Sport Related Concussion Andy Peterson MD MSPH FAAP Disclosures I - - PowerPoint PPT Presentation

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Sport Related Concussion Andy Peterson MD MSPH FAAP Disclosures I - - PowerPoint PPT Presentation

Dec 09, 2022 137 likes •2.06k views

Sport Related Concussion Andy Peterson MD MSPH FAAP Disclosures I have no financial or personal interests in products discussed today I may briefly discuss off-label use of medications for the treatment of post- concussion symptoms.

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SLIDE 1

Sport Related Concussion

Andy Peterson MD MSPH FAAP

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SLIDE 2

Disclosures

  • I have no financial or personal interests in

products discussed today

  • I may briefly discuss off-label use of

medications for the treatment of post- concussion symptoms.

  • I will discuss only 1 brand of NCT. Several
  • thers are available on the market.
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SLIDE 3
  • Definitions
  • Basic Pathophysiology (and CTE)
  • Basic Epidemiology
  • Iowa Concussion Law
  • Common Misconceptions
  • Review of Recent Concussion Guidelines
  • (Concussion Clinic Protocol and Evidence Base)
  • Recognition / Evaluation / Return to Play

Covered Today

boring not boring

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SLIDE 4

471 concussion review articles in past 5 years!

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SLIDE 5
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SLIDE 6
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SLIDE 7
  • Definitions
  • Basic Pathophysiology (and CTE)
  • Basic Epidemiology
  • Iowa Concussion Law
  • Common Misconceptions
  • Review of Recent Concussion Guidelines
  • Concussion Clinic Protocol and Evidence Base
  • Recognition / Evaluation / Return to Play

Covered Today

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SLIDE 8

Concussion definitions:

  • 1966 Congress of Neurological Surgeons

– Concussion is a clinical syndrome characterized by immediate and transient impairment of neural functions, such as alteration of consciousness, disturbance of vision, equilibrium, etc, due to mechanical forces

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SLIDE 9

Concussion definitions:

  • American Academy of Neurology:

– Trauma-induced alteration in mental status that may or may not involve loss of consciousness.

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SLIDE 10

Concussion definitions:

  • Zurich Statement
– Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic 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:
  • Concussion may be caused either by a direct blow to the head, face, neck or elsewhere
  • n the body with an “impulsive” force transmitted to the head.
  • Concussion typically results in the rapid onset of short-lived impairment of neurologic
function that resolves spontaneously.
  • Concussion may result in neuropathological changes, but the acute clinical symptoms
largely reflect a functional disturbance rather than a structural injury.
  • Concussion results in a graded set of clinical symptoms that may or may not involve loss
  • f consciousness. Resolution of the clinical and cognitive symptoms typically follows a
sequential course; however, it is important to note that, in a small percentage of cases, post-concussive symptoms may be prolonged.
  • No abnormality on standard structural neuroimaging studies is seen in concussion.
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SLIDE 11

Common features:

  • May be caused by direct blow or transmitted blow to the head.
  • Rapid onset of short-lived neurologic impairment that resolves

spontaneously.

  • May cause neuropathological changes but symptoms usually

due to functional rather than structural injury.

  • Typically follows a graded and sequential course.
  • Usually does not involve loss of consciousness.
  • Normal structural neuroimaging studies
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SLIDE 12

Common symptoms

  • Headache or head pressure
  • Balance disturbance or dizziness
  • Nausea
  • Felling “dinged,” “foggy” or “stunned”
  • Visual problems
  • Hearing problems
  • Irritibility or emotionality
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SLIDE 13

Common cognitive features

  • Unaware of score of game, period,
  • pposition
  • Confusion
  • Amnesia
  • Loss of consciousness
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SLIDE 14

Common physical signs

  • Transient impaired consciousness (GCS < 15)
  • Poor coordination or balance
  • Seizure
  • Slow to answer questions or follow directions
  • Easily distracted, poor concentration
  • Inappropriate emotions
  • Vomiting
  • Vacant stare/glassy eyed
  • Slurred speech
  • Personality changes
  • Inappropriate behavior
  • Decreased playing ability
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SLIDE 15
  • Definitions
  • Basic Pathophysiology (and CTE)
  • Basic Epidemiology
  • Iowa Concussion Law
  • Common Misconceptions
  • Review of Recent Concussion Guidelines
  • Concussion Clinic Protocol and Evidence Base
  • Recognition / Evaluation / Return to Play

Covered Today

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Gross/micro pathology

(patients with MTBI who died of other causes)

  • Microscopic axonal injury
  • Axon retraction bulbs
  • Microglial clusters
  • (Tau deposition)
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SLIDE 17

Pathophysiology

  • Cortical contusions
  • Axonal rupture/stretch/shear
  • Cell membrane permeability
  • Release of excitatory neurotransmitters from injured

axons impairs function of nearby cells

– Acetylcholine – Glutamate – Aspartate

  • ENERGETICS!
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Farkas O, Lifshitz J, Povlishock JT. J Neurosci. 2006 Mar

A-C Neurons flooded with both dextrans revealing cellular injury with irregular distorted profiles and vacuolization (arrows) Most severe show uptake in nucleus (double arrow) D – Other double labeled axons demonstrate little or no pathologic damage
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Chronic Traumatic Encephalopathy

Tau stain: NL 65yo John Grimsley 46yo 79yo former WC boxer w/ dementia
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SLIDE 23

Dave Duerson (and 153+ others)

Maroon et al. PLOS ONE. 2015.
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SLIDE 28
  • Definitions
  • Basic Pathophysiology (and CTE)
  • Basic Epidemiology
  • Iowa Concussion Law
  • Common Misconceptions
  • Review of Recent Concussion Guidelines
  • Concussion Clinic Protocol and Evidence Base
  • Recognition / Evaluation / Return to Play

Covered Today

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Epidemiology

  • Difficult due to underreporting
  • Probably 1.6 to 3.8 million per year
  • ~65% in 5-18yo
  • Most do not come to clinical attention
Nonfatal traumatic brain injuries from sports and recreation activities--United States, 2001-2005. MMWR Morb Mortal Wkly Rep. Jul 27 2007;56(29):733-737. McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported concussion in high school football players: implications for prevention. Clin J Sport Med. Jan 2004;14(1):13-17.
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SLIDE 30 Lincoln AJSM 2011
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SLIDE 31 Lincoln AJSM 2011
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SLIDE 32 Marar AJSM 2012
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SLIDE 33 Zuckerman AJSM 2015
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SLIDE 34

2.79%

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What do these have in common?

  • Football
  • Boxing
  • Hockey
  • Wrestling
  • Soccer
  • Rugby
  • Baseball
McKee Acta Neuropathol (2014) 127:29-51
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2015 NCAA Wrestling Rule Change

Rule 6.1.5 – Referee Timeout, Concussion Evaluation Timeout In the case of a possible concussion, the referee shall stop the match for a concussion evaluation. The medical staff shall have unlimited and unimpeded time to evaluate the participants. In cases of uncertainty, the medical staff shall be granted the ability to remove the participant from the wrestling area to perform the concussion evaluation. During the evaluation, the match will be suspended until a decision is rendered. The referee, the coaches

  • f both participants and the non-injured wrestler are to remain on

the mat. A concussion evaluation timeout shall not count towards the contestant’s injury timeout or recovery timeout. Coaching of the contestant being evaluated is not permitted.

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  • Definitions
  • Basic Pathophysiology (and CTE)
  • Basic Epidemiology
  • Iowa Concussion Law
  • Common Misconceptions
  • Review of Recent Concussion Guidelines
  • Concussion Clinic Protocol and Evidence Base
  • Recognition / Evaluation / Return to Play

Covered Today

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Iowa Concussion Law

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: Section 1. NEW SECTION. 280.13C Brain injury policies.
  • 1. a. The Iowa high school athletic association and the
Iowa girls high school athletic union shall work together to distribute the guidelines of the centers for disease control and prevention of the United States department of health and human services and other pertinent information to inform and educate coaches, students, and the parents and guardians
  • f students of the risks, signs, symptoms, and behaviors
consistent with a concussion or brain injury, including the danger of continuing to participate in extracurricular interscholastic activities after suffering a concussion or brain injury and their responsibility to report such signs, symptoms, and behaviors if they occur.
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SLIDE 41
  • b. Annually, each school district and nonpublic school shall
provide to the parent or guardian of each student a concussion and brain injury information sheet, as provided by the Iowa high school athletic association and the Iowa girls high school athletic union. The student and the student’s parent
  • r guardian shall sign and return the concussion and brain
injury information sheet to the student’s school prior to the student’s participation in any extracurricular interscholastic activity for grades seven through twelve.

Iowa Concussion Law

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SLIDE 42
  • 2. If a student’s coach or contest official observes signs,
symptoms, or behaviors consistent with a concussion or brain injury in an extracurricular interscholastic activity, the student shall be immediately removed from participation.

Iowa Concussion Law

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SLIDE 43
  • 3. a. A student who has been removed from participation
shall not recommence such participation until the student has been evaluated by a licensed health care provider trained in the evaluation and management of concussions and other brain injuries and the student has received written clearance to return to participation from the health care provider.
  • b. For the purposes of this section, a “licensed health care
provider” means a physician, physician assistant, chiropractor, advanced registered nurse practitioner, nurse, physical therapist, or athletic trainer licensed by a board designated under section 147.13.
  • c. For the purposes of this section, an “extracurricular
interscholastic activity” means any extracurricular interscholastic activity, contest, or practice, including sports, dance, or cheerleading.

Iowa Concussion Law

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SLIDE 44

Unintended Consequences??

(so far there is no evidence on either side)

  • Incentive to under-report
  • False sense of security

– Untrained coaches/officials – Uncertainty about who can clear

  • Bypass ATC?
  • Transfer of liability
  • Cost
  • Second guessing officials
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  • Definitions
  • Basic Pathophysiology (and CTE)
  • Basic Epidemiology
  • Iowa Concussion Law
  • Common Misconceptions
  • Review of Recent Concussion Guidelines
  • Concussion Clinic Protocol and Evidence Base
  • Recognition / Evaluation / Return to Play

Covered Today

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Johnny doesn’t have a concussion. He didn’t get knocked out and had a normal CT scan

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SLIDE 48 Berrington et al. Projected Cancer Risk from Computed Tomographic Scans Performed in the United States in 2007. Arch Intern Med. 2009;169(22).
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SLIDE 49

OK, when should I image?

  • In the hours after an injury if:

– Worsening symptoms – Declining level of consciousness – Worsening amnesia – Progressive balance disturbance – Focal neurologic deficits

  • Later if:

– Seizures – Declining mental status

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SLIDE 50

What’s coming

  • PET
  • SPECT
  • (fMRI)
  • DTI with Tractography
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Fractional Anisotropy

Wilde EA et al. Neurology. 2008 Mar

Free diffusion Diffusion in one direction

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Singh Met al. Magn Reson Imaging. 2010 Jan

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Qualities for an ideal biomarker?

  • 1. Sample source (CSF, serum, saliva, urine)
  • 2. Sensitivity and specificity
  • 3. Signal vs background
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Biomarkers of Brain Injury

Biochemical Marker Physiologic Role Location Comment Neuron Specific Enolase (NSE) Involved in increasing neuronal chloride levels Cytoplasm of neurons, platelets, RBC’s Detectable within 6 hours, serum half life of 24 hours S100B Calcium binding protein, may inhibit synaptic plasticity Astroglia, bone marrow, fat, skeletal muscle Detectable almost immediately after injury, ½ life 60 min Myelin Basic Protein (MBP) Abundant protein in myelin Myelin Increased only after severe TBI, peaks 48-72 hours Cleaved Tau (c-tau) Microtubule associated protein in axons Axons in the CNS Poor marker in pediatric population Glial Fibrillary Acidic Protein (GFAP) Intermediate protein
  • f astroglial skeleton
Astroglial skeleton Peaks in 24-48 hours found only in CNS
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The more I rest now, the quicker I will recover.

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Moser, Glatts and Schatz. Jpeds. 2012. 49 high school and college athletes. Rest for 1 or 2 weeks when concussed. Measured ImPACT.

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Moser, Glatts and Schatz. Jpeds. 2012.

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Thomas, et al. Pediatrics. 2015.

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Thomas, et al. Pediatrics. 2015.

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Thomas, et al. Pediatrics. 2015.

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Thomas, et al. Pediatrics. 2015.

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Silverberg, et al. JAMA Pediatrics. 2016.

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Silverberg, et al. JAMA Pediatrics. 2016.

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Silverberg, et al. JAMA Pediatrics. 2016.

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I just got Johnny this sweet

  • mouthguard. It will protect him from

concussions.

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John Stenger DDS Notre Dame dentist 1964 5 case reports of players who were concussion prone before mouthguard but not after

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Wisniewski DDS Guskiewicz PhD 2004 large NCAA dataset 506,297 exposures 369 concussions

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McGuine PhD Brooks MD 2014 large high school dataset 2287 players 134,437 exposures 211 concussions

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“Unfortunately, no helmet can prevent a concussion”

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“Unfortunately, no helmet can prevent acconcussion”

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What does work?

  • Limit hitting
  • Limit hitting
  • Limit hitting
  • Limit hitting
  • Maybe changing the way people hit
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Pellman et al. Neurosurgery. 2004

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Broglio, et al. JAT. 2016 Followed rule change – unlimited tackling to tackling 2x per week.

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Broglio, et al. JAT. 2016

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Johnny just got his third

  • concussion. I already told him that

this means he has to quit sports.

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Number of Concussions Amount of Badness

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When to consider disqualification

  • Multiple lifetime concussions
  • Persistent diminished performance
  • Persistent post concussive symptoms
  • Progressively prolonged recoveries
  • Easy concussability
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I sure am glad little Suzy doesn’t play such dangerous sports.

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SLIDE 111 Marar AJSM 2012
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I’m going to make sure Billy doesn’t start playing football too early. Gotta protect his brain

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OR 1.93 (1.74-2.15) 1.7% concussion 3.3% concussion Increased risk PCS with mTBI2

1. Nation et al. Football-Related Injuries Among 6- to 17-Year-Olds Treated in US Emergency Departments 1990-2007. Clin Pediatr. 2011 Mar;50(3):200-7. 2. Falk et al. The specificity of post-concussive symptoms in the pediatric population. J Child Health Care. 2009 Sept;13(3):227-38.
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SLIDE 114 Peterson et al. In press. OJSM. 2016.
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SLIDE 116
  • Definitions
  • Basic Pathophysiology (and CTE)
  • Basic Epidemiology
  • Iowa Concussion Law
  • Common Misconceptions
  • Review of Recent Concussion Guidelines
  • Concussion Clinic Protocol and Evidence Base
  • Recognition / Evaluation / Return to Play

Covered Today

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SLIDE 117

My doctor told me that I have a grade 2 concussion and can return to play in a week.

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What about LOC?

Does not predict severity, neuropsychological test results, duration of symptoms or balance test results.

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  • Maroon JC, Lovell MR, Norwig J, Podell K, Powell JW, Hartl R. Cerebral concussion
in athletes: evaluation and neuropsychological testing. Neurosurgery. Sep 2000;47(3):659-669; discussion 669-672.
  • Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet. Mar
1 1975;1(7905):480-484.
  • Lovell MR, Iverson GL, Collins MW, McKeag D, Maroon JC. Does loss of
consciousness predict neuropsychological decrements after concussion? Clin J Sport Med. Oct 1999;9(4):193-198.
  • Leininger BE, Gramling SE, Farrell AD, Kreutzer JS, Peck EA, 3rd.
Neuropsychological deficits in symptomatic minor head injury patients after concussion and mild concussion. J Neurol Neurosurg Psychiatry. Apr 1990;53(4):293-296.
  • Erlanger D, Saliba E, Barth J, Almquist J, Webright W, Freeman J. Monitoring
Resolution of Postconcussion Symptoms in Athletes: Preliminary Results of a Web- Based Neuropsychological Test Protocol. J Athl Train. Sep 2001;36(3):280-287.
  • McCrory PR, Ariens T, Berkovic SF. The nature and duration of acute concussive
symptoms in Australian football. Clin J Sport Med. Oct 2000;10(4):235-238.
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SLIDE 121 Zemek et al. JAMA. 2016.
  • 9 large peds ER (PERC)
  • 2 years
  • 46 item derivation
  • 2006 participants
  • 9 item validation
  • 1057

Low cut point

  • Sensitivity 95%
  • Specificity 18.1%
  • NPV 85%
  • PPV 36%

High cut point

  • Sensitivity 20%
  • Specificity 93%
  • NPV 70%
  • PPV 60%
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SLIDE 122

Prague subtypes:

  • Simple concussion
  • Complex concussion
McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med. Apr 2005;39(4):196-204.
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Zurich subtypes:

McCrory P, Meeuwisse W, Johnston K, et al. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br J Sports Med. May 2009;43 Suppl 1:i76-90. McCrory P, et al. Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250–258
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  • 1. Harmon KG, et al. American Medical Society for Sports Medicine Position Statement:
Concussion in Sport. Br J Sports Med. Jan 2013;47:15-26.
  • 2. McCrory P, et al. Consensus Statement on Concussion in Sport: the 4th International
Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250–258
  • 3. Herring S, et al. Concussion (Mild Traumatic Brain Injury) and the Team Physician: A
Consensus Statement – 2011 Update. Med Sci Sports Exerc. Dec 2011;43(12):2412-22.
  • 4. McCrory P, Meeuwisse W, Johnston K, et al. Consensus Statement on Concussion in
Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November
  • 2008. Br J Sports Med. May 2009;43 Suppl 1:i76-90.
  • 5. McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the
2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med. Apr 2005;39(4):196-204.
  • 6. Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the First
International Conference on Concussion in Sport, Vienna 2001. Recommendations for the improvement of safety and health of athletes who may suffer concussive injuries. Br J Sports Med. Feb 2002;36(1):6-10.
  • 7. Guskiewicz KM, Bruce SL, Cantu RC, et al. National Athletic Trainers' Association
Position Statement: Management of Sport-Related Concussion. J Athl Train. Sep 2004;39(3):280-297.
  • 8. Concussion (mild traumatic brain injury) and the team physician: a consensus statement.
Med Sci Sports Exerc. Nov 2005;37(11):2012-2016.
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Second Impact Syndrome

  • By 1998, there had been 17 published cases.

A review (McCrory 1998) demonstrated that

  • nly 5 of these were likely to be second

impact syndrome

  • Numerous case reports published in late

1990’s/early 2000’s. Validity of claims not rigorously reviewed.

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17/138 had recent concussion!

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What to know about Zurich

1. Don’t grade concussions 2. Symptoms are key (signs are less helpful) 3. LOC does not predict outcome 4. Amnesia poorly predicts outcome 5. Seizures do not predict outcome 6. Repeat concussions are probably bad 7. Kids aren’t just little adults 8. Elite athletes should not be treated differently 9. Use a graduated return to play

McCrory P, et al. Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250–258
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SLIDE 130
  • Definitions
  • Basic Pathophysiology (and CTE)
  • Basic Epidemiology
  • Iowa Concussion Law
  • Common Misconceptions
  • Review of Recent Concussion Guidelines
  • Concussion Clinic Protocol and Evidence Base
  • Recognition / Evaluation / Return to Play

Covered Today

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SLIDE 131

Concussion Clinic Protocol

  • Preseason Preparation
  • Concussion Recognition
  • Initial Concussion Evaluation
  • Initial Rest
  • Monitor Symptoms
  • +/- Neurocognitive testing
  • +/- All sorts of rehabilitation techniques
  • Graduated return to play
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Graduated RTP

  • 1. Complete physical and cognitive rest.
  • 2. Aerobic exercise (e.g. walking, swimming, stationary bike,

etc.) First easy, then harder.

  • 3. Sport-specific exercise (e.g. skating, running, etc.)
  • 4. Non-contact training drills (e.g. passing drills in football or

hockey)

  • 5. Full contact practice
  • 6. Normal game play
McCrory P, et al. Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250–258
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Preseason Assessment

  • Concussion predicts concussion
  • Girls are at higher risk
  • Sport, position and style of play are strongest

predictors of risk

  • Genetics - ???
  • Mood, Learning and Attention Disorders
  • Migraine headaches
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SLIDE 137 Marar AJSM 2012
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SLIDE 138

Pellman et al. Neurosurgery. 2004

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Pellman et al. Neurosurgery. 2004

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Genetics

  • ApoE promoter (g-219T) homo
  • OR 2.7 (1.1-6.8)1,2
  • Tau ser53pro homo
  • OR 8.4 (1.03-68.79)1
  • Apo E2 + E4 + promoter
  • OR 9.8 (1-96.6)1
  • Previous concussion
  • OR 1.75 (1.11-2.76)3
  • Family History?
  • Largest prospective cohort shows no association (Terrell,

unpublished ongoing research)

1. Terrell et al. APOE, APOE Promoter, and Tau Genotypes and Risk for Concussion in College Athletes. Clin J Sport Med. Jan 2008;18(1):10-17. 2. Tierney et al. Apolipoprotein E Genotype and Concussion in College Athletes. Clin J Sports Med. Nov 2010;20(6):464-468. 3. Hollis et al. Incidence, risk and protective factors of mild traumatic brain injury in a cohort of Australian nonprofessional male rugby players. Am J Sports Med. Dec 2009;37(12):2328-33.
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Migraine

Gordon et al. BJSM. 2006

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Concussion Clinic Protocol

  • Preseason Preparation
  • Concussion Recognition
  • Initial Concussion Evaluation
  • Initial Rest
  • Monitor Symptoms
  • +/- Neurocognitive testing
  • +/- All sorts of rehabilitation techniques
  • Graduated return to play
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Concussion Recognition

(47.3% of concussions in HS football players unreported)

McCrea et al. CJSM. 2004.

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Initial Evaluation (most use SCAT3)

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BJSM 2013

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  • 1. GCS
  • 2. Maddocks sideline assessment score
  • 3. Concussion Symptom Severity Score
  • 4. Cognitive assessment
  • 5. Neck Examination
  • 6. Balance examination (Double, Single, Tandem

stance)

  • 7. Coordination examination (FNF)
  • 8. Delayed recall
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Symptom Score Checklists

  • Lots of different scales and different items
  • Research still being conducted on usefulness
  • How many items?
  • Which questions?
  • Sensitivity/Specificity?
  • Predictability?
  • How to administer?
  • Clusters of scores?
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17 64 X X

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SLIDE 152 Time Symptoms
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SLIDE 154 10 20 30 40 50 60 70 80 90 100 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Total Score Day a2605F

Peterson, et al. CJSM 2014

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  • 70
  • 60
  • 50
  • 40
  • 30
  • 20
  • 10
10 20 30 40 50 60 70 10 20 30 40 50 60 70 80 90 100 Score Difference Mean Day Score Within Day score SD: 11.4 (95%CI: 9.9, 13.4 Repeatability coefficient: +/- 31.5 (two scores on the same day will differ within this limit 95% of the time.

Peterson, et al. CJSM 2014

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BESS – Our best validated test??

  • Sensitivity 34-64%
  • Specificity 91%
  • Assuming 2/10000 concussion rate

 99.8% of positive screening will be false positive

  • McCrea. J Int Neuropsychological Soc. 2005
  • McCrea. JAMA. 2003
  • Guskiewicz. AJSM. 2000
  • Barr. J Int Neuropsychological Soc. 2001
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SLIDE 157

BESS

  • Video 23 football athletes
  • 7 scorers
  • 18.9  15.4
  • -3.5 (“meaningful

difference” is 4)

  • 95%CI -6.2 - 0.67
  • IRR 0.745, 0.653

Mathiasen et al. CJSM 2013

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SLIDE 158

All Players

1st Test Mean (Std) (n = 48) 2nd Test Mean (Std) (n=48) Mean ∆ (95% CI) p-value

Cumulative BESS Score

20.3 (6.1) 16.8 (6.4)
  • 3.55
(-5.27 – -1.82) 0.0001

Cumulative Firm Score

5.0 (4.0) 3.6 (3.2)
  • 1.36
(-2.35 – 0.38) 0.0079

Cumulative Foam Score

15.4 (4.0) 13.2 (4.4)
  • 2.18
(-3.66 – -0.71) 0.0047

Peterson and Slayman, CJSM 2014

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SLIDE 159

King-Devick Test

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SLIDE 160

King-Devick Test

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SLIDE 161

King Devick

  • Lots of small recent studies
  • Methods can be questioned in many of the studies with

conclusions being made

  • No description of how unwitnessed concussions are being diagnosed
  • Unsure if there is applicability over time
  • Questions on confounding variables to performance
  • Fatigue, learning effect, effort on test
  • Big PR machine for this test currently
  • “King-Devick Test in association with Mayo Clinic”
  • Website says can be used for concussions, learning and reading
disabilities, dyslexia, sleep deprivation, ALS, Parkinson’s, MS, hypoxia
  • May have utility as one of the TOOLS in the toolbox but not

conclusive evidence at this point that it can be a sole determinant for sideline evaluation of concussion

  • Not immune from sandbagging
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SLIDE 162

Clinical Reaction Time Test

  • May be a ‘poor man’s’ neurocognitive

alterative to assessing reaction time

  • Good correlation with computerized reaction

times

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SLIDE 163

Vestibular/Ocular Motor Screen (VOMS)

Worse symptoms?

  • Smooth Pursuit
  • Horizontal Saccade
  • Vertical Saccade
  • Convergence
  • Horizontal VOR
  • Visual Motion

Distance

  • Near Point Convergence
slide-164
SLIDE 164
  • Mucha. AJSM 2015
slide-165
SLIDE 165
slide-166
SLIDE 166
  • Kontos. AJSM 2015
  • 264 unconcussed college athletes
  • Similar test-retest reliability as Mucha
  • 11% false positive rate men
  • 33% false positive rate women
  • 77% false positive rate if history of motion

sickness

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SLIDE 167

Other

  • C3 Logix
  • BrainScope
  • Pupilometer
  • Eye tracking / saccade tools
  • Balance tools (iPad, Wii, biosway)
  • Visual evoked potential tools
  • Abnormal speech recognition tools
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SLIDE 168

Who should perform the concussion evaluation in competition?

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SLIDE 169

Should coaches be present?

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SLIDE 170

Concussion Clinic Protocol

  • Preseason Preparation
  • Concussion Recognition
  • Initial Concussion Evaluation
  • Initial Rest
  • Monitor Symptoms
  • +/- Neurocognitive testing
  • +/- All sorts of rehabilitation techniques
  • Graduated return to play
slide-171
SLIDE 171

Rest/Monitor

  • Mood
  • Meds
  • Activity
slide-172
SLIDE 172

Concussion Clinic Protocol

  • Preseason Preparation
  • Concussion Recognition
  • Initial Concussion Evaluation
  • Initial Rest
  • Monitor Symptoms
  • +/- Neurocognitive testing
  • +/- All sorts of rehabilitation techniques
  • Graduated return to play
slide-173
SLIDE 173

ImPACT

Immediate Postconcussion Assessment and Cognitive Testing

  • Computer based NCT
  • 30-45 minutes (compared to 3h)
  • Increases sensitivity for persistent

concussion symptoms (VanKampen 2006)

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SLIDE 174

ImPACT

  • Concussion Symptom Severity Score
  • Word memory = learning and retention
  • Design memory = learning and retention
  • X&O’s = visual working memory and cognitive

speed

  • Symbol match = memory and visual motor speed
  • Color match = impulse inhibition and visual motor

speed

  • Three letter memory = verbal working memory and

cognitive speed

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SLIDE 175
slide-176
SLIDE 176
slide-177
SLIDE 177
slide-178
SLIDE 178 1. Schatz et al. Sensitivity and Specificity of the ImPACT Test Battery for Concussion in Athletes. Arch Clin Neuropsychol. 2006 Jan;21(1):91-9. 2. McCrea et al. Standard Regression-Based Methods for Measuring Recovery After Sport-Related Concussion. J Inter Neuropsychol Soc. 2005 Jan;11(1):58-69.

Remember, cNCT only improves sensitivity!

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SLIDE 179

Concussion Clinic Protocol

  • Preseason Preparation
  • Concussion Recognition
  • Initial Concussion Evaluation
  • Initial Rest
  • Monitor Symptoms
  • +/- Neurocognitive testing
  • +/- All sorts of rehabilitation techniques
  • Graduated return to play
slide-180
SLIDE 180
  • NSAID for headache?2
  • Triptans for migraines3
  • Melatonin for sleep4,5
  • TCA for somatic symptoms6,7
  • SSRI or TCA for depression8-10
  • Stimulants for distractability11
  • Psychology for coping12-14

No medications really fix the problem1

1. Beauchamp et al. Pharmacology of traumatic brain injury: where is the “golden bullet”. Mol Med 2008;14:731–40. 2. Lenaerts ME, Couch JR. Posttraumatic headache. Curr Treat Options Neurol 2004;6:507– 17. 3. Haas DC. Chronic post-traumatic headaches classified and compared with natural
  • headaches. Cephalalgia 1996;16:486–93.
4. Samantaray et al. Therapeutic potential of melatonin intraumatic central nervous system
  • injury. J Pineal Res 2009;47:134–42.
5. Maldonado et al. The potential of melatonin in reducing morbidity-mortality after craniocerebral trauma. J Pineal Res 2007;42:1–11. 6. Tyler et al. Treatment of post-traumatic headache with amitriptyline. Headache 1980;20:213–6. 7. Dinan TG, Mobayed M. Treatment resistance of depression after head injury: 8. a preliminary study of amitriptyline response. Acta Psychiatr Scand 1992;85:292–4. 9. Fann et al. Cognitive improvement with treatment of depression following mild traumatic brain injury. Psychosomatics 2001;42:48–54. 10. Silver JM, McAllister TW, Arciniegas DB. Depression and cognitive complaints following mild traumatic brain injury. Am J Psychiatry 2009;166:653–61. 11. Whyte et al. Effects of methylphenidate on attention deficits after traumatic brain injury: a multidimensional, randomized, controlled trial. Am J Phys Med Rehabil 2004;83:401– 20. 12. Tsaousides T, Gordon WA. Cognitive rehabilitation following traumatic brain injury: assessment to treatment. Mt Sinai J Med 2009;76:173–81. 13. Cicerone KD. Remediation of “working attention” in mild traumatic brain injury. Brain Inj 2002;16:185–95. 14. Ho MR, Bennett TL. Efficacy of neuropsychological rehabilitation for mildmoderate traumatic brain injury. Arch Clin Neuropsychol 1997;12:1–11.
slide-181
SLIDE 181 Leddy and Willer. Use of graded exercise testing in concussion and return to activity management. Curr Sports Med
  • Reports. 2013;12(6):370-6.
slide-182
SLIDE 182

Concussion Clinic Protocol

  • Preseason Preparation
  • Concussion Recognition
  • Initial Concussion Evaluation
  • Initial Rest
  • Monitor Symptoms
  • +/- Neurocognitive testing
  • +/- All sorts of rehabilitation techniques
  • Graduated return to play
slide-183
SLIDE 183

Graduated RTP

  • 1. Complete physical and cognitive rest.
  • 2. Aerobic exercise (e.g. walking, swimming, stationary bike,

etc.) First easy, then harder.

  • 3. Sport-specific exercise (e.g. skating, running, etc.)
  • 4. Non-contact training drills (e.g. passing drills in football or

hockey)

  • 5. Full contact practice
  • 6. Normal game play
McCrory P, et al. Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250–258
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SLIDE 184
slide-185
SLIDE 185

OR, to frame as covered, not- covered

slide-186
SLIDE 186

Covered

  • Things we all agree on
  • Things we kind of agree on
  • Areas of controversy / disagreement
  • Most common sideline tests
  • Guided discussion:
  • Sideline evaluation
  • Graduated RTP
  • Disqualification / retirement
slide-187
SLIDE 187

Things we agree on

  • Concussions are probably bad.
  • Injured athletes should be removed from play
  • No same day RTP
  • Symptomatic athletes should not RTP
  • Graduated RTP
  • There is little to no role for protective equipment
  • If you are going to do testing, having a baseline

makes it more useful

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SLIDE 188

Things we kind of agree on

  • All sideline concussion tests have significant limitations
  • Biomarkers, imaging and physiologic tests might be the

future, but aren’t ready for prime time

  • Sub-symptom aerobic exercise can safely be used when

the athlete is still symptomatic

  • Rest doesn’t really help that much.
  • Rules and legislation make a difference
  • No number of concussions threshold
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SLIDE 189

Number of Concussions Amount of Badness

slide-190
SLIDE 190

Things we disagree on / don’t know

  • cNCT
  • Role of sensors
  • Natural history
  • Risk stratification
  • Role of coincident mood disorder on persistent symptoms
  • Sport vs Blast vs MVA
  • Independent evaluators
  • Disqualification / retirement
  • Athletes who have ever had ICH