NO! Syndrome Decreased (younger Grading of concussions? Quality - PDF document

“Sport as a Concussion Laboratory” Preventing Concussion in Sport: From the Lab to the Law Neurophysiology Kevin Guskiewicz, PhD, ATC Treatment & Concussion Rehabilitation University of North Carolina at Chapel Hill Biomechanics Neuropathology Behavior Modification Education & Annual Meeting & Clinical Symposium Awareness Buffalo, NY January 5, 2013 Peer- reviewed publications on “Sports Concussion” Concussion Epidemiology – Current Trends 600 546 Football, ice hockey, soccer and lacrosse have the highest concussion incidence rates when calculated by athlete exposure (HS 500 & College combined ) . 400 Competition concussion incidence rates are consistently higher than PUBLICATIONS practice rates. 300 In sports with the same rules ( basketball & soccer ) , recent research suggests the reported concussion incidence rate is higher in 200 females. 135 100 Reported differences between the incidence of concussion between 37 27 adolescent and adult athletes is inconclusive. 8 0 1960-1969 1970-1979 1980-1989 1990-1999 2000-present (Lincoln et al., 2011; Hootman et al., 2009; Gessel et al., 2007) PubMed Central, October 2012 Concussion = Brain Injury Worsening of Long Term Prolonged • Traumatically induced alteration in mental status that Short Term post-concussive concussion Risks of Risks of signs and symptoms (daily may or may not involve a loss of consciousness (LOC) Mismanagement Mismanagement symptoms basis) • Should not be dismissed as “ding” or “bell - ringer” Repeat Depression, concussion with cognitive post concussion impairment, - “Ding”/Grade 1 injuries resulted in neurocognitive deficits 36 syndrome What are the What are the dementia, CTE hours after injury (Lovell et al. 2004) risks of risks of School-related Ignoring not reporting? Long-term - 33% of players w/ concussion returned on same day experienced issues in student academic issues recurrent athletes in student delayed onset of sx at 3 hrs, compared w/ only 12.6% of those who athletes concussions? didn’t RTP same day (Guskiewicz, et al., JAMA 2003) Second Impact NO! Syndrome Decreased (younger • Grading of concussions? Quality of Life athletes) 1

Clinical Symptoms The Concussion Solution Recovery Amnesia Acute Dx Linear acceleration Balance - Biomarkers? Symptoms Frequency Sex LOC Neurocognitive Impact function Biomechanics Balance Angular Brief Mental Status acceleration Chronic effects (PCS, depression, Concussion Hx Location MCI) Acute Tx - Omega 3-FA? -Hyperbarics? -Progesterone? JINS (2012), 18, 1 – 12 . JINS (2012), 18, 1 – 12 . 570 Concussed HS & College Athletes 570 Concussed HS & College Athletes 166 Control (uninjured) Athletes 166 Control (uninjured) Athletes Prolonged Recovery (s/s >7 days) Prolonged Recovery (s/s >7 days) Typical Recovery (s/s <7 days) Typical Recovery (s/s <7 days) Controls (uninjured) Controls (uninjured) PM R 2011;3:S445-S451 Purpose : Examine the proportion of concussed athletes with impairment disagreements across various clinical JINS (2012), 18, 1 – 12 . concussion assessment measures. Methods : N= 100 concussed collegiate – aged athletes assessed at BL & <72 hrs post-injury on GSC , computerized NP , 570 Concussed HS & College Athletes and balance 166 Control (uninjured) Athletes Controls (uninjured) Typical Recovery (s/s <7 days) Prolonged Recovery (s/s >7 days) 2

- Significant disagreements (~52% of cases) between symptom severity scores and all other clinical measures (NP & Balance Tests). - Symptom severity scores identified more impairments than all other measures. - Emphasizes multifaceted approach to concussion assessment. PM&R 2011;3:S445-S451 Purpose : Examine the proportion of concussed athletes with impairment disagreements across various clinical concussion assessment measures. Methods : N= 100 concussed collegiate athletes assessed at BL & <72 hrs post-injury on GSC , computerized NP , and balance - Disagreements between symptom severity total scores and all other clinical measures (NP & Balance Testing). Disagreement proportions ranged from 22-52%. - Symptom severity total scores identified more impairments than all other measures. - Emphasizes need for multifaceted approach to concussion assessment. Serial Evaluations Balance Error Scoring System (BESS) TOI: clinical eval & symptom checklist Clinical Test Battery Six 20 sec trials using 3 1-3 hrs: symptom checklist different stances (double, 24 hrs: follow-up clinical eval & symptom checklist single, tandem) on 2 different surfaces (firm, foam) Symptomatic Asymptomatic Recorded Errors - Hands lifted off iliac crests - Opening eyes 1. Neuropsychological testing 1. Continued rest - Step, stumble, or fall 2. Balance testing 2. Monitoring of s/s - Moving into >30 deg. of hip 3. If deteriorating – consider 3. Monitoring of s/s flexion or abduction imaging - Remaining out of testing position for >5 secs. 3

Serial Evaluations (con’t) 5 Step Graduated Return to Play • Exertion Step 1 : 20 minute stationary bike ride (10-14 MPH) Once athlete has been asymptomatic for 24 hrs: - Reassess on clinical measures and compare to • Exertion Step 2 : Interval bike ride: 30 sec sprint (18-20 MPH/10- baseline scores. 14 MPH)/30 sec recovery x 10; and BW circuit: Squats/Push Ups/Situps x 20 sec x 3 - Continue to monitor symptoms for 24 hrs after • Exertion Step 3 : 60 yard shuttle run x 10 (40 sec rest); and assessment. plyometric workout: 10 yard bounding/10 medicine ball - If remain asymptomatic, reassess on clinical measures throws/10 vertical jumps x 3; and non-contact, sports-specific to see where they are relative to baseline and to drills for approximately 15 minutes previous day . • Exertion Step 4 : Limited, controlled return to non-contact - Start Graduated RTP Progression if: practice * 95% baseline achieved • Exertion 5 : Full sport participation in a practice * no deterioration from previous day NO! Working through the RTP Progression Concussion-proof helmets? - The 5 steps do not necessarily require 5 days . • Helmets do a great job of preventing catastrophic head injuries - No more than 2 steps should be performed on the same day, – Skull Fracture which allows for monitoring of both acute symptoms (during the activity) and delayed symptoms (within 24 hrs after the – More focal injuries activity). - In general, If the exertional activities do not produce acute symptoms, • Properly fitted, properly worn, and good condition! the athlete may progress to the next step. - The athlete may advance to Step 5 and return to full participation once they have remained asymptomatic for 24 hrs Managing energy inside the following Step 4 of the protocol. cranial cavity - Always document the process, day by day, step by step! Helmet Testing: Challenges • Different methods used for head injury risk assessment – Peak linear acceleration (a) – Head Injury Criterion (HIC) – Severity Index (SI) • Predicts traumatic skull & brain injury risk – Peak angular acceleration ( α ) • Best predictor of loss of consciousness • NOCSAE standard – Severe head injury prevention (skull fx, hematomas, etc.) – Drop to rigid surfaces over 5 m/s – Severity Index <1,200 to pass; one size fits all 4