4 DAY 7 Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98: ,2003 Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32;47-54, 2004 Recovery from Concussion in Athletes: How Long Does it Take? Collins, Lovell, Iverson, Ide, Maroon et al, Neurosurgery, In Press 9

Recovery From Concussion: How long does it take?

17 19 21 23 25 27 29 31 33 35 37 38 40+ All Athletes No Previous Concussions 1 or More

, 2006, Neurosurgery Factors That Affect Recovery Age History of prior concussion

10 Recovery From Concussion: How long does it take? WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK All Athletes No Previous Concussions 1 or More Previous Concussions N=134 High School athletes Collins et al., 2006, Neurosurgery Factors That Affect Recovery Age History of prior concussion History of headache Pre-existing psychiatric condition History of learning disability Genetics? Thank You Jamie Pardini Ph.D pardinij@upmc.edu 10

Concussion Facts & Stats

Jeffrey Liang, MD Concussion Facts & Stats 10% of all contact sport athletes sustain concussions yearly. 63% of all concussions occur in football. Estimated that up to 20% of football players will sustain