Preventing & Treating Concussions An evidence-based approach Presented by: Laura Abbott, MS, LMT Course developed by: Heather Clawson, MD, CSCS Presenter Laura Abbott, MS, LMT Master s Degree, Sports Medicine Licensed Massage Therapist Undergraduate degree in Exercise Science Instructor of Kinesiology, Georgia State University ACE Certified Personal Trainer Instructor at Atlanta area massage schools and at the Georgia State University Physical Therapy department. Owner of Premier Performance, Atlanta, GA Heather Clawson, MD, CSCS Doctor of Internal Medicine BS in Microbiology & Immunology. Certified Strength and Conditioning Specialist. ACE certified personal trainer. Heather has spent over 20 years incorporating her medical experience into a fitness career, educating other physicians on how to correctly teach patients to exercise. Course Developer: reserved. 1
How to Get Your CE Certificates View the complete webinar Make sure your printer is on Log on to our website: www.exerciseetc.com Click on Administration Click on Webinar on Demand Certificates Complete all required fields & click submit Your CE certificate will appear on the screen; you may either save or print your certificate; even if you do not have a working printer, make sure to complete this form Remember: The WebEx program records when you log on and off; logging off early or fast forwarding to the end of the meeting may result in denial of your CEs. PROGRAM OBJECTIVES The purpose of this program is to discuss the incidence of concussions in young athletes, the increasing incidence in young female athletes, and the various methods for determining severity and ability to return to play. Learning Objectives (5) After viewing this webinar you will be able to: Identify the possible causes of increased concussions in female athletes Explain the incidences of concussions in young athletes Define concussion Provide options for addressing the severity of concussions List methods and factors used to identify safe return to sport after a concussion reserved. 2
Definition of Concussion A concussion is a traumatic brain injury that alters the way the brain functions. Effects are usually temporary but can include headaches and/or problems with concentration, memory, balance and coordination. Although concussions usually are caused by a blow to the head, they can also occur when the head and upper body are violently shaken. These injuries can cause a loss of consciousness, but most concussions do not. Because of this, some people have concussions and don't realize it. Sports most frequently associated with concussions. Football Soccer Lacrosse Basketball Wrestling Hockey Possible Long-term Effects of Multiple Concussions Mild Cognitive Impairment (MCI) Chronic Traumatic Encephalopathy (CTE) Post-Concussion Syndrome (PCS) Parkinson s Like Disease Alzheimer's reserved. 3
Symptoms of Single Concussion Concussion causes temporary loss of brain function leading to cognitive, physical and emotional symptoms, such as confusion, vomiting, headache, nausea, depression, disturbed sleep, moodiness, and amnesia. Article #1 Epidemiology of concussions among United States high school athletes in 20 sports American Journal of Sports Medicine April, 2012 Marar M, McIlvain NM, Fields SK, Comstock RD Study Objectives Understand the major health concern across many sports. Show that although most research focuses on football, despite evidence that woman are at a greater risk for concussions. Focus on comparing concussion rates within gender across sports reserved. 4
Study Methodology Information was analyzed from National High School Sports-Related Injury Surveillance Systems and High School Reporting Information Online. Certified athletic trainers from high schools around the country reported injuries and exposures for 20 sports. Study Results Describes the details of concussion injury patterns by sport in terms of severity (i.e. days lost), mechanisms, activities, symptoms, and amount of time for resolution of symptoms. During the 2008-2012 seasons, 1,936 concussions were reported during 7,780,064 athletic exposures In gender-comparable sports, girls had higher concussion rates than boys. Study Results-Continued Injury rates were higher in competition at 67% than practice at 33%. Incidence of concussions 47% football 8% girls soccer 6% wrestling 5.5% girl s basketball reserved. 5
Reported signs and symptoms 94% headache 76% dizziness 55% difficulty concentrating 45% confusion Conclusions Overall concussion rates were higher during contests than in practice (except cheerleading) Girls may have a biomechanical disadvantage, lacking sufficient neck neuromuscular control to decelerate and absorb the energy of the head. Two-thirds of concussions occurred during games, reinforcing the need for trained medical personnel at games. Majority of athletes return to play in 1 to 3 weeks. Education is needed for players and coaches to recognize the signs and symptoms of concussions. Clinical question # 1 Due to the fact that two-thirds of concussions occurred during games in this study, what is the implication for athletes, families, coaches, referees and school administrators? reserved. 6
Clinical question # 2 Which two sports were analyzed that are gender-comparable sports? Clinical question # 3 What are the most important signs and symptoms that players and coaches need to be able to recognize? Article #2 Concussion among female middle-school soccer players JAMA Pediatrics March, 2014 O Kane JW, Spieker A, Levy MR, Neradilek M, Polissar NL, Schiff MA reserved. 7
Study Objectives Describe the incidence rate, frequency, and duration of concussion symptoms in female youth soccer players. Determine if these symptoms caused the athlete to stop playing or seek medical care Study Methodology 351 female youth soccer players aged 11 to 14 years old from 4 youth soccer clubs were observed for at least one full season from 2008 to 2012. During preseason, athletes answered a health history questionnaire. In season, an injury surveillance system was used for weekly Internet-based parental surveys. A trained medical personnel called players with reported symptoms using a standardized interview within one week of injury. Weekly follow-up interviews to assess symptom resolution and recovery time Study Results Players in the study had 59 concussions For those with concussions, 73% had 1 concussion, 27% had 2 concussions. Symptoms lasted a mean of 9 days. 52% of the players symptoms lasted 1 to 7 days. 86% of the concussions occurred during a game. reserved. 8
Additional Data 59% continued to play with concussion symptoms. 56% of those reporting symptoms were not examined by a qualified medical professional. Cumulative concussion incidence was 13% per season. Conclusion This is the first study to look at middle school female soccer concussion rates, and the rates are higher compared to high school rates. Because of the lack of medical personnel at middle school games and practices, players must seek medical attention. Only 44% of the athletes sought medical attention, even after being directed to do so. Additionally, over half of the athletes continued to play with concussion symptoms. Clinical Question #1 What are the immediate implications of this study? reserved. 9
Clinical Question #2 What is a key risk factor for new concussions? Article #3 Assessment and management of sportrelated concussions in United States high schools. American Journal of Sports Medicine November, 2011 Weehan WP 3 rd, d Hemecourt P, Collins CL, Comstock RD Study Objectives Describe the medical providers and medical studies used when assessing sport-related concussions as well as to determine the effects of medical provider type on timing of return to play, frequency of imaging, and frequency of neuropsychological testing. reserved. 10
Study Methodology This study followed 192 U.S. high schools with at least one full-time athletic trainer during the 2009-2010 academic year. Study Results Nearly 15% of the athletic injuries were concussions. Male contact sports had the highest number of concussions per 100,000 athletic exposures. 53% of concussions occurred during a varsity contest, and grade level was about the same. 78% had resolution of symptoms within 7 days. 2.8% had symptoms lasting up to 1 month. Study Conclusions This epidemiologic report found that most of the concussions were first evaluated by an athletic trainer, but this study only included schools with at least one full-time athletic trainer on staff. 60% of the athletes were evaluated by a physician who does not specialize in athletic injuries. 1 in 5 concussed athletes received a CT scan. reserved. 11
Clinical question #1 What is the best way to explain to school administrators why a school needs proper onsite medical personnel? Clinical Question #2 How can this study be used when we talk to our coaches about the importance of athletes being properly cleared for return to play by a qualified medical professional (athletic trainer or physician). Article #4 Prospective Clinical Assessment Using Sideline Concussion Assessment Tool-2 Testing in Evaluation of Sport-Related Concussion in College Athletes Clinical Journal of Sports Medicine 2014 Putukian M., Echemendia R., Dettwiler- Danspeckgruber Duliba T., Bruce J., Furtado JL., Murugavel M. reserved. 12
Study Overview Medical personnel use sideline tools for assessment of acute concussion, such as the SCAT-2, to make on-field decisions. However, the sensitivity and specificity of the SCAT-2 with or without baseline SCAT-2 measures are unclear. The accuracy (sensitivity and specificity) need to be known to determine an on-field concussion prognosis. Study Objectives Evaluate the utility of the SCAT-2 (with and without baseline testing) for the assessment of sport-related concussion in college athletes. Assess potential modifiers that could influence SCAT-2 scores such as age, sex, history of concussion, loss of consciousness, depression and anxiety. Study Methodology Study included 263 college athletes with baseline SCAT-2 scores. Among the athletes in the study, 32 sustained a concussion. Athletes were evaluated by a team physician and completed the posttest SCAT-2 within 2 days of the concussive injury Nonconcussed athletes in contact sports served as the control group. reserved. 13
Study Results Athletes with history of depression or anxiety symptoms during baseline testing demonstrated worse concussion-related symptom severity and more symptoms during baseline screening. Modifiers did not effect baseline SCAT-2 performance. Athletes who sustained a concussion scored worse than the control group on each subcomponent of the SCAT-2 retest. Study results-continued The study demonstrates the utility of the SCAT-2 in a college population to assess acute sport-related concussions. The total SCAT-2, total symptom score, total symptoms, and modified BESS (only using firm stances) were all worse postconcussion compared with baseline scores. Clinical Question #1 What role does the SCAT-2 have in managing concussed athletes? reserved. 14
Clinical Question #2 How confident can medical personnel be when using the SCAT-2 as part of their assessment protocol? Clinical Question #3 What impact does Depression or Anxiety have on the usefulness of the SCAT-2 assessment? Article #5 Sensitivity and specificity of the online version of ImPACT in high school and collegiate athletes American Journal of Sports Med. February 2013 Schatz P, Sandel N. reserved. 15
Study Objectives Analysis of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) tool. Study Methodology Test the sensitivity and specificity of the online version of ImPACT using carefully matched samples of concussed and nonconcussed high school or college athletes. Data was obtained by the lead programmer at ImPACT Applications, Inc., who was blinded to the study s hypothesis Baseline and Postconcussion data were extracted for 81 athletes with symptomatic concussions, 37 athletes with asymptomatic concussions, and 81 athletes with no concussion. Study Results Overall, the extracted data yielded a sensitivity and specificity of 91.4% and 69.1%, respectively. The results indicate that the online ImPACT test is a valid test to diagnose acute concussions in high school and collegiate athletes. The probability that the test will detect a concussion if one is present (sensitivity) was 91.4%, and the probability that the test will be negative when no concussion is present (specificity) was 69.1% reserved. 16
Study Results-continued Even further, the online ImPACT test detected a concussion even among athletes suspected of a concussion but did not report symptoms The test may perform better among the asymptomatic group and suggested that by attempting to hide symptoms of concussion, or otherwise look good on testing, these athletes displayed more variable behavior and paradoxically distinguished themselves from the healthy controls. Question #1 What role does the online ImPACT assessment have for athletes that may try to hide their symptoms? Clinical Question #2 What is the role of using the online ImPACT assessment? reserved. 17
Clinical Question #3 How could the information obtained from the online ImPACT assessment be maximized? Article #6 Effect of sport-related concussion on clinically measured simple reaction time British Journal of Sports Medicine January 2014 Eckner JT, Kutcher JS, Broglio SP, Richardson JK. Study Objectives The purpose of this study was to determine the effect of concussion on clinical reaction time in a sample of athletes from one high school and two colleges reserved. 18
Study Methodology Clinical reaction time was measured by conducting a simple task using a measuring stick embedded in a weighted rubber disk that was released and caught by the tested athlete as quickly as possible. Athletes were baseline tested during preparticipation examinations and within 48 hours after sustaining a concussion Injured athletes were paired with a nonconcussed sex- and team-matched control athlete. Study Results 26 athletes sustained 28 concussions over the 2 year study period. 71% of the concussions were seen in college football athletes. Results showed that clinical reaction time was impaired after a concussion, while the control group showed a small in-season improvement in clinical reaction time. Additionally, the authors showed that the best diagnostic cutoff for concussion was any decline from baseline in clinical reaction time (75% sensitive and 68% specific). Study Conclusions The results of this study are important because they show that clinical reaction time can be a useful test for diagnosing concussion When used as part of an assessment battery with other clinical tools such as the graded symptom checklist (80% sensitive, 100% specific) and balance error scoring system (34% sensitive, 91% specific), clinicians can assess athletes for concussion in a con trolled, reliable manner from the sidelines to the exam room. reserved. 19
Question #1 How can reaction time testing be of value to those diagnosing and treating concussions on the sidelines? Question #2 Could a clinician rely solely on this test to accurately diagnose a concussion? Question #3 What additional research would prove useful for this particular form of evaluation? reserved. 20
Article #7 Systematic review of the balance error scoring system Sports Health May 2011 Bell DR, Guskiewicz KM, Clark MA, Padua DA. Study Objectives Determine the validity of the Balance Error Scoring System (BESS) when assessing athletes for concussions. Systematic review of the reliability and validity of the BESS (included 20 articles). Study Results Intra-tester reliability (repeatability of a measure when one person does the measurements) for the total BESS score ranged from 0.60 to 0.92 (ideally this number is 0.80 or higher) Test retest reliability (repeatability of the test over time) was moderate, but one study reported that performing the BESS three times and averaging the scores provided excellent repeatability. reserved. 21
Study Results-continued The review found that the BESS can detect differences between groups when there are large differences (concussions or fatigue) but not when the differences are more subtle. Furthermore, the BESS scores increase with age, are higher among patients with ankle instability, and improve after neuromuscular training. Study Conclusions The BESS can be a valuable tool for evaluating patients with suspected concussions and monitoring progression during a rehabilitation program. Reliability (repeatability) can vary greatly. Evaluating reliability among clinicians in a clinic (by comparing your results to another clinician or your results on multiple occasions) may lead to improved training and communication, recognition of tests that are not performing well, and fewer errors in evaluating patients. Clinical Question #1 In which ways is the BESS test a valuable tool for assessing patients? reserved. 22
Clinical Question #2 What are three ways in which the BESS test can be optimized for accurate results? Article #8 Evidence for added value of baseline testing in computer-based cognitive assessment Journal of Athletic Training July-August 2013 Roebuck-Spencer TM, Vincent AS, Schlegel RE, Gilliland K. Study Objectives Baseline computer-based cognitive testing is commonplace in athletics More information is needed regarding the validity of comparing post-injury results with baseline performance. reserved. 23
Study Methodology A study of 8,002 military service members (91% male, approximately 27 years old) to examine the added value of baseline testing in computerbased cognitive testing by comparing two methods of classifying atypical performance: (1) baseline comparison and (2) normal reference. All participants took the Automated Neuropsychological Assessment Matrix (ANAM) before and after deployment. Study Results Overall, the two methods were similar and classified 3.7% and 3.4% of participants with atypical post-deployment scores using the baseline-referenced and norm-referenced method, respectively. Both methods were inconsistent regarding which individual was considered atypical. Of the 147 individuals classified as atypical using the baseline-based method, 68% (100 individuals) were classified as normal using the norms-based method. of the 137 participants classified as atypical by the normbased method, 66% (90 individuals) showed no change in test performance from pre-deployment to postdeployment. Study Conclusions Both methods classified different participants as atypical in a seemingly healthy population, when an atypical performance would not be anticipated. The number of misclassified individuals was small (3 or 4 out of 100) It is concerning that 190 (approx. 2%) individuals had different results with the two methods. reserved. 24
Clinical Question #1 What is the role of computer-based neurocognitive testing methods in determining the presence of a concussion? Clinical Question #2 How can the risk of misclassifying a patient be decreased? Article #9 Age and test setting affect the prevalence of invalid baseline scores on neurocognitive tests American Journal of Sports Medicine February 2014 Lichtenstein JD, Moser RS, Schatz P. reserved. 25
Study Objectives Review previously collected baseline tests to examine the prevalence of invalid baseline tests between younger and older youth athletes who completed their testing in a small- or large-group setting. Study Methodology 502 athletes (10 to 18 years old, 85% male)who participated in a non-scholastic sport completed the online ImPACT between 2010 and 2013. Majority of athletes participated in ice hockey (59%) or lacrosse (28%). 207 athletes completed their baseline testing in a large group. 295 athletes completed baseline testing in small group settings at a neuropsychology center. Study Results An athlete younger than 13 years should be tested in a smaller-group environment under strict supervision to decrease the risk of an invalid baseline test. Group settings did not influence the rate of invalid baseline tests among athletes older than 13 years. reserved. 26
Study Conclusions Factors such as amount of sleep, reading level, and history of concussions influence the rate of invalid results among older athletes. We still need a better understanding of what influences results among younger athletes. Younger athletes need to take their standardized baseline testing in small groups to decrease the rate of invalid baseline tests. s Clinical Question #1 What are the factors that contribute to invalid baseline ImPACT exams in the 10 to 12 year old age group? Clinical Question #2 How do older athletes differ from younger populations when it comes to valid baseline measurements with ImPACT testing? reserved. 27
Article #10 Baseline neurocognitive scores in athletes with attention deficit-spectrum disorders and/or learning disability Neurosurgical Pediatrics August 2013 Zuckerman SL, Lee YM, Odom MJ, Solomon GS, Sills AK. Study Objectives Assess baseline neurocognitive differences between athletes with and without ADHD or learning disabilities. Establish normative data for this population group. Study Methodology 6,636 athletes were analyzed who previously completed baseline ImPACT scores that they defined as valid based on an impulse composite sub score of >30 From this sample, 90 athletes with a selfreported history of learning disability, 262 athletes with a self-reported history of ADHD, and 55 athletes with a self-reported history of learning disability and ADHD were identified. reserved. 28
Study Methodology-cont d These athletes were matched to athletes without ADHD and learning disability based on age, sex, years of education, height, weight, and concussion history. Study Results Athletes with ADHD had lower verbal memory, visual memory, and visual motor process as well as higher reaction time, impulse control, and symptom score compared with the matched athletes without ADHD and learning disability. Study Conclusions A baseline neurocognitive exam is a beneficial part of the postconcussion assessment. Athletes with ADHD or learning disabilities may have different ImPACT baseline scores on all five neurocognitive parameters and one symptom parameter. Preliminary baseline normative data for adolescents with ADHD and/or learning disabilities are presented. If the frequency of invalid test is high within this special population, then ImPACT tests may be an inappropriate tool for assessing concussions and deciding on return to play. reserved. 29
Clinical Question #1 Why is it important to determine if an athlete has ADHD and/or learning disabilities when ImPACT testing is being done? How to Get Your CE Certificates View the complete webinar Make sure your printer is on Log on to our website: www.exerciseetc.com Click on Administration Click on Webinar on Demand Certificates Complete all required fields & click submit Your CE certificate will appear on the screen; you may either save or print your certificate; even if you do not have a working printer, make sure to complete this form Remember: The WebEx program records when you log on and off; logging off early or fast forwarding to the end of the meeting may result in denial of your CEs. Post-course Learning Assessment This assessment must be completed if you are certified by BOC, CSCS or NSCA Question 1 True or False The effects of a concussion are usually temporary. reserved. 30
Question 2 True or False Girls may have more concussions due to a lack of sufficient neck neuromuscular control to decelerate and absorb the energy of the head. Question 3 In the article, Assessment and management of sport related concussions in United States high schools, what percentage of injuries were concussions? Question 4 In the article, Sensitivity and specificity of the online version of ImPACT in high school and collegiate athletes Which test appeared to show that it is a valid test to diagnose acute concussions in high school and collegiate athletes. reserved. 31
Question 5 In the article, Effect of sport related concussion on clinically measured simple reaction time, what else can be a useful test for diagnosing concussions? 1. True 2. True 3. 15% 4. ImPACT 5. Clinical reaction time Correct Your Work: Answer Key Make sure to keep this assessment with your other recertification documents for 4 years. Questions about any answer? Email us at: info@exerciseetc.com PLEASE NOTE: Remember to complete this webinar and print the certificate by December 31 of this year. Certificates with next year s date may not be accepted by your credentialing organization. reserved. 32
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